1. Copyright restrictions may apply JAMA Ophthalmology Journal Club Slides: Single-Nucleotide Polymorphisms and Age-Related Macular Degeneration Maguire MG, Ying G, Jaffe GJ, et al; CATT Research Group. Single- nucleotide polymorphisms associated with age-related macular degeneration and lesion phenotypes in the Comparison of Age-Related Macular Degeneration Treatments Trials. JAMA Ophthalmol. Published online April 21, 2016. doi:10.1001/jamaophthalmol.2016.0669.

2. Copyright restrictions may apply Introduction Features of neovascular age-related macular degeneration (AMD) vary widely across patients and influence vision outcomes. Previous investigations have evaluated the influence of CFH and ARMS2 with features on fluorescein angiography, with inconsistent results. Associations with optical coherence tomography (OCT) features have not been assessed previously. Objective –To evaluate the influence of single-nucleotide polymorphisms (SNPs) associated with increased risk of developing AMD (CFH, ARMS2, C3, LIPC, CFB, C2) on features of neovascular lesions apparent on fluorescein angiography and OCT.

3. Copyright restrictions may apply Study Design –Cross-sectional observational study Participants –Patients who participated the Comparison of AMD Treatments Trials (CATT), a multicenter, randomized clinical trial to compare ranibizumab vs bevacizumab and monthly dosing vs as-needed dosing. –Eligibility criteria for CATT: Aged 50 years or older. Visual acuity 20/25 to 20/320. Leakage on fluorescein angiography and fluid on OCT. Neovascularization, fluid, or blood under the fovea. No previous treatment, no limit on lesion size. ≥1 drusen >63 µm in either eye, or late AMD in fellow eye. Methods

4. Copyright restrictions may apply Data Collection –Prior to enrollment and treatment in the clinical trial, patients had fluorescein angiography and time-domain OCT. –Images were graded at the CATT Fundus Photography Reading Center (University of Pennsylvania) and CATT OCT Reading Center (Duke University). –Between July 2010 and September 2011, CATT patients were asked to provide a blood sample for genetic testing after some patients had exited the clinical trial. –835 of the 1149 patients (73%) invited provided a blood sample. –DNA was extracted using Gentra Systems PUREGENE DNA Purification Kit (Qiagen); SNPs were genotyped on a custom-made TaqMan OpenArray genotyping system. Methods

5. Copyright restrictions may apply Statistical Analysis –SNPs previously associated with development of AMD were evaluated: CFH, ARMS2, C3, LIPC, CFB, and C2. –Regression analysis was performed with the feature of neovascularization as the dependent variable and the number of risk alleles (0, 1, or 2) as the independent variable. –Adjusted for age, sex, and smoking. –P value interpretation for multiple comparisons: If analyses were performed to confirm previously identified associations, no adjustment was made for multiple comparisons. If analyses were performed to identify new associations, a Bonferroni correction was made to account for the 6 SNPs (ie, P <.008 [.05/6 =.008] was the cutoff for statistical significance). Methods

6. Copyright restrictions may apply Mean Area of Total Choroidal Neovascularization Lesion and the Risk Allele (T) for ARMS2 P<0.0001 P =.03 (n=266) (n=399)(n=170) Results

7. Copyright restrictions may apply Baseline FeatureCFHARMS2C3LIPCCFBC2 Total CNV lesion area ---- Summary of CATT Findings Angiographic Features No other associations with CNV area, total CNV lesion, classic or occult type, retinal angiomatous proliferation, or hemorrhage. Association of Feature With a Higher Number of Risk Alleles Results

8. Copyright restrictions may apply Presence of Intraretinal Fluid and the Risk Allele (T) for ARMS2 P<0.0001 P=0.03 Results

9. Copyright restrictions may apply Presence of Intraretinal Fluid and the Risk Allele (G) for C3 P<0.0001 P=0.03 P =.001 (n=461)(n=318)(n=56) Results

10. Copyright restrictions may apply Center Point Retinal Thickness and the Risk Allele (G) for C3 P<0.0001 P=0.03 P =.02 (n=461) (n=318)(n=56) Results

11. Copyright restrictions may apply Center Point Total Thickness and the Risk Allele (C) for CFH P<0.0001 P=0.03 P =.01 Results

12. Copyright restrictions may apply Baseline FeatureCFHARMS2C3LIPCCFBC2 Intraretinal fluid ---- Retinal thickness ---- Total thickness ---- Summary of CATT Findings OCT Features No other associations with presence of intraretinal, subretinal, or subretinal pigment epithelium fluid, retinal pigment epithelium elevation, subretinal hyperreflective material, retinal thickness, total thickness, epiretinal membrane, or vitreomacular attachment. Association of Feature With a Higher Number of Risk Alleles (P =.01) (P =.02) Results

13. Copyright restrictions may apply Limitations –Cross-sectional analysis but lesion features change over time. –Strength of the associations of SNP genotypes with features is modest; neovascular lesions did not segregate neatly by any of the genotypes examined. No association of CFH or ARMS2 with classic or occult angiographic patterns. –Previously, CFH was associated with classic in 2 studies, associated with occult in 1 study, and not associated with either in 5 studies. –Previously, ARMS2 was associated with classic in 2 studies and occult in 2 studies. No associations identified with LIPC, CFB, or C2. ARMS2 was associated with larger total lesion area in CATT, as in 5 other studies. Newly identified associations with OCT features and CFH, ARMS2, and C3 require replication. Comment

14. Copyright restrictions may apply If you have questions, please contact the corresponding author: –Maureen G. Maguire, PhD, Department of Ophthalmology, University of Pennsylvania, 3535 Market St, Ste 700, Philadelphia, PA 19104-3309 (maguirem@mail.med.upenn.edu). Funding/Support This work was supported by grants U10 EY017823, U10 EY017825, U10 EY017826, and U10 EY017828 from the National Eye Institute of the National Institutes of Health, US Department of Health and Human Services. Conflict of Interest Disclosures All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Toth reported receiving research grants from Bioptigen. Dr Jaffe reported receiving personal fees from Heidelberg Engineering. No other disclosures were reported. Contact Information