Advances in the Management of Age-Related Macular Degeneration - Episode 2
Strategies that can be used to screen and confirm a diagnosis of age-related macular degeneration, as well as monitor patients to optimize care.
Arshad Khanani, MD: Looking at patients with age-related macular degeneration, most show up for regular eye exams to their optometrist thinking they need new glasses, or to their general ophthalmologist thinking they have cataracts and that’s why they can’t see. Most retina physicians get these patients as referrals. My practice is a subspecialty-based referral practice, so if a patient has mild dry or intermediate age-related macular degeneration, we don’t have any treatments for dry AMD. Of course, we’re excited that there are many programs looking at treatment for dry AMD, especially the advanced form geographic atrophy, and we’re expecting some data later this year. But currently, we don’t have any treatment for dry macular degeneration. Most of these patients are managed by optometrists or general ophthalmologists because we cannot offer them anything, but if a patient has wet macular degeneration, or neovascular AMD, they’re urgently referred to us for treatment with anti-VEGF [vascular endothelial growth factor] agents. Those patients sometimes present quite late with bleeding or permanent vision loss, and we cannot help them much even with treatment. But if they present early, we can preserve vision, and actually improve vision, in most of these patients.
When I get a referral for a patient for age-related macular degeneration, especially the neovascular or wet form, we need to make sure there are no “masqueraders.” Central serous retinopathy is a big one, but there are other conditions: macular telangiectasia, vitelliform dystrophy. When a patient comes to me, even though they are diagnosed as having wet form of macular degeneration, I use multimodal imaging as well as clinical examination to come up with the diagnosis, so they get Snellen [Snellen eye chart] visual acuity, they get the full dilated eye exam. All these patients get OCT [optical coherence tomography] imaging to look at fluid. We also have OCT angiography, which looks at neovascularization. And then if they need, I routinely do fluorescein angiograms on my new patients with neovascular AMD. If I have some other concerns about PCV [polypoidal choroidal vasculopathy], then I also do ICG [indocyanine green angiography]. Between examination and multimodal imaging, we can rule out all the “masqueraders.” If the patient has wet AMD, then we’ll treat him obviously with anti-VEGF therapy.
In terms of intervention, we don’t have any treatment for dry age-related macular degeneration, but the future is looking bright, and hopefully we’ll have some treatments soon. But we have enough data showing that if you have a patient with wet age-related macular degeneration, the timing is crucial. If you catch the disease early, and if you treat the patients quickly, you end up with very good visual acuity outcomes. We did a small study and presented at ARVO [Association for Research in Vision and Ophthalmology] a couple of years ago looking at patients with their fellow eye. If I have a patient with neovascular AMD in 1 eye, I scan the fellow eye. What we found was—and this has been confirmed by other trials, other studies at other centers — that we can diagnose the fellow eye disease very early. We treated them quickly and right away, their vision loss didn’t progress, and their need for injections was less. The timing of the diagnosis is crucial, but unfortunately a lot of times patients come in too late, and they have a central subretinal hemorrhage in the macula and permanent vision loss even with treatment.
Obviously if a patient has age-related macular degeneration, even if they have the dry form, we ask them to monitor themselves. If they have any new changes, we can catch neovascularization early and treat them quickly, so they don’t end up losing vision. We can actually maintain their vision. Of the tools we use, Amsler grid is a very traditional way to do this. There are some apps out there that patients can use, if they are tech savvy, to monitor themselves and compare their baseline grade with any changes. We also have some monitoring devices. ForeseeHome has a device that is FDA approved for patients to use at home. If they have a change in that test, the physicians get an alert. That’s a really good way to monitor patients. Of course, we don’t have approval yet, but home OCT is another very exciting technology that’s being utilized in clinical trials, where patients do OCT at home, and the physicians can actually access the image through a portal. Monitoring is crucial, not only to diagnose patients, but as we go to drugs that require less frequent visits and treatment, we can monitor them more frequently at home and figure out when the patient needs treatment. It’s the future: You’re going to be monitoring these patients remotely to make sure they don’t have new diseases or a worsening of their disease.
When the majority of my patients get referred to me, usually they have disease in 1 eye only in terms of the wet macular degeneration. Most of the time they have dry macular degeneration in both eyes because that’s how the disease progresses, but frequently we’ll have patients who come in with wet AMD in both eyes. Usually, if I’m doing an exam on my patients, I dilate both eyes because we need to make sure we do an exam to rule out hemorrhage or anything else that can be missed by OCT or other imaging modality. But I don’t dilate patients every time. They’re coming in for treatment. I usually dilate them every few months, so they don’t have the burden of waiting longer in my clinic. Once they’re on treatment, we know the majority of the patients are going to be on treatment for a really long time. Once I have the diagnosis by doing my exam in multimodal imaging, I decide how to treat them. Then they come in for chest injection visits before we do another dilated exam. If they had disease in both eyes, the option is to treat them on the same day with anti-VEGF agents or do 1 eye at a time.
It depends on the patients. Most patients prefer to get both eyes done the same day, so they don’t have to come and wait in my clinic for an additional 2 or 3 hours to get their fellow eye done. But if somebody has no family support or does not have a ride, then of course it becomes difficult to treat both eyes—they can’t really see for next few hours because they’re blurry from all the drops. There is a high treatment burden on these patients with neovascular AMD, and that’s why we need treatments that can last longer. We know that based on the SIERRA-AMD trial, which we published in a host of publications, that patients lose vision over time because of the treatment burden associated with frequent injections. That’s why it’s exciting for our patients with wet macular degeneration that multiple options are going to be available in the future to decrease their treatment burden and increase their duration between injections.
Transcript Edited for Clarity