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BLOG: Telemonitoring allows for earlier detection and timely treatment of AMD
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Recently, I have predicted that telemedicine is poised to become more routinely used in our management of age-related macular degeneration patients. We know that in order to make a significant difference in a patient’s quality of life, we must detect the progression from dry AMD to the wet form of the disease immediately after conversion.
Home monitoring with telemedicine
I have incorporated home monitoring with the ForeseeHome (FSH, Notal Vision) adaptive preferential hyperacuity perimetry test into my management plan for AMD to help preserve my patients’ vision and quality of life. Patients in the intermediate stage of dry AMD do not typically convert to wet AMD when they present in the clinic for follow-up appointments, and therefore telemonitoring gives me the ability to monitor and protect their vision between scheduled visits. Telemonitoring with the device to detect metamorphopsia associated with choroidal neovascularization (CNV) in at-risk patients was validated in the AREDS2-HOME study.
The study randomized 1,520 patients to test their eyes daily with the FSH along with standard testing vs. standard care alone (this was based on the investigator’s preference, usually routine visits, Amsler grid testing and self-reporting symptoms). In the group using FSH at the recommended frequency, at least twice weekly, 94% maintained 20/40 or greater visual acuity at the time CNV was detected compared with 62% of patients assigned to the methods of standard detection.
The HOME study was stopped at the interim analysis because patients using FSH demonstrated significantly better vision at CNV detection compared with standard care alone, and thus patients from the control arm were offered use of the device. The FSH is the only remote vision monitoring device with FDA clearance, Medicare coverage and level 1 scientific evidence.
Evidence for benefit of earlier detection
A review of the clinical data confirms that visual acuity at the time of wet AMD diagnosis strongly predicts visual acuity after 1 and 2 years of anti-VEGF treatment. A meta-analysis by Liu and colleagues, however, estimated that patients had wet AMD on average for 7.7 months before entering clinical trials. The duration of exudative disease determines CNV lesion size, which in turn correlates with visual acuity. With early detection comes smaller lesions, which typically correlates to better visual outcomes.
A further look at the data reveals that in the clinical trials, relatively few eyes with CNV were detected when visual acuity was still relatively functional (ie, driving vision), 20/40 or greater. In fact, only a small group of patients begins with functional vision. This significant gap provides us as retina specialists with an opportunity to catch the disease earlier to preserve vision. Using data from the American Academy of Ophthalmology’s IRIS Registry, which analyzed more than 160,000 eyes, Ho and colleagues performed a real-world retrospective cohort analysis to characterize visual acuity upon diagnosis of new-onset wet AMD.
The mean baseline visual acuity at the time of wet AMD diagnosis was 20/83, and less than 35% of all eyes had a visual acuity of 20/40 or better at the time of wet AMD diagnosis. When the second eye converted, its outcome was just slightly better than the first — 20/79 — even when patients were managed by a retina specialist. The investigators noted that relatively poor mean visual acuity at diagnosis corresponds with previously reported baseline visual acuity from the IRIS Registry.
Intermediate AMD
Because visual acuity at the time of wet AMD diagnosis is the best predictor of visual outcomes following anti-VEGF treatments, it is imperative that all of the eye care providers involved in the patient’s management team are doing their part to identify and follow patients who are at risk.
Certainly, a change in visual acuity is an important measure when evaluating efficacy in clinical trials of treatments, such as anti-VEGF clinical trials, but functional vision is what truly matters to our patients. Those who are eligible to be monitored with ForeseeHome, should be given the opportunity to learn about the technology. Eligible patients have intermediate dry AMD with a visual acuity of at least 20/60 in the testing eye(s).
Conclusion
When we consider what is at stake for our AMD patients, it becomes clear that we need to take advantage of technological advances that enhance and streamline our ability to monitor their vision. From the data, it can be hypothesized that many patients have neovascular AMD for months before it is diagnosed and potentially treated. This is devastating to their visual prognosis and quality of life.
When we provide our patients the opportunity to use technology to monitor their vision and use the data generated by their testing results, we can achieve a superior level of care. If we can detect wet AMD at the earliest possible moment, we have the potential to treat a less-aggressive disease and improve the benefit of anti-VEGF therapy, while reducing the burden of injections and ultimately preserving functional vision.
AMD patients have a high amount of anxiety about their disease, and they greatly appreciate knowing that I am watching out for them on a daily basis. Their comfort level is a big part of my motivation for incorporating FSH in my practice.
References:
AREDS2-HOME Study Research Group, et al. Ophthalmology. 2014;doi:10.1016/j.ophtha.2013.10.027.
Ho AC. Retrospective analysis of real-world disease detection and visual acuity outcomes in patients with dry AMD converting to wet AMD using the AAO IRIS Registry database. Paper presented at: ASCRS Retina; April 15, 2018; Washington.
Liu TY, et al. JAMA Ophthalmol. 2013;doi:10.1001/jamaophthalmol.2013.818.
Rao P, et al. Ophthalmology. 2018;doi:10.1016/j.ophtha.2017.10.010.
Ying GS, et al. Ophthalmology. 2013;doi:10.1016/j.ophtha.2012.07.042.
Ying GS, et al. Ophthalmology. 2015;doi:10.1016/j.ophtha.2015.08.015.
Disclosure: Mali reports he is a consultant, speaker and stock shareholder for Alimera Sciences, a consultant for and recipient of research funding from Allergan, a consultant and speaker for Genentech, a consultant, speaker and stock shareholder for and recipient of research funding from Regeneron, a consultant and speaker for and recipient of research funding from Notal Vision, a consultant and speaker for Sun Pharmaceutical Industries, and a consultant and speaker for Macular Degeneration Association.