Lapse in care may yield lost visual acuity in AMD
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Patients with neovascular age-related macular degeneration who have a 3 month or longer lapse of anti-VEGF treatment may experience unrecoverable loss of vision, according to a study.
“We saw significant loss of vision, even for those who were initiated back on anti-VEGF therapy after these lapses,” study co-author Rishi P. Singh, MD, told Healio/OSN.
The retrospective study included 241 patients in the study group and 241 control patients. The researchers evaluated macular thickness measured by central subfield thickness (CST) and visual acuity at baseline, at the first post-lapse appointment, and at 3, 6 and 12 months after the lapse.
The average length of lapse in the study group was 5 ± 3.7 months.
Mean best corrected visual acuity (BCVA) at baseline in the control group was 59.2 letters compared with 58.9 letters in the study group. Mean CST at baseline in the control group was 259.8 µm compared with 252.4 µm in the lapse group.
BCVA decreased at each timepoint after lapse in the study group. At 12 months after the lapse, the mean BCVA in the study lapse group was 51.2 ETDRS letters compared with 57.1 letters in the control group. The mean CST at 12 months was 258.8 µm in the lapse group compared with 250.8 µm in the control group.
The loss of visual acuity in the study cohort from baseline to 12 months, 58.9 to 51.2 letters, was a statistically significant decrease (P < .01).
After resumption of anti-VEGF therapy, CST in the lapse cohort normalized through 12 months of follow-up; however, visual acuity loss did not recover.
The study, which was conceived before the pandemic, was aimed at understanding the effect a lapse in treatment has on patients with neovascular AMD, Singh said.
“Obviously with the COVID pandemic this becomes far more relevant. Patients were missing 3 months of therapy because of the pandemic and fear of coming in to see us,” Singh said.
Perspective
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Jason Hsu, MD
Treatment lapses and loss to follow-up are fairly common among patients being treated with anti-VEGF agents. A study performed by my group previously found that almost a quarter of 9,007 neovascular age-related macular degeneration patients were LTFU for more than a year or never returned after receiving an anti-VEGF injection, driving home the magnitude of the problem. But this is just the tip of the iceberg.
Ultimately, the question is how bad is it to have a treatment lapse? My research team previously published a study demonstrating that neovascular AMD patients with treatment lapses of more than 6 months had permanent vision loss that generally could not be recovered even after resumption of anti-VEGF injections. Rishi Singh and colleagues performed a commendable study exploring the effects of shorter treatment lapses lasting 3 or more months. What is most concerning about their study is that even relatively short treatment lapses correlated with more than a line of vision loss that also could not be recovered even after restarting therapy.
It is critical to continue to study the issues surrounding treatment lapses and LTFU so we can better understand who is most at risk and what, if anything, can be done to improve patient compliance with care. Fortunately, we may be entering a new era in the management of neovascular AMD. Longer-term delivery devices and new drugs with extended duration of effect are on the horizon and may decrease the burden of treatment for patients. Similar to studies showing that patient compliance is generally better with medications that require less frequent dosing, I expect these developments in the AMD arena will have a similar positive impact on our patients’ quality of life and outcomes.
References:
- Greenlee TE, et al. Retina Phila Pa. 2020;doi:10.1097/IAE.0000000000002888
- Obeid A, et al. JAMA Ophthalmol. 2018;doi:10.1001/jamaophthalmol.2018.3578.
- Soares RR, et al. Ophthalmol Retina. 2020;doi:10.1016/j.oret.2019.07.010.
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