Risk of incident macular neovascularization in eyes with focal choroidal excavation: A retrospective cohort study with time-to-event analysis

Purpose To evaluate the long-term risk of incident macular neovascularization (MNV) in eyes with focal choroidal excavation (FCE) compared with non-FCE pachychoroid-spectrum controls in routine clinical practice. Methods This retrospective cohort study included eyes with pachychoroid-spectrum disease and no evidence of MNV at baseline that were evaluated at the University of Tokyo Hospital between January 2008 and March 2025. Eyes were classified according to the presence or absence of optical coherence tomography-defined FCE. Eyes without FCE, including those with central serous chorioretinopathy and pachychoroid pigment epitheliopathy, served as the non-FCE control group. MNV-free survival was assessed using the Kaplan–Meier method, and hazard ratios (HRs) were estimated using an age-adjusted Cox proportional hazards model. An exploratory within-FCE analysis evaluated serous retinal detachment (SRD) involving the excavation site on baseline OCT. Results A total of 608 eyes were included in the analysis, comprising 54 eyes with FCE and 554 non-FCE control eyes. Among the control eyes, 515 were classified as central serous chorioretinopathy and 39 as pachychoroid pigment epitheliopathy. During follow-up, incident MNV developed in 31 eyes overall, including 6 eyes in the FCE group and 25 eyes in the control group. The median follow-up period was 3.0 [interquartile range, 2.0–9.0] years in the FCE group and 3.0 [interquartile range, 1.0–7.0] years in the control group. In the age-adjusted Cox proportional hazards model, increasing age was associated with a higher hazard of incident MNV (HR 1.04 per year; 95% confidence interval: 1.01–1.07; p = 0.0133), and FCE was associated with a higher hazard of incident MNV compared with the non-FCE control group after adjustment for age (HR 2.74; 95% confidence interval: 1.003–6.387; p = 0.0298). In an exploratory within-FCE analysis, incident MNV developed in 5 of 13 eyes with SRD involving the excavation site at baseline, compared with 1 of 41 eyes without baseline SRD (Fisher’s exact test, p = 0.0021). Conclusions In this real-world cohort of eyes with pachychoroid-spectrum disease, FCE was associated with a higher age-adjusted hazard of incident MNV compared with non-FCE controls. SRD involving the excavation site was more frequently observed among FCE eyes that developed incident MNV; however, this exploratory observation should be interpreted as hypothesis-generating.