Acta Ophthalmologica 2016

Review Article

Association of the polymorphism Y402H in the

CFH gene with response to anti-VEGF treatment
in age-related macular degeneration: a systematic
review and meta-analysis
Nan Hong, Ye Shen, Chen-Ying Yu, Shu-Qun Wang and Jian-Ping Tong
Department of Ophthalmology, the First Affiliated Hospital of College of Medicine, Zhejiang University, Hangzhou, China

ABSTRACT. physiological and pathological angio-

To explore whether the complement factor H (CFH) polymorphism rs1061170/ genesis (Grisanti & Tatar 2008). It has
Y402H is associated with responsiveness to antivascular endothelial growth been found to be highly expressed in
factor (VEGF) agents in age-related macular degeneration (AMD). We reviewed CNV membranes obtained from patients
the English literature to examine the association between the polymorphism with AMD (Reddy et al. 1995). Anti-
rs1061170/Y402H of the CFH gene and responsiveness to treatment with anti- VEGF agents, such as ranibizumab
VEGF drugs in AMD patients. A meta-analysis of eligible studies was also (Lucentis; Genentech Inc., South San
performed. Pooled odds ratios (ORs) and 95% CIs were estimated using Stata Francisco, CA, USA) and bevacizumab
V.12.0. Statistical heterogeneity was measured using Q-statistic testing. (Avastin; Genentech), which antagonize
the activity of VEGF to reduce fluid
Fourteen relevant studies including a total of 2963 AMD patients were eligible.
leakage across blood vessel walls, have
In AMD patients without a treatment history, individuals carrying the
become the gold standard treatment for
rs1061170/Y402H TT genotype were more likely to achieve a better outcome neovascular AMD (Group CR et al.
(OR = 1.932, 95% CI = 1.125–3.317, p = 0.017) than those carrying the CC 2011; Saeed et al. 2013). A series of
genotype. The polymorphism rs1061170/Y402H might be a genetic predictor of clinical trials have supported the efficacy
treatment response to anti-VEGF therapy in AMD patients. Further prospective of anti-VEGF agents for treating AMD
research including a larger number of patients is needed to validate this finding. (Rosenfeld et al. 2006; Brown et al.
2009; Group CR et al. 2011; Lim et al.
Key words: age-related macular degeneration – complement factor H – pharmacogenetics 2012). Additionally, a randomized clin-
– polymorphism – vascular endothelial growth factor ical trial found that ranibizumab had
equivalent visual acuity effects on neo-
Acta Ophthalmol. 2016: 94: 334–345 vascular AMD with bevacizumab when
ª 2016 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd administered on the same schedule
(Group CR et al. 2011). However, vari-
doi: 10.1111/aos.13049
ability in therapeutic responsiveness
among AMD patients was also recorded
ized by the development of choroidal in these clinical trials, and this caught
Introduction neovascularization (CNV) in the mac- the attention of investigators.
Age-related macular degeneration ula. The mechanism of CNV patho- Through linkage and association
(AMD) is a major cause of irreversible genesis in neovascular AMD remains studies, single-nucleotide polymor-
blindness among individuals >50 years unclear, but the secretion of angiogenic phisms (SNPs) in several genes, includ-
old in developed countries. Age-related factors, such as vascular endothelial ing complement factor H (CFH),
macular degeneration (AMD) has been growth factor (VEGF), is thought to be age-related maculopathy susceptibility
commonly classified into two clinical involved in the onset of the condition 2 (ARMS2), high-temperature require-
forms: dry AMD and neovascular (Veritti et al. 2012). ment factor A1 (HTRA1) and
AMD (wet AMD or exudative AMD) Vascular endothelial growth factor apolipoprotein E (APOE), were identi-
(Lim et al. 2012). The vast majority of (VEGF) is an endothelial cell mitogen fied being associated with AMD or
AMD-related vision loss results from and a potent vasopermeability factor AMD progression (Lim et al. 2012).
neovascular AMD, which is character- that plays a pivotal regulatory role in Because variation in therapeutic

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responsiveness to anti-VEGF agents
has been observed in AMD patients,
some authors have speculated that
genetic factors might be involved in
this variation. Several studies focusing
on the pharmacogenetic influence of
anti-VEGF therapy in AMD patients
have been reported (Dedania et al.
2015).
Numerous studies have revealed that
variants of the CFH gene may influ-
ence treatment outcomes in patients
with AMD (Dedania et al. 2015), and
rs1061170/Y402H of the CFH gene has
been the most extensively studied. A
former meta-analysis showed that an
association might exist between the
polymorphism rs1061170/Y402H of
the CFH gene and treatment response
in AMD patients, especially for treat-
ment with anti-VEGF agents (Chen
et al. 2012). In the present meta-analy-
sis, we conducted a more meticulous,
updated meta-analysis of the research,
and we have included many more new
studies. In addition, we have summa-
rized all of the studies that have indi-
cated an association between this
genetic variant and treatment response
to anti-VEGF agents.
Materials and Methods
Literature search
We performed a computerized search
of PubMed and Web of Science that
covered all papers published up to May
2015 using the following search terms:
‘macular degeneration OR AMD’
AND ‘vascular endothelial growth fac-
tor OR VEGF OR anti-VEGF OR
bevacizumab OR ranibizumab OR
aflibercept’ AND ‘CFH or complement
factor H’. Only studies that were pub-
lished in English were included. We
manually retrieved potentially relevant
publications by reviewing abstracts and
titles. Eligible publications were
extracted by a reading of the full text
and all references cited in the studies.
Two investigators (N.H. and Y.C.Y.)
independently collected the publica-
tions and resolved their disagreements
by consensus.
Selection criteria
Inclusion criteria: (1) the study patients
had AMD, (2) all trials had to include
monotherapy with an anti-VEGF drug,
and patients had to be treatment-na€ıve,
and (3) the study provided sufficient
original data information regarding
genotype frequencies of the polymor-
phisms rs1061170/Y402H and estima-
tions of the genetic effect on response
to anti-VEGF treatment. Exclusion
criteria are as follows: (1) the study
lacked available original data informa-
tion that could be used to estimate an
odds ratio (OR) with a 95% confidence
interval (CI); (2) the study investigated
progression or susceptibility, regardless
of the treatment effect; and (3) the
study was an editorial, duplicate pub-
lication, review article, meeting
abstract or case report.
Data extraction
Two investigators (N.H. and Y.C.Y.)
independently extracted the data. The
following parameters were extracted:
first author’s name, publication date,
country (ethnicity), number of patients
included in the study, therapeutic
agents, frequency of the C-allele,
detailed response criteria, study end-
point and study design.
Statistical methods
The end-point considered for analysis
was visual acuity or an observed
anatomical change on optical coher-
ence tomography (OCT) after anti-
VEGF therapy. We divided the
patients into groups of non-responders
(NR) and good responders (GR) and
summarized the definitions of good
responders in different studies
(Table 1). The association between
the polymorphism rs1061170/Y402H
genotype and treatment responses in
neovascular AMD patients who
received anti-VEGF therapy was cal-
culated using crude odds ratios (ORs)
with corresponding 95% confidence
intervals (95% CIs). Meta-analyses
were performed for five genetic models:
the allele contrast model (rs1061170/
Y402H, T versus C), the recessive
model (rs1061170/Y402H, TC+TT
versus CC), the dominant model
(rs1061170/Y402H, TT versus CC+TC),
the homozygote model (rs1061170/
Y402H, TT versus CC) and the
heterozygote model (rs1061170/Y402H,
TT versus TC). Statistical hetero-
geneity was measured using a Q test
(Zintzaras & Lau 2008). A p value
<0.10 was considered to indicate the
existence of significant statistical
Acta Ophthalmologica 2016
heterogeneity. This allowed the use of
a random-effects model; otherwise, a
fixed-effects model was used. We also
performed a subgroup analysis for the
SNP rs1061170/Y402H by ethnicity
and the drug used in the study. Egger’s
linear regression tests and Begger’s
funnel plots were conducted to evalu-
ate possible publication bias in the five
genetic models. We also performed an
influence analysis (sensitivity analysis)
by omitting a single study sequentially
to identify potential influence of each
study set to the pooled ORs. Analyses
were performed using Stata/SE v.12.0
software (Stata Cor., College Station,
TX, USA), all tests were 2-tailed, and a
p value <0.05 was considered to be
statistically significant.
Results
Eligible studies and characteristics of the
studies
A total of 76 related published studies
were identified by an initial screen, and
29 papers were chosen after further
examination (Brantley et al. 2007; Lee
et al. 2009; Imai et al. 2010; Teper
et al. 2010; Kloeckener-Gruissem et al.
2011; Nischler et al. 2011; Kang et al.
2012; McKibbin et al. 2012; Menghini
et al. 2012; Orlin et al. 2012; Smail-
hodzic et al. 2012; Tian et al. 2012;
Yamashiro et al. 2012; Abedi et al.
2013; Chang et al. 2013; Dikmetas
et al. 2013; Habibi et al. 2013; Hag-
strom et al. 2013; Hautamaki et al.
2013, 2014; Kitchens et al. 2013;
Lotery et al. 2013; Yuan et al. 2013;
van Asten et al. 2014; Matsumiya et al.
2014; Park et al. 2014; Piermarocchi
et al. 2014; Veloso et al. 2014; and
Beykin et al. 2015). Fourteen of these
studies that lacked sufficient raw data
that could be used to calculate an OR
with a 95% CI were discarded (Lee
et al. 2009; Imai et al. 2010; Teper
et al. 2010; Kang et al. 2012; Smail-
hodzic et al. 2012; Tian et al. 2012;
Abedi et al. 2013; Chang et al. 2013;
Kitchens et al. 2013; Yuan et al. 2013;
Hautamaki et al. 2014; Piermarocchi
et al. 2014; Veloso et al. 2014; Beykin
et al. 2015). Of two studies from the
same research group that investigated
the SNP rs1061170/Y402H (Kloeck-
ener-Gruissem et al. 2011; Menghini
et al. 2012), only the most recent study
was used (Menghini et al. 2012).
Finally, 14 published studies that
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Table 1. Characteristics of the studies included in the meta-analysis.

Frq* Definition of good

First author (Year) Eyes Ethnicity (C) (%) Genotype Treatment responders End-point Study design

Brantley (2007) 86 CA 55.20 TT/TC/CC Beva Improved VA VA (Snellen) Retrospective

Nischler (2011) 197 CA 48.22 TT/TC/CC Beva ≥3 lines gain in distance VA VA Prospective
McKibbin (2012) 104 CA 49.65 TT/TC/CC Rani >5 letter score gain in VA (ETDRS) Retrospective
BCVA after 6 months
Orlin (2012) 143 CA 47.20 TT/TC/CC Rani or An improvement or no VA (Snellen) Retrospective
Beva change in VA compared
with baseline
Menghini (2012) 127 CA 49.61 TT/TC/CC Rani A 5 or more letter increase VA (ETDRS) Retrospective
in VA compared to
baseline at a 12-month
follow-up
Yamashiro (2012) 75 AS 16.70 TT/TC/CC Rani Retinal exudation resolved OCT Retrospective
after 3 months
Lotery (2013) 254 CA 56.30 T/C VEGF Changes in TRT greater OCT Prospective
inhibition than or equal to the 75th
percentile at a 12-month
follow-up
Hautamaki (2013) 96 CA 61.46 TT/TC/CC Beva Neither cystic changes nor OCT Retrospective
neuroepithelial detachment
after three injections
Habibi (2013) 70 AF 41.43 TT/TC/CC Beva Stable/improved VA VA (Snellen) Retrospective
Hagstrom (2013) 834 CA 55.82 TT/TC/CC Rani or >15 letter increase in VA VA (ETDRS) Prospective
Beva from baseline
Dikmetas (2013) 193 CA 58.29 TT/TC/CC Rani An increase in visual acuity VA (ETDRS) Retrospective
(VA) of five letters or more
compared to baseline
Park (2014) 273 AS 10.99 TT/TC/CC Rani ≥8 letter gain at 5 months VA (ETDRS) Prospective
van Asten (2014) 391 CA 57.16 TT/TC/CC Rani <3 letter loss from baseline VA (ETDRS) Retrospective
VA
Matsumiya (2014) 120 AS 39.17 TT/TC/CC Rani Dry lesion in OCT at OCT Retrospective
3 months

* Frequency of the C-allele variant of rs1061170 (T1277C, Y402H).

AS = Asian, AF = African, Beva = bevacizumab, BCVA = best-corrected visual acuity, CA = Caucasian, NA = not available, ETDRS = Early
Treatment Diabetic Retinopathy Study, Frq = frequency, GR = good response, META = meta-analysis, NR = non-response, OCT = optical
coherence tomography, OR = odds ratio, PR = poor response, Rani = ranibizumab, VA = visual acuity, TRT = total retinal thickness,
VEGF = vascular endothelial growth factor.

included 2963 AMD patients were
found to be eligible for the meta-
analysis according to the selection
criteria. The mean subject number in
the reported studies was 212 (range,
70–834). Of the 14 included studies,
four were prospective and 10 were
retrospective. Regarding ethnicity, 10
studies were performed on Caucasian
subjects, three on Asian subjects, and
one on African subjects. For the geno-
type comparisons in the 14 studies, 13
provided the number of good respon-
ders or non-responders with TT/TC/
CC, with the exception of the study by
Lotery et al. (2013), which focused on
a comparison of T versus C. As for
study end-points, 10 studies used a VA
outcome, and four studies used an
anatomical outcome on OCT. The
detailed definitions of a good response
are included in Table 1. Figure 1
describes the process of study selection.
The characteristics of all of the studies
are presented in Table 1. In addition,
studies which were not included in the
meta-analysis are listed in Table 2.
Meta-analysis results
Table 3 presents the results of the
meta-analysis (14 studies for T versus
C and 13 studies for the other four
genetic models). Heterogeneity was
observed in the meta-analysis of Cau-
casian populations in all five genetic
models. Hence, a random-effects model
was used for analysis. The p value of
the Q test in the meta-analysis of Asian
populations in all five genetic models
was >0.1; we therefore pooled the three
included studies using a fixed-effects
model. Due to the heterogeneity in the
overall population in four of the
genetic models (T versus C, TT versus
CC+TC, TC+TT versus CC, and TT
versus CC), a random-effects model
was used for analysis. A fixed-effects
model was used for analysis of the
overall population in the other genetic
model (TC versus CC).
We found a significant p value for T
versus C (OR = 1.287, 95% CI = 1.027–
1.612, random-effects model, p = 0.028),
TC+TT versus CC (OR = 1.650, 95%
CI = 1.051–2.591, random-effects model,
p = 0.029) and TT versus CC
(OR = 1.932, 95% CI = 1.125–3.317,
random-effects model, p = 0.017) in
the overall population (Fig. 2). No
significant difference was found for
TT versus TC or TT versus TC+CC
(Fig. 2).
Subgroup analysis by ethnicity iden-
tified a statistically significant difference
in the Caucasian subgroup for T versus
C (OR = 1.354, 95% CI = 1.019–1.799,
random-effects model, p = 0.037),
TC+TT versus CC (OR = 1.682, 95%

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Fig. 1. Flow chart of the literature search and study selection.
CI = 1.010–2.800, random-effects model,
p = 0.046) and TT versus CC (OR =
2.091, 95% CI = 1.102–3.968, random-
effects model, p = 0.024) (Fig. 2). No
associations were observed for TT ver-
sus TC or TT versus TC+CC (Fig. 2).
Subgroup analysis revealed no statisti-
cally significant difference in Asian sub-
jects in the five genetic models (Fig. 3).
Because only one published study that
was performed in an African population
was included in the meta-analysis, we
could not conduct a subgroup analysis
for African subjects.
We also performed a subgroup anal-
ysis according to the drugs used in the
study. A statistically significant differ-
ence was found in the bevacizumab
subgroup for T versus C (OR = 1.354,
95% CI = 1.007–1.82, fixed-effects
model, p = 0.045) and TT versus CC
(OR = 2.146 2.091, 95% CI = 1.102–
4.181, fixed-effects model, p = 0.025).
No statistically significant difference
was found in the ranibizumab sub-
group in the five genetic models
(Table S1).
Publication bias
Begger’s funnel plots and Egger’s tests
were performed to assess potential
publication bias in the studies used
for the meta-analysis. The shape of the
funnel plot was not particularly sym-
metric in the five genotype comparison
models (Fig. 4). However, the results
of Egger’s tests did not indicate signif-
icant publication bias in the studies
included (data not shown).
Heterogeneity test and sensitivity analysis
There was significant heterogeneity in
the four genetic comparisons of CFH
Y402H and treatment responses
(Table 3) (p value <0.1) (T versus C,
TT versus TC/CC, TC/TT versus CC
and TT versus CC). In the subgroup
analysis, heterogeneity was still signif-
Acta Ophthalmologica 2016
icant in the Caucasian population in all
five genetic models (Table 3). To eval-
uate the robustness of our meta-analy-
sis, we performed a sensitivity analysis
by iteratively removing a single study
at a time and then recalculating the
numerical value of the summary OR.
The results showed that the odds ratio
was not significantly influenced by the
omission of any single study in three
genetic models (T versus C, TC+TT
versus CC and TT versus CC), which
indicated that our meta-analysis was
not driven by any single study (Fig. 5).
This analysis also revealed that one
study, by Dikmetas et al. (2013), might
be the main source of heterogeneity.
After removing this study, the hetero-
geneity in the Caucasian and overall
populations disappeared in four of the
genetic models (T versus C, TT versus
TC/CC, TT versus TC and TT versus
CC). The statistical significance of T
versus C and TT versus CC in the
overall and Caucasian populations was
not altered, but it was no more signif-
icant in the genetic model of TC+TT
versus CC (Table 4).
Discussion
Complement factor H (CFH) is a
critical soluble glycoprotein that can
protect cells from inflammatory dam-
age by regulating the complement
pathway in humans and by acting as
a cofactor with factor I to regulate the
activity of component three convertase
(Zipfel 2001; Rodriguez de Cordoba
et al. 2004; Donoso et al. 2006). The
Y402H coding variant (rs1061170) in
the CFH gene was defined as a T to C
substitution at nucleotide position 1277
in exon 9 of the CFH gene that leads to
a tyrosine (Y) to histidine (H) substi-
tution at codon 402 of the protein
(Kanoff & Miller 2013). This polymor-
phism was found to be located in a
region of CFH that binds to both
heparin and C-reactive protein, and
this binding could be altered by a
tyrosine (Y) to histidine (H) substitu-
tion in CFH protein, which resulted in
the dysregulation of CFH (Rodriguez
de Cordoba et al. 2004). Genetic and
molecular studies have provided strong
statistical evidence to show that this
variant is associated with the pathogen-
esis and progression of AMD in Asian
and Caucasian populations (Thakkins-
tian et al. 2006; Kondo et al. 2011;
Quan et al. 2012; Garcıa et al. 2015).
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Table 2. Characteristics of studies investigating an association between Y402H and treatment response to anti-VEGF agents that were not included
in the meta-analysis.

Association

Follow-up VA Anatomical Injection

First author (Year) Eyes Ethnicity Previous Treatment (months) change change on OCT times

Lee (2009) 156 Caucasian No 9 No NA Yes

Teper (2010) 90 Caucasian PDT or TA 12 Yes NA NA
Imai (2010) 83 Japanese NA 6 Yes No NA
Kloeckener-Gruissem (2011) 243 Caucasian NA 12 Yes NA NA
Tian (2012) 144 Chinese NA 3 No No NA
Smailhodzic (2012) 420 Caucasian No 3 Yes NA NA
Kang (2012) 75 Korean No 12 No No Yes
Chang (2013) 102 Korean No 6 No No NA
Abedi (2013) 224 Caucasian No 9 No NA NA
Yuan (2013) 168 Chinese NA 6 No No NA
Kitchens (2013) 97 Caucasian NA 6 No No NA
Hautamaki (2014) 50 Caucasian No 24 NA Yes Yes
Piermarocchi (2014) 94 Caucasian No 12 Yes NA NA
Veloso (2014) 95 Brazilian No 12 Yes No Yes
Beykin (2015) 44 NA PDT 48 No Yes NA

BCVA = best-corrected visual acuity, NA = not available, OCT = optical coherence tomography, PDT = photodynamic therapy, TA = triamci-
nolone, VA = visual acuity.

Table 3. Determination of the genetic effect of the Y402H polymorphism on antivascular endothelial growth factor (VEGF) treatment in neovascular
age-related macular degeneration (AMD) and subgroup analyses.

Heterogeneity OR (95% CI) p value

Polymorphism OR in META No of studies p value I2 (%) Fixed Random Fixed Random

T versus C Caucasian 10 0 75 – 1.354 (1.019, 1.799) – 0.037*

Asian 3 0.754 0 1.099 (0.773, 1.563) 1.101 (0.773, 1.568) 0.599 0.593
African 1 – – 1.131 (0.510, 2.510) 1.131 (0.510, 2.510) 0.762 0.762
Overall 14 0 66 – 1.287 (1.027, 1.612) – 0.028*
TT versus CC+TC Caucasian 9 0.034 51.9 – 1.421 (0.953, 2.121) – 0.085
Asian 3 0.345 5.9 1.135 (0.721, 1.785) 1.139 (0.708, 1.831) 0.584 0.592
African 1 – – 0.833 (0.261, 2.657) 0.833 (0.261, 2.657) 0.758 0.758
Overall 13 0.078 38.4 – 1.294 (0.962, 1.739) – 0.088
TC+TT versus CC Caucasian 9 0 77.5 – 1.682 (1.010, 2.800) – 0.046*
Asian 3 0.465 0 1.242 (0.311, 4.960) 1.195 (0.237, 6.037) 0.759 0.829
African 1 – – 1.917 (0.493, 7.453) 1.917 (0.493, 7.453) 0.348 0.348
Overall 13 0 67.9 – 1.650 (1.051, 2.591) – 0.029*
TT versus TC Caucasian 9 0.097 40.6 – 1.242 (0.851, 1.812) – 0.262
Asian 3 0.281 21.3 1.111 (0.706, 1.747) 1.116 (0.645, 1.934) 0.649 0.694
African 1 – – 0.643 (0.179, 2.306) 0.643 (0.179, 2.306) 0.498 0.498
Overall 13 0.153 29.1 1.231 (0.993, 1.525) – 0.058 –
TT versus CC Caucasian 9 0 73.0 – 2.091 (1.102, 3.968) – 0.024*
Asian 3 0.584 0 1.487 (0.351, 6.308) 1.352 (0.263, 6.954) 0.590 0.718
African 1 – – 1.500 (0.330, 6.822) 1.500 (0.330, 6.822) 0.600 0.600
Overall 13 0.002 60.9 – 1.932 (1.125, 3.317) – 0.017*

* p < 005. OR = odds ratio.

In addition, numerous studies have
revealed that this variant might influ-
ence treatment outcomes in patients
with AMD (Dedania et al. 2015).
The relatively small sample sizes of
previous studies have hindered the reli-
able evaluation of the association
between the CFH polymorphism
rs1061170/Y402H and treatment
response to anti-VEGF agents in
AMD. To overcome these barriers, we
summarized the pertinent published
studies and performed a systematic
meta-analysis of 14 eligible studies
involving 2963 subjects. In this meta-
analysis, we found that individuals
carrying the rs1061170/Y402H TT
genotype were more likely to achieve a
better outcome (OR = 1.932, 95% CI =
1.125–3.317, p = 0.017) than those
carrying the CC genotype. Our results
are in accordance with the results of a
previous meta-analysis performed by
Chen et al. (2012). However, we
included many more new studies and
patients in our meta-analysis. The pre-
vious meta-analysis included only six
studies of 808 patients. In their study,
patients who were homozygous for the
T-allele exhibited a 1.42-fold better

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Fig. 2. Forest plot of the meta-analysis showing the association between CFH rs1061170/Y402H and treatment response to anti-VEGF agents in
neovascular AMD using random-effects models. Subgroup comparisons were based on ethnicity.

response to anti-VEGF treatments Sensitivity analysis indicated the according to analyses by Egger’s tests,
compared to individuals who were robustness of our findings, and poten- in our meta-analysis. Significant
homozygous for the C-allele. tial publication bias was not observed, heterogeneity was observed in the

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Fig. 3. Forest plot of the meta-analysis showing the association between CFH rs1061170/Y402H and treatment response to anti-VEGF agents in
neovascular AMD using fixed-effects models. Subgroup comparisons were based on ethnicity.

overall and Caucasian populations in Dikmetas et al. (2013) might be the in the Caucasian and overall popula-
the meta-analysis. Sensitivity analysis main source of this heterogeneity. After tions disappeared in four of the genetic
showed that the study performed by removing this study, the heterogeneity models (T versus C, TT versus TC/CC,

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Begg's funnel plot with pseudo 95% confidence limits T vs. C Begg's funnel plot with pseudo 95% confidence limits TT vs. TC/CC
2
3

2
1

logrr 1
logrr
0
0

-1
-1
0 .2 .4 .6 0 .2 .4 .6 .8

s.e. of: logrr s.e. of: logrr

Begg's funnel plot with pseudo 95% confidence limits TC/TT vs. CC Begg's funnel plot with pseudo 95% confidence limits TT vs. TC
4
4

logrr
0 logrr

0
-2

-4
-2
0 .5 1 1.5
0 .2 .4 .6 .8

s.e. of: logrr s.e. of: logrr

Begg's funnel plot with pseudo 95% confidence limits TT vs. CC

4

logr
0

-2

-4
0 .5 1 1.5

s.e. of: logrr

Fig. 4. Funnel plots of studies included in the meta-analysis.

TT versus TC and TT versus CC). This
analysis did not change the estimates of
the effects of T versus C or TT versus
CC in the overall and Caucasian pop-
ulations, suggesting the reliability of
the pooled results in these two genetic
models.
After reviewing the study performed
by Dikmetas et al. (2013), we found that
the results of the study differed from
those of other studies that were included
in this meta-analysis, with an OR >3
(OR = 3.95, 95% CI = 2.57–6.07) in the
T versus C genetic model comparison,
while the odds ratios in the other studies
were <2. Differences in the definition of
response, the environmental and genetic
backgrounds of patients, study follow-
up times and the average age of the
patients might be reasons for the hetero-
geneity observed in different studies.
Attention should be given to the defini-
tion of response in the studies included
in the meta-analysis. The threshold of
visual acuity used to discriminate a good
versus a non-response might influence
the interpretation of the results. The
adoption of a uniform definition for
response in studies investigating associ-
ations between genetic variants and
treatment responses in AMD would be
helpful for allowing meta-analyses to
obtain precise and persuasive results in
the future.
In the subgroup analysis according
to the drugs, a statistically significant

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Meta-analysis fixed-effects estimates (exponential form) Meta-analysis fixed-effects estimates (exponential form)
Study omitted T vs. C Study omitted TT vs. TC/CC
1 1
2 2
3
3
4
4
5
5
6
6
7
7
8
9 8

10 9

11 10

12 11
13 12
14 13
1.02 1.13 1.28 1.44 1.56 0.96 1.02 1.26 1.55 1.62

Meta-analysis fixed-effects estimates (exponential form) Meta-analysis fixed-effects estimates (exponential form)
Study omitted TC/TT vs. CC Study omitted TT vs. TC
1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9

10 10

11 11

12 12

13 13

1.02 1.18 1.46 1.80 2.30 0.86 0.93 1.16 1.45 1.51

Meta-analysis fixed-effects estimates (exponential form)

Study omitted TT vs. CC
1

10

11

12

13

1.07 1.21 1.60 2.11 2.72

Fig. 5. Sensitivity analysis showing the odds ratio and its 95% CI after sequentially omitting each study If the lower CI limit or the upper CI limit did
not surpass 1, it was determined that the pooled odds ratio was not affected by the study.

difference was found in the beva-
cizumab subgroup for the allelic and
homozygote models, whereas no sig-
nificant difference was found in the
ranibizumab subgroup for any of the
five genetic models. The reason for the
inconsistency between the two drugs is
difficult to determine, which might
include differences in characteristics of
patients, characteristics of the study
designs and so on.
We also summarized another 15
published studies that were not
included in this meta-analysis. Of these
studies, six reported an association
between the rs1061170/Y402H poly-
morphism and visual acuity outcomes
(Imai et al. 2010; Teper et al. 2010;
Kloeckener-Gruissem et al. 2011;
Smailhodzic et al. 2012; Piermarocchi
et al. 2014; Veloso et al. 2014), two
reported an association between the
variant and anatomical outcomes on
OCT (Hautamaki et al. 2014; Beykin
et al. 2015), and four described an
association with the number of injec-
tions (Lee et al. 2009; Kang et al. 2012;
Hautamaki et al. 2014; Veloso et al.
2014). In summary, patients who were
homozygous for the risk allele C were
more likely to experience worse visual
and anatomical outcomes and to
require more intravitreal injections

342
 Acta Ophthalmologica 2016

Table 4. Determination of the genetic effect of the Y402H polymorphism on antivascular endothelial growth factor (VEGF) treatment in neovascular
age-related macular degeneration (AMD) and subgroup analyses after one study was discarded (Dikmetas et al. 2013).

Heterogeneity OR (95% CI) p value

2
Polymorphism OR in META No of studies p value I (%) Fixed Random Fixed Random

T versus C Caucasian 9 0.337 11.7 1.172 (1.023, 1.343) – 0.022* –

Asian 3 0.754 0 1.099 (0.773, 1.563) – 0.599 –
African 1 – – 1.131 (0.510, 2.510) – 0.762 –
Overall 13 0.639 0 1.162 (1.025, 1.317) – 0.019* –
TT versus CC+TC Caucasian 8 0.978 0 1.219 (0.955, 1.555) – 0.111 –
Asian 3 0.345 5.9 1.145 (0.733, 1.787) – 0.552 –
African 1 – – 0.833 (0.261, 2.657) – 0.758 –
Overall 12 0.965 0 1.187 (0.962, 1.465) – 0.110 –
TC+TT versus CC Caucasian 8 0.008 63.4 – 1.382 (0.894, 2.136) – 0.146
Asian 3 0.465 0 1.242 (0.311, 4.960) – 0.759 –
African 1 – – 1.917 (0.493, 7.453) – 0.348 –
Overall 12 0.033 47.7 1.301 (1.049, 1.614) 1.383 (0.946, 2.022) – 0.094
TT versus TC Caucasian 8 0.915 0 1.121 (0.865, 1.453) – 0.388 –
Asian 3 0.281 21.3 1.111 (0.706, 1.747) – 0.649 –
African 1 – – 0.643 (0.179, 2.306) – 0.498 –
Overall 12 0.880 0 1.100 (0.881, 1.373) – 0.399 –
TT versus CC Caucasian 8 0.221 26.1 1.426 (1.070, 1.900) – 0.016* –
Asian 3 0.584 0 1.487 (0.351, 6.308) – 0.590 –
African 1 – – 1.500 (0.330, 6.822) – 0.600 –
Overall 12 0.482 0 1.430 (1.084, 1.887) – 0.011* –

* p < 005. OR = odds ratio.

compared with patients who were
homozygous for the T-allele. However,
there were not sufficient original data
to calculate the ORs with 95% CIs in
these studies; therefore, we could not
include these studies in the meta-
analysis, and this might have led to
publication bias and may have affected
the final results of the meta-analysis.
Some researchers have suggested
that multiple genes may have combined
effects on treatment responses to anti-
VEGF therapy. Kloeckener-Gruissem
et al. (2011) found that patients who
were heterozygous for both rs1061170/
Y402H in CFH and rs10898563 in
frizzled homolog 4 (FZD4) showed
better visual improvement, indicating
a gene-to-gene interaction between
these polymorphisms and treatment
response. In a study by Smailhodzic
et al. (2012), the mean age at AMD
onset in individuals with 4 or 6 high-
risk alleles of CFH, ARMS2 and
VEGFA was younger than individuals
with 0 or 1 high-risk allele. They also
identified that an additive effect of
high-risk alleles in these three genes
might be associated with poor visual
outcome in AMD patients who
received intravitreal ranibizumab injec-
tions. Straight genotype and phenotype
effects might be covered up by gene-
to-gene interactions; therefore, com-
bining a series of genetic factors and
clinical and other biomarkers would be
useful for addressing this issue.
Despite our efforts aimed at per-
forming an accurate and comprehen-
sive analysis, limitations should be
considered before making conclusions.
First, several studies were excluded
from our analysis due to a lack of
sufficient original data that could be
used to calculate the ORs according to
our rigid selection criteria, which might
have led to issues related to methodol-
ogy, such as publication bias. Although
Egger’s tests did not show an apparent
publication bias in our meta-analysis,
this problem could not be ruled out.
Second, among the 14 included studies,
only three Asian cohorts and one
African cohort were incorporated.
Therefore, more studies of Asian and
African patients should be included in
future meta-analyses. Third, most of
the studies included in the meta-analy-
sis were retrospective; this might have
influenced the persuasion of the meta-
analysis. Fourth, differences in charac-
teristics of the study designs, including
follow-up time, characteristics of
patients, pathological stage of AMD
and the definition of responders, may
have caused heterogeneity in the
results. Sensitivity analysis might not
have been effective enough to analyse
the reason for the heterogeneity. To
explore the source of heterogeneity
more precisely, a meta-regression anal-
ysis should be performed. However,
because the data from some of the
studies were limited, this approach was
not considered here. Finally, it is
unclear whether the polymorphism
rs1061170/Y402H alone or in combi-
nation with other polymorphisms,
genes or clinical factors was responsible
for responses to anti-VEGF treat-
ments. More studies regarding poten-
tial co-functionality between VEGF,
HTRA1, ARMS2, pigment epithelium-
derived factor (PEDF) and other genes
and clinical factors and the effects of
such interactions on responses to anti-
VEGF treatments are needed.
In summary, our findings suggest
that the SNP rs1061170/Y402H of the
CFH gene might be a useful predictor
of treatment responses in AMD
patients who are treated with anti-
VEGF agents. For AMD patients
who carry the rs1061170/Y402H CC
genotype, more effective therapeutic
strategies might be needed. However,
further prospective research including a
larger number of patients is needed to
validate these findings.

343
Acta Ophthalmologica 2016
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345