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After successful treatment of wet AMD, in what patients would retina specialists continue to treat dry AMD and what treatment should be used?
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Patients must be monitored in order to maintain dryness
 Judy E. Kim |
Currently, there is no clear guidance on management of eyes with exudative AMD once it becomes dry with therapy. One way would be continuing monthly anti-VEGF treatments with which the patient had already been treated. Another way would be to see these patients monthly but only treat them when and if the wet AMD were to recur — meaning their vision dropped or the OCT revealed fluid or increasing retinal thickness. Another option would be the treat-and-extend mode, in which treatment is continued, but if patients are dry at each visit, you can schedule more time between their visits. They are not getting monthly treatments, but the treatments are tailored to maintain their dryness.
I think there are advantages to all three treatment options, and we have seen patients who have continued to improve after monthly treatments, even after it became dry, in terms of improving their vision. However, there comes a point when one can theoretically overtreat with pan-VEGF suppression. At that point, some physicians might switch over to targeted VEGF suppression, such as Macugen (pegaptanib, Eyetech), rather than Lucentis (ranibizumab, Genentech) or Avastin (bevacizumab, Genentech). Others prefer treating wet AMD only when it recurs in order to minimize potential side effects of injections and/or medication.
I have chosen to use the treat-and-extend mode because it seems to keep the patient dry while minimizing the potential risk of too many injections. I have stopped treating some patients after I thought they were dry and doing well and then returned them to their primary ophthalmologist. However, it seems that, sooner or later, they will come back with recurrence. Obviously this can vary from patient to patient and from eye to eye.
Judy E. Kim, MD, is an OSN Retina/Vitreous Board Member. She recently served on the advisory boards of Alimera Sciences, Allergan and Genentech.
Follow AREDS formula
 George A. Williams |
Unfortunately, there is no effective treatment for dry AMD. However, there are some exciting new therapies in development involving visual cycle inhibitors, neuroprotection and complement inhibitors. Progression of atrophic AMD is a significant problem for wet AMD patients now that we are able to stabilize their neovascular process. Increasingly, retina specialists are seeing patients in whom the neovascularization is inactive during anti-VEGF therapy, but their geographic atrophy continues to progress and they start to lose vision from atrophic macular degeneration. We did not recognize this before, because, until we could stop the neovascular process, the underlying atrophic disease was masked by the development of fibrosis and hemorrhage. I think that virtually every patient who is undergoing treatment for neovascular AMD will benefit from effective therapy against atrophic or dry AMD; we are just waiting for those therapies to become available.
So what can retina specialists do today? I keep my patients on vitamins as outlined by the AREDS study after they have developed neovascularization. I do that not only for the fellow eye, but also if they have neovascularization in both eyes because I think that may be some benefit in slowing down the atrophic progression. Obviously, I do not have any firm evidence to support that, but I think it is a reasonable approach until specific treatments for atrophic AMD are available.
George A. Williams, MD, is an OSN Retina/Vitreous Board Member.