Management of Wet Age-Related Macular Degeneration - Episode 6

Evolution of Wet AMD Treatment Options

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Roger A. Goldberg, MD, MBA, discusses the evolution of therapy from pre– to post–anti-VEGF agents for patients with wet AMD.

John W. Kitchens, MD: Roger, can you describe the evolution of therapy from pre–anti-VEGF to post–anti-VEGF?

Roger A. Goldberg, MD, MBA: I’d be happy to, although I feel blessed. One of the things that got me excited about becoming an ophthalmologist and a retina specialist was watching the development of these agents in medical school. By the time I was a resident, we were using a lot of off-label Avastin, or bevacizumab, and had the first agents FDA approved. Before that, perhaps some of my older colleagues on the call could speak to what they used to do. Sometimes they would see a choroidal neovascular membrane, or a net as Lloyd called it, and you could laser it. What the laser did is, it cauterized those blood vessels and stopped them from leaking. The downside was the laser induced a scar, so patients would lose vision acutely where the macula was lasered, including sometimes right at the fovea, right at the center of the macula, and patients would drop their vision acutely forever. On average, they would be better than they would have been had they just watched it for the next 2 years, where they would have lost their central vision and then some. They would have lost even more vision. Laser was a mainstay of treatment.

There was a little window where we used photodynamic therapy, or PDT, and in that therapy, you infuse a light-sensitive dye into the vein. Then you’d activate it, not with a hot or thermal laser, but with a cold laser, and that dye would get soaked up in the choroidal neovascular membrane. You can cause regression of those vessels with PDT. PDT helped slow some of the rapid vision loss of wet AMD, and in a subtype of patients with wet AMD [age-related macular degeneration], it wasn’t good for all of them. Then starting around 2006, we had the first FDA approval, so it’s been at least 15 years since the dawn of anti-VEGF agents. There was Macugen [pegaptanib], which was a weaker anti-VEGF agent, that came out a few years before that. Those really have been the mainstay of treatment now, as you said, for 2 decades.

John W. Kitchens, MD: It’s not a hard limb to go out on to say that the anti-VEGF therapies are the gold standard, and we use them in 99%-plus of our cases of exudative age-related macular degeneration. It’s been a tremendous game-changer for us.

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Transcript Edited for Clarity