This study has some limitations. Each reader had access to CFP as a surrogate to biomicroscopic fundus examination to be close to the current clinical practice. However, it was not stereophotography, which would have allowed clinicians to view retinal thickness and macular edema. The diagnosis was simply based on a consensus opinion because no follow-up data were included in this study. The reference was purely qualitative because we did not try to quantify any CNV feature. We did not follow the procedures of a reading center,29 but rather remained as close as possible to the current practice: the reading was made by retina specialists involved in the management of exudative AMD and relied on their clinical expertise. The study was performed using the Cirrus 4000 spectral domain OCT. Results could have been different with a device including eye tracking and averaging. However, the advantage of this device was to simply provide a high-density mapping with acquisition of a dense macular cube (128 lines × 512 pixels) in 2.4 seconds. In this study, we did not use indocyanine green angiography because this test is not routinely used in current practice. Indocyanine green angiography could help making a diagnosis, especially in some cases with Type 1 CNV or polypoidal choroidal vasculopathy. The investigators could ask to perform indocyanine green angiography and it was performed for some patients, but this examination was not used to make the reference diagnosis. As indocyanine green angiography is not routinely used as a first diagnostic tool, we preferred to mimic the situation upstream of its prescription.
Our study was conducted before OCTA was available. This new technique will certainly change completely the paradigm of CNV detection in association with structural OCT and we have previously shown its value.7 Our results may thus also be useful for designing prospective studies assessing the value of SD-OCT combined with OCTA capacities for the diagnosis of CNV. For example, the benefit of OCTA in terms of sensitivity for the diagnosis of CNV should be more easily confirmed in Type 1 CNV than in Type 2 CNV where structural OCT + CFP has already a nearly 100% sensitivity. This work could also have an interest in the development of telemedicine. The combination of SD-OCT and CFP has the advantage of not requiring the presence of a physician and could be a valid telemedicine or computer artificial intelligence screening method for AMD where the access to retina specialists is limited.
In conclusion, our results showed no statistical difference between SD-OCT + CFP and FA + CFP in terms of sensitivity and specificity to detect the presence of recent-onset CNV secondary to AMD when the reference diagnosis is based on SD-OCT combined with FA and CFP. The sensitivity of SD-OCT + CFP, such as FA + CFP, in Type 2 CNV is very high. If Type 1 CNV is suspected, combining both imaging techniques could be needed until determining whether OCTA is sensitive enough.
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