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Comprehensive ophthalmologists face tough decisions on early AMD treatment
The advances in our ability to treat exudative age-related macular degeneration are nothing short of amazing, and their potential impacts on individual patients and society as a whole are equally significant.
 Richard L. Lindstrom |
In most patients, AMD progresses relentlessly over decades, from asymptomatic precursor signs such as fine drusen and mild pigment dispersion to a more severe non-exudative AMD such as evidenced by geographic atrophy and, in some 20% of patients, to exudative AMD. We comprehensive ophthalmologists who follow these patients today are forced to make many decisions that are not fully evidence- based, but such has always been the case and defines the art of medicine.
Nutritional supplements
A few thoughts on some of the tough calls I make every day in clinical practice. First, what about nutritional supplements? I usually recommend some form of nutritional supplement therapy in any patient with precursor findings of AMD or even a positive family history. Some of us are more aggressive, recommending antioxidant vitamins, lutein and supplemental omega-3 fatty acids at an early stage, while others wait for the development of intermediate stage non-exudative AMD, as defined in the Age-Related Eye Disease Study.
This therapy is relatively inexpensive, has been confirmed to delay the progression of a potentially blinding condition and in general is also likely to benefit the general health and well-being of most patients. Still, according to some studies, fewer than half the patients with non-exudative AMD are taking an appropriate regimen of nutritional supplements. I believe we can do better, and just like in glaucoma, we need to diagnose and treat those patients at risk of progression.
When to initiate therapy is a joint decision of the ophthalmologist and the patient, and several studies are in progress to help us further understand the risks and benefits of each of the nutritional supplements. I personally take an antioxidant supplement, high-quality omega-3 and a daily multiple vitamin, even though I have a normal macula.
Because my classic patient-centered decision process leads me repeatedly back to the question, what would I do for myself or my family, I find myself discussing nutritional supplements with patients who have any precursor macular findings or a positive family history of AMD. Many choose to initiate therapy. Some might criticize this approach, but by the time we know what is the best preventive therapy, it will likely be too late for millions of people, including many of my patients and close friends.
Following the disease
Second, how should we follow the patient with early AMD? Again, evidence suggests that we miss the transition to early exudative disease in many patients, which is when they can best be treated. It is not possible or appropriate to see patients monthly or quarterly for decades, and even then we might miss the earliest signs of transition. We need a sensitive and specific test that our patients with risk factors can do at home daily.
Our classic use of the Amsler grid is convenient and inexpensive, but I expect new tests, including a home-based device called preferential hyperacuity perimetry, to enhance our ability to follow these patients and diagnose any progression at the earliest possible time.
Referring to a specialist
Third, we need to get the right patients to our preferred retina specialist at the right time to ensure optimal response to therapy and the best use of our now somewhat overextended colleagues. As described above, the advances in therapy of exudative AMD are remarkable and continuously evolving.
Finally, the progressive increase in life expectancy and aging of the world’s senior population is on a collision course with our global financial crisis and an expected inadequate number of ophthalmologists by 2020. How our profession chooses to deal with the issues of exponentially better but ever more expensive therapies in the face of limited capital and manpower resources will define us in the years to come.