LAUSR

We read with great interest the retrospective study by Lylyk et al on the use of ophthalmic artery (OA) angioplasty in patients with agerelated macular degeneration (AMD). With the premise in mind that AMD is correlated with a compromised blood flow in the ocular pathway, the authors selected five patients with clinically significant latestage AMD with profound vision loss in one or both eyes suitable for the compassionate use of OA angioplasty. The authors carefully described the OA angioplasty procedure that was performed successfully in all patients despite some difficulties relating to the acute takeoff angle of the OA, partial restriction of the OA ostium, and challenging device performance. The results reported by the authors were a gain in visual acuity in all patients at the followup visit. We greatly appreciate the effort of the authors in performing this study since theirs is the first known publication describing the use of OA angioplasty for the treatment of AMD; we do, however, have some concerns. Although the authors reported a gain in visual acuity of all patients, no imaging examination to analyze retinal vasculature, such as optical coherence tomography angiography (OCTA), was performed. Interestingly, the authors mentioned in their discussion that they performed spectral domain optical coherence tomography (OCT) on most patients and simply reported that the outcomes were inconclusive without providing detailed information. We believe this represents a critical point aimed at a better comprehension of the effects of the treatment. OCT is a noninvasive, highresolution optical imaging technology that has significantly improved our capability to investigate retinal layers and choroid. OCT is a key device in the diagnosis and followup of AMD patients since its use largely in clinical ophthalmology. Our group investigated choroidal thickness (CT) in patients with dry AMD (dAMD) using sweptOCT. We demonstrated that choroidal thickness was significantly reduced in patients with reticular pseudodrusen (RPD), in patients with variable combination of large soft drusen and RPD, and in patients with geographic atrophy (GA). Therefore, choroidal thinning seems to precede the development of RPE atrophy. Moreover, according to the introduction of a new structural OCT tools, namely choroidal vascularity index (CVI), total choroidal area (TCA), luminal choroidal area (LCA), and stromal choroidal area (SCA), currently we are able to better investigate choroidal changes. 6 Previous studies have investigated whether the CVI is reduced in AMD patients, considering that decreased choroidal vascularity could result in choroidal ischemia, which may result in choroidal neovascularization (CNV). 7 Interestingly, our group discovered that the vascular choroidal area is significantly reduced in patients with dAMD compared with a control cohort of healthy subjects. In addition, recent studies have described changes in choroidal thickness after the administration of intravitreal injection in neovascular AMD patients. Yamazaki et al and Gharbiya et al reported reductions in choroidal thickness after intravitreal injections of ranibizumab and aflibercept. 11 Accordingly, we can report that morphologic changes occurred in terms of choroidal thickness following treatment in neovascular AMD eyes. OCT may therefore provide interesting data about choroidal perfusion. As regards this, we wonder whether the authors might be willing to provide the results of their evaluations, even if they were inconclusive, since their study represents the first evidence of the use of an endovascular treatment that would appear to ameliorate vision loss in AMD, such that their data may provide further insights into the role of such an approach.