Apr 7, 2021


Welcome everybody, to Dr. Mali’s AMD awareness month podcast series. I’m your host, Dr. Joshua Mali. It’s an honor to be here today to present to you a great podcast series in which I hope to provide a unique perspective into age-related macular degeneration and its management. I like to present this podcast in two parts. This will be part one in which I’ll discuss the clinical aspects of AMD and how eye care professionals can present AMD to patients and how to help them to understand AMD and all the treatments and how to explain to patients and really provide a great overview of how to manage AMD in eye care professionals practice. Part two will actually be an interview with one of my patients. And I think that’s almost just as important as the clinical side, is really the patient side and the patient perspective and how AMD really affects patients lives and how they’re able to overcome that and live full lives.

So, I want to provide both perspectives and I think that’ll be a very unique podcast series, providing all different angles of AMD management. So without further ado, I’d like to give you a little background on me. I’m a board-certified ophthalmologist and fellowship-trained retina specialist. I did my undergraduate and medical school training at West Virginia University. Let’s go mountaineers. I did my ophthalmology fellowship and residency at Albany Medical College in Albany New York. So I did my ophthalmology residency at Albany medical college and then stayed on board with Retina Consultants and Albany Medical College in Albany New York to do my surgical retina fellowship. And then I moved on to private practice in Sarasota, Florida. And I’ve been here since. You know, frankly, AMD is the most common diagnosis that I see here. So it’s really near and dear to my heart and I really strive to give my patients the best possible treatment and care that they need to really live their lives to the fullest.

I think it’s important to that holistic approach and really provide patients not only with great clinical care but also, education and motivation to stay compliant with treatments and to maintain their great vision. So for me, I really try and take that holistic approach in the way I manage patients. And so, I’d like to kind of, you know, go over the things that I’ve learned throughout the years and through my training and now in private practice and how I talk to patients, how I present to them their diagnosis of AMD, how to get them through that journey and the kind of tips and tricks that I’ve picked up throughout the years as well, to sort of help that process to be as smooth as possible and make it a good experience.

I think it’s important. We have these sight-threatening conditions that can really affect people, not only physically, but also emotionally and psychologically. And I think it’s really important to keep those things in mind whenever we’re presenting these conditions to patients. And I think it’s about how you do it and the steps you take to implement to do that in that process, which really can determine how a patient can overcome it. And I think that’s really an important part of the battle with conditions like AMD. So the way I usually present, you know, when I see a patient that comes to the door with AMD, I first obviously I talk to them about the two forms of AMD. I break it down very simply that there’s a dry form and a wet form.

So let’s start with a dry form first. So when a patient has dry AMD, I always make sure to tell them that this is obviously the more common form of AMD. Just going on the numbers, there’s a lot more patients in the world that have the dry form of AMD than the wet form. So that hopefully helps to decrease the anxiety a little bit there. And I always do a complete eye exam, full dilated eye exam. I think it’s so important that we carefully examine our patients each and every time they come. I always get an optical coherence tomography or OCT scan on each and every patient with AMD. I think that’s a really important factor that I’ve found, is that you’re able to pick up very subtle changes in retinal anatomy when you get an OCT scan on every AMD patient.

And then finally when I counsel patients about okay, you know, they have AMD, you know, I think it’s really important that you be careful with that word, you know, with age-related macular degeneration or AMD, you want to be really careful with how you say it because when patients hear that word, they really get very scared and anxious. But I think if you provide good education upfront, I think that helps to alleviate their anxiety. So I talk about the things that they can control or I talk about risk factors that they can really address or be aware of. And so when I talk to patients, I like to really kind of give them the key phrases that they can remember. So I always use this kind of acronym called the big three, I would talk about the big three.

So the big three risk factors for AMD. And so you know, this is really three things that I really want to hammer home. I know there are other risk factors that we can consider that are probably less I guess, less important, but these are the three risk factors that I want them to remember. And these are the ones that are really the most important because you’re going to want them to have a good background on their disease and what makes it worse and what to keep in mind. And what they can tell their family members whenever they want to discuss their condition. So, the big three that I call the three big risk factors for AMD are age, so advancing age. And again, they can’t do anything about that unless they come here to Florida and they go through the fountain of youth.

But, you know, really, there’s no way to change your age, obviously. So that’s a risk factor to be aware of, but again, it’s nothing that they can do about it. The second thing is genetics. So obviously we know that there’s a genetic component to AMD. It typically runs in families. And again, that’s another thing they can’t really control. So those are the two big risk factors that they clearly can’t control, but I want them to be aware of those two. And then finally, this is the one that they can control and this is the one that I really stress that they really want to focus on is smoking. So, we know that smoking is a really big risk factor. It’s a big-time environmental risk factor for their bodies overall, but in particular, for AMD, we know it makes it worse for sure.

And even if patients can quit, even after being a smoker for many years and they quit, they can certainly help their eye disease and condition and their AMD. So really, I stress to patients that smoking is one risk factor of those three that they can actually control. And so that’s the one they should really focus on and implement. And I remember, you know, giving talks around the country. And I remember at one particular talk, I was able to get that message across to patients and the audience. And I remember they came up after the discussion afterward, and they just kind of thanked me for really hammering home that point about smoking, and they actually made a pledge to stop smoking after that talk. So, you know, that makes a big difference, what we say makes a big difference.

And I think that if we could even change one patient’s mind with, you know, even if you tell a thousand patients to stop smoking and only one of them does, you’re still making a big difference in that patient’s life and keeping their sight for as long as possible. So, I certainly hammer home that, that smoking factor. And then finally, when we talk about treatments, you know, dry AMD right now there are some experimental things going on with complement inhibitors that are in the final stages. But overall, we don’t have anything, you know, whether it’s geographic atrophy or, you know just kind of moderate early dry AMD, you know, we don’t have any active treatment. But there are another big three that I recommend in regards to quote on quote treatments, which are number one, to take AREDS 2 vitamins.

And I always mention to patients that, you know, in the clinical trials, that they saw that about 25% of patients were able to lower the risk of progression to more advanced forms of AMD when they took AREDS 2 formulation vitamins. So again, very important factor. You always want to make sure that they’re taking an AREDS 2 vitamin again if they’re moderate or severe. And that’s kind of I think, a very confusing point to patients because some patients think that they should be taking it even if they have early stages of AMD, which technically the study didn’t really look at that. They didn’t see any benefit for early AMD patients. So, I think it’s that proper education upfront helps to clear up any confusion about that. So, it’s really only for moderate and severe dry AMD patients.

The second factor or second treatment I should say is to really stop smoking. And again, I kind of include other environmental things in this, you know, I say good diet, exercise, sunglasses are important. But really the smoking part to stop smoking, is really kind of the key thing there that you want to highlight. And that you can really make a big difference in their disease modification. And then finally, the third thing of the big three in regards to treatment is some sort of home monitoring system. So traditionally we have the Amsler grid to help monitor patients vision at home where they check each eye individually. And so you look at the grid paper, make sure the lines are nice and straight. If they ever become wavy or distorted, they want to give the office a call right away.

But I’ve actually also utilized a fairly newer home monitoring system called the Foresee home device, which is based on a combination of artificial intelligence and telemedicine in order to monitor patients at home. And it’s been shown in a large study to be very effective. In the home study, actually, it showed that over 90% of patients were able to maintain 20 or 40 vision, upon wet AMD diagnosis as compared to about 60% of patients that were on the Amsler grid only. So clearly it has a much better efficacy rate and monitoring rate than the traditional Amsler grid. So, I like to use the Foresee home device for patients that meet the qualifications. There are certain criteria that they have to meet in the dry AMD realm. But I found it to be very effective and I have many patients on it, and if there’s ever a change in either eye, it alerts my office and me directly.

And I’m able to get patients in to be seen and diagnose wet AMD upon initial event. So, it really helps to fine-tune that kind of communication between finding things a lot sooner, and you always get a better outcome that way. So, I really like the Foresee home device as a good monitoring at home for patients with moderate to severe dry AMD. So that’s kind of the way I manage my dry AMD patients. I always like to also involve their caregiver as well in these conversations, if possible. I think it’s really important to get the patient’s family involved if they’re there at the appointments to make sure they understand things. I like to have those discussions amongst all the caregivers, as well as the patient, to have that discussion, because we’re all in this together, we’re all kind of a team effort.

Now we talked about wet AMD. Again, this is that kind of devastating diagnosis that people always worry about. And I mean, frankly, I think it’s been a lot more publicized than dry AMD, but it gets really all the headlines, but of course, as we know, it’s less common, right? If it affects much less people as compared to AMD, but it’s responsible for the vast majority of visual loss that we see in AMD. It’s rightfully so it gets all the headlines. And it’s just growing in epidemic proportions of patients that are getting this disease. So really, it’s one that we have been focusing our treatments on and it’s really one that we’ve come such a long way and with our new treatments available.

So, when I talk about treatments for wet AMD, I always tell patients that15 years ago or so we really didn’t have any great treatments. It was kind of a cold laser that didn’t do much or just people would lose vision from that. Really now that we have anti-VEGF agents like Eylea, Lucentis, Beovu, Avastin. We’ve really revolutionized the way we treat patients and we’re able to regain vision as well as preserve vision for the long run. So, I mean, it’s just been such an exciting and blessed time to be a retina specialist at this time where we have all these great treatments available, and we’re able to get these to patients to save their vision.

I think the idea of an eye injection is certainly an anxiety-provoking situation for patients. But I really think just talking with patients, describing the procedure itself, and frankly, a lot of them have already sort of heard about it, even before they walk in the door because I mean, some of their friends that may have gotten it, gotten eye injections and so forth. And I think that it’s actually made my job a little bit easier because the injection idea is more pervasive out in the community. So I think it’s certainly one of the things that you have to talk to patients about. And I think that helps to relieve anxiety. I think as retina specialists, we all do things a little bit differently in regards to anesthesia techniques for the injections and how we actually do the injections.

But I think the most important thing to remember is setting patient expectations. So I always describe to patients the way I do things. I talk about my procedure, the way I do it, my technique, but I think the key thing is what to expect. The most common question that I get probably is doc, how long do I have to be on these shots for? It’s kind of the main thing. It’s always obviously a very difficult question to answer, but I think the key thing here, is you want to just tell them exactly kind of what your strategy is. And I think for most retina specialists, we use a treat and extend, treating regiment where we start out with monthly injections until the disease becomes quiescent. And then we extend those injections out by one or two weeks, each visit they come and we’re able to get patients out further and further on the shots, to much less frequent intervals such as 12 weeks.

And I think for me, I always like to describe that treating extend treatment strategy. I don’t know if a lot of specialists go into those details, but I think it’s important that patients are aware of what I’m thinking, why I’m thinking and why I’m doing what I’m doing. So I like to always tell them that, Hey, we’re going to be on monthly shots initially, but my goal is to extend these injections to go out further and further, each time you come. Once your disease is inactive and hopefully get to a point where on a maintenance treatment of every 12 weeks, and then we can have the discussions about possibly continuing every 12-week dosing or sort of a PRN or as needed treatment regimen. So I like to tell them upfront about that because then they have expectations going in.

And I think that’s a really important thing to set. And again, I don’t think it’s really heavily discussed, but I think that’s an important point, that I think would help to give them some clarity on what we are doing as eye care professionals, as well as give them a set of expectations so that they know, okay well I’m going to stay compliant with my treatment regimen, and I’m going to make sure that I get the proper care. So that way I’m able to be extended out further and further. It’s sort of like a goal for them. And that’s a really important thing to do. And I found my practice that it’s been, it’s been so helpful to do that. What’s great is that we have these four great treatments already, and we have some more that are on the way.

A couple of ones that are in the final stages, like Faricimab, which is potentially an every 16-week dosing agent, which is a combination anti-VEGF and Ang2 treatment made by Genentech as well as the port delivery system, with ranibizumab, which is also a Genentech product. That’s an implant that can be refilled in the office and potentially could be every six months refilling process of Anti-VEGF that slowly releases the anti-VEGF into the eye over that period of time and keeps patients stable. So again, the goal is to just reduce the patient injection burden, but maintain still our robust visual gains with these longer-acting treatments. But I mean, I would have to say that we have fantastic anti-VEGF treatments, and it’s just really exciting to see all the focus on this treatment of this condition and all the advances we made in such a small amount of time.

I mean, it takes years and years to really develop these kinds of molecules, and the fact that we’ve had so many and we’re able to deliver these to patients. It’s just been an incredible and incredible experience. So kind of, in a nutshell, that’s the way I talked to patients about AMD. Kind of the additional pearls I like to present to eyecare professionals, as well as patients. And I hope that this discussion has been very helpful from a clinical standpoint and stay tuned for part two. We’re actually going to talk to one of my patients directly and gather their perspective on the patient journey and to get that perspective. So, it’s been such a pleasure to have everybody today and please stay tuned for part two. And thank you very much. Looking forward to continuing the journey with you.

This material is the property of Ophthamolgy360-permission to use this must be obtained from ophthamology360 and you may listen to the podcast here: https://ophthalmology360.com/amd-awareness-month-part-1

Joshua Mali, MD- Macular Degeneration Association-Medical Director-Retina

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