Panel: Preferred treatment depends on severity of AMD

MONTREAL – The best treatment for age-related macular degeneration depends on the severity of the disease, a panel of experts said here.

Visudyne (verteporfin for injection, Novartis/QLT) photodynamic therapy, PDT with injection of intravitreal triamcinolone, and Macugen (pegaptanib sodium injection, Eyetech/Pfizer) are all treatment options in patients with larger lesions and poorer visual acuities, panel members said. When the patient’s visual acuity is still relatively good, they said, treatment choices should be based on the individual physician’s experience and the patient’s preference.

The panel, led by Philip J. Rosenfeld, MD, here at the American Society of Retina Specialists conference, discussed a series of case presentations of AMD at increasing levels of severity. The panel members included David S. Boyer, MD; Neil M. Bressler, MD; Thomas A. Ciulla, MD; Jennifer I. Lim, MD; Elias Reichel, MD; and Steven Schwartz, MD.

Dr. Rosenfeld presented optical coherence tomography and other diagnostic images and described patient characteristics for a number of cases, and the panel discussed the best way or ways to manage each patient.

PDT was the preferred treatment for many cases, either with or without intravitreal triamcinolone. For patients with relatively good visual acuity (20/40 or better) and small lesions, most panel members recommended following the patient rather than beginning any treatment.

In cases in which lesions seemed to be progressing and visual acuity decreasing (to 20/80 or worse), the panel almost unanimously recommended Macugen as the preferred treatment. A poll of the audience, however, showed that they were fairly evenly split between preferring PDT, PDT with intravitreal triamcinolone or Macugen for these cases.

Once a patient has progressed to very poor vision (20/800 or worse) and large lesions, the panel debated whether any treatment is beneficial.

“When there’s such a low level of vision and such a large lesion, it’s not necessarily true that any treatment will be beneficial,” Dr. Bressler said. “If the patient presents with 1/200 with a large scar, are you doing anything beneficial for them?”

Dr. Schwartz agreed: “There’s no guidance on when to stop treatment altogether, or how to relate that to patient comfort.”

Dr. Rosenfeld countered, “Where’s there’s fluid, there’s hope [for improved vision].”

But ultimately, Dr. Bressler said, “If the lesion continues to progress, vision continues to deteriorate and the patient won’t notice further decline in vision, you just have to stop.”