Quantification of metamorphopsia using M-CHARTS in myopic choroidal neovascularization treated with aflibercept: a prospective case series

Quantification of metamorphopsia using M-CHARTS in myopic choroidal neovascularization treated with aflibercept: a prospective case series | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Quantification of metamorphopsia using M-CHARTS in myopic choroidal neovascularization treated with aflibercept: a prospective case series Juan Manuel Assad, Vidal Soberon, Priscila Verduzco This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9247974/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Metamorphopsia is a frequent and clinically meaningful symptom in macular disease, yet it is often assessed qualitatively rather than quantitatively. Although M-CHARTS have been used in several macular disorders, their role in myopic choroidal neovascularization (mCNV) has not been established. We aimed to quantify short-term changes in metamorphopsia after intravitreal aflibercept in patients with symptomatic mCNV managed with a pro re nata regimen. Methods This prospective, longitudinal, observational case series included 33 eyes of 33 patients with symptomatic mCNV. Best-corrected visual acuity (BCVA), vertical metamorphopsia, and horizontal metamorphopsia were recorded at baseline and 4 weeks after a single intravitreal injection of aflibercept 2 mg. Optical coherence tomography (OCT) was used in all eyes to assess activity, and fluorescein angiography was obtained when OCT findings were inconclusive. Because normality could not be assumed, paired comparisons were performed with the Wilcoxon signed-rank test. Results Median vertical metamorphopsia improved from 0.40 (interquartile range [IQR] 0.25–0.65) at baseline to 0.20 (IQR 0.00–0.40) at week 4 (p = 0.01). Median horizontal metamorphopsia improved from 0.50 (IQR 0.30–0.80) to 0.30 (IQR 0.20–0.40) (p = 0.01). Median BCVA improved from 0.60 logMAR (IQR 0.43–0.94) to 0.47 logMAR (IQR 0.30–0.69), without reaching statistical significance (p = 0.07). Conclusions Metamorphopsia quantified with M-CHARTS improved significantly 4 weeks after aflibercept in eyes with mCNV, whereas BCVA did not change significantly over the same interval. Quantitative metamorphopsia assessment may therefore provide a useful functional biomarker to complement imaging and visual acuity in pro re nata management. myopic choroidal neovascularization metamorphopsia M-CHARTS aflibercept anti-VEGF optical coherence tomography visual function Figures Figure 1 Figure 2 Introduction Metamorphopsia is one of the most relevant functional symptoms in macular disease because it affects visual quality in a way that is not always captured by high-contrast visual acuity testing [ 1 , 2 ]. In routine clinical care, the symptom is often explored with the Amsler grid; however, the Amsler grid is qualitative, and its diagnostic performance for monitoring neovascular macular disease is suboptimal [ 3 ]. Quantitative tools may therefore provide more clinically useful information when treatment decisions depend on subtle changes in symptoms. M-CHARTS were developed as a simple office-based method to quantify metamorphopsia by determining the minimum visual angle at which a dotted line is perceived as straight [ 4 ]. The method has been used in epiretinal membrane, idiopathic macular hole, and other macular conditions, and M-CHARTS values have been shown to correlate with subjective visual function [ 4 – 6 ]. Myopic choroidal neovascularization is a vision-threatening complication of pathologic myopia. Anti-vascular endothelial growth factor (anti-VEGF) therapy is the current standard of care, and many centers use one-plus-PRN or loading-plus-PRN approaches after diagnosis and stabilization [ 7 , 8 ]. In this setting, treatment decisions are guided by a combination of patient-reported symptoms and multimodal imaging, especially OCT and, when needed, fluorescein angiography [ 7 , 9 , 10 ]. Although patients with mCNV often report metamorphopsia as a dominant symptom, there is very limited evidence on the quantitative behavior of metamorphopsia after treatment in this disease. The purpose of the present study was to quantify vertical and horizontal metamorphopsia using M-CHARTS in patients with symptomatic mCNV treated with intravitreal aflibercept and followed after 4 weeks. Methods Study design and setting This prospective, longitudinal, observational case series was conducted at Asociación para Evitar la Ceguera en México, I.A.P., in Mexico City. The study adhered to the tenets of the Declaration of Helsinki and was approved by the institutional ethics committee under protocol RET.VSV.24 − 01. All participants provided informed consent before inclusion. Participants We enrolled adults with symptomatic mCNV who had previously received anti-VEGF therapy, were being managed under a PRN strategy, and presented with new visual symptoms suggestive of activity. Eyes were eligible if they had pathologic myopia and adequate media clarity for imaging. Exclusion criteria included prior retinal detachment surgery, advanced glaucoma, significant corneal opacity, infectious keratitis, uveitis, retinal vascular occlusive disease with possible macular ischemia, or other macular disorders capable of causing metamorphopsia. Examination protocol At baseline, all eyes underwent best-corrected visual acuity (BCVA) testing with ETDRS charts, fundus imaging, and macular OCT using Spectralis (Heidelberg Engineering, Heidelberg, Germany). Metamorphopsia was quantified monocularly using M-CHARTS (Inami & Co., Tokyo, Japan) according to the published method [ 4 – 6 ]. Vertical and horizontal measurements were obtained three times each, and the mean of the three measurements was recorded for analysis. Fluorescein angiography was performed when OCT findings did not clearly demonstrate activity. After baseline evaluation, all eyes received a single intravitreal injection of aflibercept 2 mg and were reevaluated 4 weeks later with the same protocol. Outcomes and statistical analysis The primary outcomes were changes in vertical and horizontal metamorphopsia scores from baseline to week 4. BCVA change was analyzed as a secondary functional outcome. The sample size rationale was based on prior work using M-CHARTS in macular hole, where a change of approximately 0.3° was considered clinically meaningful [ 5 ]. In our dataset, normality was assessed with the Shapiro–Wilk test and was not supported for the main functional variables; therefore, paired comparisons were performed using the Wilcoxon signed-rank test. Continuous variables are presented as median (IQR) for the main before–after outcomes and as mean ± standard deviation (SD) when describing baseline characteristics. Statistical significance was set at p < 0.05. Results Thirty-three eyes of 33 patients completed the 4-week follow-up and were included in the final analysis. Most patients were women (27/33, 81.8%), and 18 study eyes (54.5%) were right eyes. Mean age was 59.5 ± 12.0 years, and the mean refractive error was − 8.88 ± 7.59 diopters. Table 1 Baseline characteristics Characteristic Value Eyes, n 33 Female sex, n (%) 27 (81.8) Right eyes, n (%) 18 (54.5) Age, mean ± SD, years 59.5 ± 12.0 Age, median (IQR), years 61 (54–68.5) Refractive error, mean ± SD, D −8.88 ± 7.59 Baseline BCVA, median (IQR), logMAR 0.60 (0.43–0.94) Baseline vertical metamorphopsia, median (IQR) 0.40 (0.25–0.65) Baseline horizontal metamorphopsia, median (IQR) 0.50 (0.30–0.80) At week 4, both vertical and horizontal metamorphopsia showed statistically significant improvement. In contrast, BCVA showed a numerical improvement that did not reach statistical significance. Table 2 Functional outcomes at baseline and week 4 Outcome Baseline Week 4 p value Vertical metamorphopsia, median (IQR) 0.40 (0.25–0.65) 0.20 (0.00–0.40) 0.01 Horizontal metamorphopsia, median (IQR) 0.50 (0.30–0.80) 0.30 (0.20–0.40) 0.01 BCVA, median (IQR), logMAR 0.60 (0.43–0.94) 0.47 (0.30–0.69) 0.07 The lines within the boxes represent medians, the boxes represent the interquartile range, whiskers extend to 1.5 × IQR, and circles denote outliers. The baseline image shows a subretinal hyperreflective lesion with associated exudative structural change. At week 4, the lesion appears more compact, consistent with short-term anatomic response. Discussion This study shows that metamorphopsia quantified with M-CHARTS improved significantly 4 weeks after intravitreal aflibercept in eyes with symptomatic mCNV. By contrast, BCVA improved numerically but did not reach statistical significance over the same period. This pattern suggests that metamorphopsia may capture clinically relevant short-term functional change that is not fully reflected by ETDRS acuity alone [ 1 , 2 , 6 ]. The result is clinically plausible. In macular disease, visual acuity is only one component of function, whereas metamorphopsia reflects distortion perceived during daily tasks such as reading and fixation. Previous work has emphasized that metamorphopsia is an overlooked but important symptom, and that M-CHARTS offer a practical way to quantify it in the clinic [ 1 , 2 , 4 ]. In addition, correlations between M-CHARTS and subjective visual function have been reported in other macular disorders [ 6 ]. For mCNV specifically, modern management depends on anti-VEGF therapy and careful follow-up guided by symptoms and multimodal imaging [ 7 – 10 ]. In PRN strategies, the physician often has to integrate subtle symptom changes with OCT findings, and there are situations in which OCT biomarkers of activity are limited or not dramatic despite meaningful patient complaints [ 7 , 9 , 10 ]. In that context, a simple quantitative symptom-based measure may be especially useful. Our findings also fit the structure of the disease. mCNV lesions are often small and type 2 in configuration, and short-term response after treatment may be accompanied by a reduction in exudative change and lesion compactness on OCT before substantial gain in high-contrast acuity becomes evident [ 8 – 10 ]. The representative pre-treatment and post-treatment OCTs included here illustrate that concept. The main novelty of the present study is that, to our knowledge, it is the first prospective case series specifically examining M-CHARTS in mCNV treated with aflibercept under a PRN-oriented framework. This is relevant because the method is inexpensive, fast, office-based, and easy to explain to patients, making it realistic for routine vitreoretinal practice [ 4 , 5 ]. Limitations This study has several limitations. The sample size was modest, follow-up was limited to 4 weeks, and metamorphopsia was assessed only in the vertical and horizontal meridians. We did not administer a vision-related quality-of-life questionnaire, and the design does not allow assessment of long-term recurrence behavior or durability of functional improvement. Future studies with larger cohorts, longer follow-up, and combined functional and imaging endpoints are warranted. Conclusions In eyes with symptomatic mCNV treated with intravitreal aflibercept, vertical and horizontal metamorphopsia improved significantly at 4 weeks, whereas BCVA did not change significantly over the same interval. Quantitative assessment with M-CHARTS may therefore serve as a useful adjunctive functional biomarker in PRN management. Declarations Ethics approval and consent to participate This study was approved by the institutional ethics committee under protocol RET.VSV.24-01. All participants provided written informed consent. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The authors received no specific funding for this work. Authors’ contributions JM conceived the study, collected the data, interpreted the results, and drafted the manuscript. VSV contributed to the statistical analysis and interpretation. All authors reviewed and approved the final manuscript. Acknowledgements The authors thank the clinical staff involved in patient care and study logistics. References Simunovic MP. Metamorphopsia and its quantification. Retina. 2015;35(7):1285–1291. doi:10.1097/IAE.0000000000000581. Midena E, Vujosevic S. Metamorphopsia: an overlooked visual symptom. Ophthalmic Res. 2015;55(1):26–36. doi:10.1159/000441033. Bjerager J, Schneider M, Potapenko I, et al. Diagnostic accuracy of the Amsler grid test for detecting neovascular age-related macular degeneration: a systematic review and meta-analysis. JAMA Ophthalmol. 2023;141(4):315–323. doi:10.1001/jamaophthalmol.2022.6396. Matsumoto C, Arimura E, Okuyama S, Takada S, Hashimoto S, Shimomura Y. Quantification of metamorphopsia in patients with epiretinal membranes. Invest Ophthalmol Vis Sci. 2003;44(9):4012–4016. doi:10.1167/iovs.03-0117. Wada I, Yoshida S, Kobayashi Y, et al. Quantifying metamorphopsia with M-CHARTS in patients with idiopathic macular hole. Clin Ophthalmol. 2017;11:1719–1726. doi:10.2147/OPTH.S144981. Arimura E, Matsumoto C, Nomoto H, et al. Correlations between M-CHARTS and PHP findings and subjective perception of metamorphopsia in patients with macular diseases. Invest Ophthalmol Vis Sci. 2011;52(1):128–135. doi:10.1167/iovs.09-3535. Cheung CMG, Arnold JJ, Holz FG, et al. Myopic choroidal neovascularization: review, guidance, and consensus statement on management. Ophthalmology. 2017;124(11):1690–1711. doi:10.1016/j.ophtha.2017.04.028. Ikuno Y, Ohno-Matsui K, Wong TY, et al. Intravitreal aflibercept injection in patients with myopic choroidal neovascularization: the MYRROR study. Ophthalmology. 2015;122(6):1220–1227. doi:10.1016/j.ophtha.2015.01.025. Chhablani J, Deepa MJ, Tyagi M, Narayanan R, Kozak I. Fluorescein angiography and optical coherence tomography in myopic choroidal neovascularization. Eye (Lond). 2015;29(4):519–524. doi:10.1038/eye.2014.345. Castellino N, Battaglia Parodi M, Russo A, et al. Morphological parameters of myopic choroidal neovascularization as predictive factors of anti-VEGF treatment response. Sci Rep. 2022;12(1):10435. doi:10.1038/s41598-022-14287-7. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9247974","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":614836074,"identity":"0ca23e8b-d9ce-40ff-81fc-2892f531aea6","order_by":0,"name":"Juan Manuel Assad","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIiWNgGAWjYBACxgYYix1MMsuByAMPiNLCDCGNwVoSiLIPqiURbAY+Lcwzkp89ulFzJ7Gfmfnxxx811unzww4/BNpiJ6fbgF0L44w0c+OcY88SZzazmUnzHEvP3Xg7zQCoJdnY7AAuLQlm0jlshxM3HGYwY2ZgO5y7cXYCSMuBxG04taR/k875dzhx/2H2zx9//Ducbjg7/QMBLTlm0rltQFuYeQwkeNsOJ8hL5xCwpedNmXRu32HjGYd5yqR5+9INN0jnFBxIMMDtF8P29G3SOd8Oy/a3t2/++OObtbz87PTNHz5U2Mnh1NKALmIAVmmAXTkIyGOKYBgyCkbBKBgFIx0AAG56ZE+OwGkZAAAAAElFTkSuQmCC","orcid":"","institution":"Asociacion Para Evitar la Ceguera en México Hospital Dr. Luis Sánchez Bulnes","correspondingAuthor":true,"prefix":"","firstName":"Juan","middleName":"Manuel","lastName":"Assad","suffix":""},{"id":614836075,"identity":"3800cb43-4daf-43af-8b4f-3ec9d417591f","order_by":1,"name":"Vidal Soberon","email":"","orcid":"","institution":"Asociacion Para Evitar la Ceguera en México Hospital Dr. Luis Sánchez Bulnes","correspondingAuthor":false,"prefix":"","firstName":"Vidal","middleName":"","lastName":"Soberon","suffix":""},{"id":614836076,"identity":"0e182b2f-ae08-44b9-9be7-95e60a77f7a4","order_by":2,"name":"Priscila Verduzco","email":"","orcid":"","institution":"Asociacion Para Evitar la Ceguera en México Hospital Dr. Luis Sánchez Bulnes","correspondingAuthor":false,"prefix":"","firstName":"Priscila","middleName":"","lastName":"Verduzco","suffix":""}],"badges":[],"createdAt":"2026-03-27 19:53:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9247974/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9247974/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105882345,"identity":"62bc7f64-e4f2-481a-ae2b-ceb47a573ef9","added_by":"auto","created_at":"2026-04-01 06:56:28","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":59410,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eBoxplots of vertical metamorphopsia, horizontal metamorphopsia, and BCVA at baseline and week 4.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9247974/v1/3ba17fe967e8989785c26c5e.jpg"},{"id":105882092,"identity":"93d0171a-fcae-46ea-8ec4-a8fe2c9f5686","added_by":"auto","created_at":"2026-04-01 06:55:37","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":114027,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRepresentative OCT images before treatment and at week 4 after intravitreal aflibercept.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9247974/v1/a7df561e03137717b6ddf314.jpg"},{"id":107975078,"identity":"e90c96cf-db62-49f3-96a9-cc2fb9268c9e","added_by":"auto","created_at":"2026-04-28 07:26:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":330127,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9247974/v1/7c4ff73a-9447-4655-8dfd-6bb6d2acaa3a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Quantification of metamorphopsia using M-CHARTS in myopic choroidal neovascularization treated with aflibercept: a prospective case series","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMetamorphopsia is one of the most relevant functional symptoms in macular disease because it affects visual quality in a way that is not always captured by high-contrast visual acuity testing [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In routine clinical care, the symptom is often explored with the Amsler grid; however, the Amsler grid is qualitative, and its diagnostic performance for monitoring neovascular macular disease is suboptimal [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Quantitative tools may therefore provide more clinically useful information when treatment decisions depend on subtle changes in symptoms.\u003c/p\u003e \u003cp\u003eM-CHARTS were developed as a simple office-based method to quantify metamorphopsia by determining the minimum visual angle at which a dotted line is perceived as straight [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The method has been used in epiretinal membrane, idiopathic macular hole, and other macular conditions, and M-CHARTS values have been shown to correlate with subjective visual function [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMyopic choroidal neovascularization is a vision-threatening complication of pathologic myopia. Anti-vascular endothelial growth factor (anti-VEGF) therapy is the current standard of care, and many centers use one-plus-PRN or loading-plus-PRN approaches after diagnosis and stabilization [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In this setting, treatment decisions are guided by a combination of patient-reported symptoms and multimodal imaging, especially OCT and, when needed, fluorescein angiography [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough patients with mCNV often report metamorphopsia as a dominant symptom, there is very limited evidence on the quantitative behavior of metamorphopsia after treatment in this disease. The purpose of the present study was to quantify vertical and horizontal metamorphopsia using M-CHARTS in patients with symptomatic mCNV treated with intravitreal aflibercept and followed after 4 weeks.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eThis prospective, longitudinal, observational case series was conducted at Asociaci\u0026oacute;n para Evitar la Ceguera en M\u0026eacute;xico, I.A.P., in Mexico City. The study adhered to the tenets of the Declaration of Helsinki and was approved by the institutional ethics committee under protocol RET.VSV.24\u0026thinsp;\u0026minus;\u0026thinsp;01. All participants provided informed consent before inclusion.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eWe enrolled adults with symptomatic mCNV who had previously received anti-VEGF therapy, were being managed under a PRN strategy, and presented with new visual symptoms suggestive of activity. Eyes were eligible if they had pathologic myopia and adequate media clarity for imaging. Exclusion criteria included prior retinal detachment surgery, advanced glaucoma, significant corneal opacity, infectious keratitis, uveitis, retinal vascular occlusive disease with possible macular ischemia, or other macular disorders capable of causing metamorphopsia.\u003c/p\u003e\n\u003ch3\u003eExamination protocol\u003c/h3\u003e\n\u003cp\u003eAt baseline, all eyes underwent best-corrected visual acuity (BCVA) testing with ETDRS charts, fundus imaging, and macular OCT using Spectralis (Heidelberg Engineering, Heidelberg, Germany). Metamorphopsia was quantified monocularly using M-CHARTS (Inami \u0026amp; Co., Tokyo, Japan) according to the published method [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Vertical and horizontal measurements were obtained three times each, and the mean of the three measurements was recorded for analysis. Fluorescein angiography was performed when OCT findings did not clearly demonstrate activity. After baseline evaluation, all eyes received a single intravitreal injection of aflibercept 2 mg and were reevaluated 4 weeks later with the same protocol.\u003c/p\u003e\n\u003ch3\u003eOutcomes and statistical analysis\u003c/h3\u003e\n\u003cp\u003eThe primary outcomes were changes in vertical and horizontal metamorphopsia scores from baseline to week 4. BCVA change was analyzed as a secondary functional outcome. The sample size rationale was based on prior work using M-CHARTS in macular hole, where a change of approximately 0.3\u0026deg; was considered clinically meaningful [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In our dataset, normality was assessed with the Shapiro\u0026ndash;Wilk test and was not supported for the main functional variables; therefore, paired comparisons were performed using the Wilcoxon signed-rank test. Continuous variables are presented as median (IQR) for the main before\u0026ndash;after outcomes and as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) when describing baseline characteristics. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThirty-three eyes of 33 patients completed the 4-week follow-up and were included in the final analysis. Most patients were women (27/33, 81.8%), and 18 study eyes (54.5%) were right eyes. Mean age was 59.5\u0026thinsp;\u0026plusmn;\u0026thinsp;12.0 years, and the mean refractive error was \u0026minus;\u0026thinsp;8.88\u0026thinsp;\u0026plusmn;\u0026thinsp;7.59 diopters.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEyes, n\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale sex, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (81.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight eyes, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (54.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59.5\u0026thinsp;\u0026plusmn;\u0026thinsp;12.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, median (IQR), years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (54\u0026ndash;68.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRefractive error, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, D\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;8.88\u0026thinsp;\u0026plusmn;\u0026thinsp;7.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline BCVA, median (IQR), logMAR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.60 (0.43\u0026ndash;0.94)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline vertical metamorphopsia, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.40 (0.25\u0026ndash;0.65)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBaseline horizontal metamorphopsia, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.50 (0.30\u0026ndash;0.80)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAt week 4, both vertical and horizontal metamorphopsia showed statistically significant improvement. In contrast, BCVA showed a numerical improvement that did not reach statistical significance.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFunctional outcomes at baseline and week 4\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWeek 4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVertical metamorphopsia, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.40 (0.25\u0026ndash;0.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.20 (0.00\u0026ndash;0.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHorizontal metamorphopsia, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.50 (0.30\u0026ndash;0.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.30 (0.20\u0026ndash;0.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBCVA, median (IQR), logMAR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.60 (0.43\u0026ndash;0.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.47 (0.30\u0026ndash;0.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe lines within the boxes represent medians, the boxes represent the interquartile range, whiskers extend to 1.5 \u0026times; IQR, and circles denote outliers.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe baseline image shows a subretinal hyperreflective lesion with associated exudative structural change. At week 4, the lesion appears more compact, consistent with short-term anatomic response.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study shows that metamorphopsia quantified with M-CHARTS improved significantly 4 weeks after intravitreal aflibercept in eyes with symptomatic mCNV. By contrast, BCVA improved numerically but did not reach statistical significance over the same period. This pattern suggests that metamorphopsia may capture clinically relevant short-term functional change that is not fully reflected by ETDRS acuity alone [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe result is clinically plausible. In macular disease, visual acuity is only one component of function, whereas metamorphopsia reflects distortion perceived during daily tasks such as reading and fixation. Previous work has emphasized that metamorphopsia is an overlooked but important symptom, and that M-CHARTS offer a practical way to quantify it in the clinic [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In addition, correlations between M-CHARTS and subjective visual function have been reported in other macular disorders [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor mCNV specifically, modern management depends on anti-VEGF therapy and careful follow-up guided by symptoms and multimodal imaging [\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In PRN strategies, the physician often has to integrate subtle symptom changes with OCT findings, and there are situations in which OCT biomarkers of activity are limited or not dramatic despite meaningful patient complaints [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In that context, a simple quantitative symptom-based measure may be especially useful.\u003c/p\u003e \u003cp\u003eOur findings also fit the structure of the disease. mCNV lesions are often small and type 2 in configuration, and short-term response after treatment may be accompanied by a reduction in exudative change and lesion compactness on OCT before substantial gain in high-contrast acuity becomes evident [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The representative pre-treatment and post-treatment OCTs included here illustrate that concept.\u003c/p\u003e \u003cp\u003eThe main novelty of the present study is that, to our knowledge, it is the first prospective case series specifically examining M-CHARTS in mCNV treated with aflibercept under a PRN-oriented framework. This is relevant because the method is inexpensive, fast, office-based, and easy to explain to patients, making it realistic for routine vitreoretinal practice [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThis study has several limitations. The sample size was modest, follow-up was limited to 4 weeks, and metamorphopsia was assessed only in the vertical and horizontal meridians. We did not administer a vision-related quality-of-life questionnaire, and the design does not allow assessment of long-term recurrence behavior or durability of functional improvement. Future studies with larger cohorts, longer follow-up, and combined functional and imaging endpoints are warranted.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn eyes with symptomatic mCNV treated with intravitreal aflibercept, vertical and horizontal metamorphopsia improved significantly at 4 weeks, whereas BCVA did not change significantly over the same interval. Quantitative assessment with M-CHARTS may therefore serve as a useful adjunctive functional biomarker in PRN management.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This study was approved by the institutional ethics committee under protocol RET.VSV.24-01. All participants provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors received no specific funding for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;JM conceived the study, collected the data, interpreted the results, and drafted the manuscript. VSV contributed to the statistical analysis and interpretation. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors thank the clinical staff involved in patient care and study logistics.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSimunovic MP. Metamorphopsia and its quantification. Retina. 2015;35(7):1285\u0026ndash;1291. doi:10.1097/IAE.0000000000000581.\u003c/li\u003e\n\u003cli\u003eMidena E, Vujosevic S. Metamorphopsia: an overlooked visual symptom. Ophthalmic Res. 2015;55(1):26\u0026ndash;36. doi:10.1159/000441033.\u003c/li\u003e\n\u003cli\u003eBjerager J, Schneider M, Potapenko I, et al. Diagnostic accuracy of the Amsler grid test for detecting neovascular age-related macular degeneration: a systematic review and meta-analysis. JAMA Ophthalmol. 2023;141(4):315\u0026ndash;323. doi:10.1001/jamaophthalmol.2022.6396.\u003c/li\u003e\n\u003cli\u003eMatsumoto C, Arimura E, Okuyama S, Takada S, Hashimoto S, Shimomura Y. Quantification of metamorphopsia in patients with epiretinal membranes. Invest Ophthalmol Vis Sci. 2003;44(9):4012\u0026ndash;4016. doi:10.1167/iovs.03-0117.\u003c/li\u003e\n\u003cli\u003eWada I, Yoshida S, Kobayashi Y, et al. Quantifying metamorphopsia with M-CHARTS in patients with idiopathic macular hole. Clin Ophthalmol. 2017;11:1719\u0026ndash;1726. doi:10.2147/OPTH.S144981.\u003c/li\u003e\n\u003cli\u003eArimura E, Matsumoto C, Nomoto H, et al. Correlations between M-CHARTS and PHP findings and subjective perception of metamorphopsia in patients with macular diseases. Invest Ophthalmol Vis Sci. 2011;52(1):128\u0026ndash;135. doi:10.1167/iovs.09-3535.\u003c/li\u003e\n\u003cli\u003eCheung CMG, Arnold JJ, Holz FG, et al. Myopic choroidal neovascularization: review, guidance, and consensus statement on management. Ophthalmology. 2017;124(11):1690\u0026ndash;1711. doi:10.1016/j.ophtha.2017.04.028.\u003c/li\u003e\n\u003cli\u003eIkuno Y, Ohno-Matsui K, Wong TY, et al. Intravitreal aflibercept injection in patients with myopic choroidal neovascularization: the MYRROR study. Ophthalmology. 2015;122(6):1220\u0026ndash;1227. doi:10.1016/j.ophtha.2015.01.025.\u003c/li\u003e\n\u003cli\u003eChhablani J, Deepa MJ, Tyagi M, Narayanan R, Kozak I. Fluorescein angiography and optical coherence tomography in myopic choroidal neovascularization. Eye (Lond). 2015;29(4):519\u0026ndash;524. doi:10.1038/eye.2014.345.\u003c/li\u003e\n\u003cli\u003eCastellino N, Battaglia Parodi M, Russo A, et al. Morphological parameters of myopic choroidal neovascularization as predictive factors of anti-VEGF treatment response. Sci Rep. 2022;12(1):10435. doi:10.1038/s41598-022-14287-7.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"myopic choroidal neovascularization, metamorphopsia, M-CHARTS, aflibercept, anti-VEGF, optical coherence tomography, visual function","lastPublishedDoi":"10.21203/rs.3.rs-9247974/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9247974/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMetamorphopsia is a frequent and clinically meaningful symptom in macular disease, yet it is often assessed qualitatively rather than quantitatively. Although M-CHARTS have been used in several macular disorders, their role in myopic choroidal neovascularization (mCNV) has not been established. We aimed to quantify short-term changes in metamorphopsia after intravitreal aflibercept in patients with symptomatic mCNV managed with a pro re nata regimen.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis prospective, longitudinal, observational case series included 33 eyes of 33 patients with symptomatic mCNV. Best-corrected visual acuity (BCVA), vertical metamorphopsia, and horizontal metamorphopsia were recorded at baseline and 4 weeks after a single intravitreal injection of aflibercept 2 mg. Optical coherence tomography (OCT) was used in all eyes to assess activity, and fluorescein angiography was obtained when OCT findings were inconclusive. Because normality could not be assumed, paired comparisons were performed with the Wilcoxon signed-rank test.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMedian vertical metamorphopsia improved from 0.40 (interquartile range [IQR] 0.25\u0026ndash;0.65) at baseline to 0.20 (IQR 0.00\u0026ndash;0.40) at week 4 (p\u0026thinsp;=\u0026thinsp;0.01). Median horizontal metamorphopsia improved from 0.50 (IQR 0.30\u0026ndash;0.80) to 0.30 (IQR 0.20\u0026ndash;0.40) (p\u0026thinsp;=\u0026thinsp;0.01). Median BCVA improved from 0.60 logMAR (IQR 0.43\u0026ndash;0.94) to 0.47 logMAR (IQR 0.30\u0026ndash;0.69), without reaching statistical significance (p\u0026thinsp;=\u0026thinsp;0.07).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eMetamorphopsia quantified with M-CHARTS improved significantly 4 weeks after aflibercept in eyes with mCNV, whereas BCVA did not change significantly over the same interval. Quantitative metamorphopsia assessment may therefore provide a useful functional biomarker to complement imaging and visual acuity in pro re nata management.\u003c/p\u003e","manuscriptTitle":"Quantification of metamorphopsia using M-CHARTS in myopic choroidal neovascularization treated with aflibercept: a prospective case series","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-01 06:53:12","doi":"10.21203/rs.3.rs-9247974/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"58b061f0-be43-490a-9dd6-581f2d27cb7e","owner":[],"postedDate":"April 1st, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-28T07:26:13+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-01 06:53:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9247974","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9247974","identity":"rs-9247974","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}