Management of Wet Age-Related Macular Degeneration - Episode 4

Screening for Wet AMD

January 5, 2022
John W. Kitchens, MD

,
Roger A. Goldberg, MD, MBA

,
Dante J. Pieramici, MD

,
Lloyd Clark, MD

A panel of eye care specialists review tests used in clinical practice to screen patients for wet AMD and comment on the clinical benefit of early intervention in patients.

John W. Kitchens, MD: When we see patients, and when optometrist and ophthalmologist see patients who are having acute symptoms, they do an exam, and they do a variety of testing. Dante, can you talk to us a bit about the testing required to diagnose a patient with exudative age-related macular degeneration?

Dante J. Pieramici, MD: Yes, some of the key components to any eye exam would be, of course, measuring the visual acuity. We’ve often measured at the distance, but you may want to do a near vision measurement as well. We check the interocular pressure, although that’s not key for macular degeneration. As Lloyd mentioned, glaucoma, and other problems, can pick this up with high intraocular pressure, we do something called a slit lamp where we sit down and look at the anterior part of the eye, the cornea, and the lens, and then we do a dilated examination. We can use lenses at the slit lamp, or we can use something called an indirect ophthalmoscope to look at the more periphery of the eye. A regular eye exam is also good. Nowadays we have a lot of fancy equipment, and most of the primary eye care professionals have these things. One’s called OCT, optical coherence tomography, and this gives a nice cross-sectional view of the retina. It’s almost like doing a little biopsy of the retina, you can get a nice picture. For macular degeneration, this is the key test of all the imaging tests that we can do for the photograph’s angiography. An OCT test can be helpful, but you don’t always need that to diagnose age-related macular degeneration [AMD]. It helps differentiate the different types of AMD better, then it tells you exactly where the pathology is. A nice, dilated examination with a slit lamp, intraocular pressure and vision, are the key components that need to be done for a start.

John W. Kitchens, MD: Roger, how important is early diagnosis of wet age-related macular degeneration in successful treatment of these patients?

Roger A. Goldberg, MD, MBA: I would say that is enormous. I couldn’t overemphasize how important the early recognition and initiation of treatment is, because from basically every single study we have, for all of our treatments for the wet form of macular degeneration, the best predictor of what your vision is a year to 3 years into treatment, is what was your vision on the day you got your first treatment? Picking it up before patients have lost a lot of vision is ideal. We’re not always great at that, unfortunately. There’s a lot of room for improvement in that regard, but picking it up early, and getting that patient to the right retina specialist so they could get treatment, is the key.

John W. Kitchens, MD: When you’re talking about picking up early, are we talking about within a day, a week, a month? What should we strive for?

Roger A. Goldberg, MD, MBA:In general, what I was talking about was just their vision. When patients have good vision is when you want to pick it up. We usually don’t know how long the oxidation, the fluid has been there underneath the retina because we’re only seeing that. Maybe we know because the referring doctor saw them on Monday, and then we’re seeing the patient on Tuesday or Wednesday. We don’t know unless we happen to have seen that patient 2 weeks earlier randomly, but in general, we don’t know how long the fluid has been there. A good rule of thumb is, longer is worse, so the shorter amount of time the fluid is there, the better for the patient. Because the longer the wet macular degeneration sits there untreated, it’s a bit of a, I don’t want to say a ticking time bomb, but there’s this risk of what starts off as just a bit of fluid, or blood, can turn into a lot of fluid or blood and vision loss. That can happen on any given day, and that’s why getting treatment on board early before that massive vision loss occurs, is so important.

John W. Kitchens, MD: We have this phenomenon of acute awareness vs acute onset, and in many cases with patients, because it’s not their dominant eye, they don’t recognize the onset as readily, until they accidentally cover up their good eye. Suddenly they go, “This just must have happened, because how would I have not realized my left eye gradually went downhill?” Your point, Roger, is, if you have a patient who’s having a problem, get them seen expeditiously, because we don’t know how long the issue has been going on. A matter of weeks can be the difference between 20-50 vision and 2200 vision for some of these patients.

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Transcript Edited for Clarity

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