The 101 on wet AMD treatment, from identification to the best treatment regimen. Goal: to support patient education around retinal disease.
Identifying and referring for wet age-related macular degeneration (AMD) are among the most important actions an optometrist can take in a patient’s ocular health; understanding how best to treat such a patient while not disrupting his or her life ranks among the most difficult equations a retina specialist must balance. Here, Jeffry Gerson, OD, FAAO, and Christina Weng, MD, MBA, discuss their respective roles in the spectrum of wet AMD management.
Knowing When to Refer Wet AMD Patients
By Jeffry Gerson, OD, FAAO
Retina specialists will often identify wet AMD patients on routine examination or when a patient visits the office reporting a visual disturbance. As primary eye care providers, it is our job as optometrists to correctly identify disease and determine when it is appropriate to refer to a retina specialist. Here are three items to consider when examining a patient with wet AMD.
1. Confidence in Diagnosis
How confident are you in identifying wet AMD on OCT or funduscopic examination? If you have even a mild suspicion that the patient has wet AMD, or if you are unsure about the results of your clinical examination, then referral to a retina specialist is appropriate. Of course, if you are confident that a patient has wet AMD, then prompt referral is necessary.
2. What to Look for on Examination
OCT imaging and funduscopic examination are effective tools for identifying AMD patients. For clinicians with access to OCT imaging, fluid under or within the retina should trigger a referral. For those who do not have access to an OCT platform, a thorough fundus exam yields useful data. Thickening or elevation of the retina and discolored tissue may be evidence of disease activity.
3. Thinking Outside the Box
In optometric training, many of us are taught to look for green-gray lesions during fundus exams. However, it should be noted that lesions can have other appearances. Don’t limit yourself to this green-gray framework. Any other retinal abnormalities that may raise a red flag are worthy of referral.
PREPARING YOUR PATIENT FOR REFERRAL
As a clinician who has likely fostered a long-term relationship with a patient, it is your job to prepare them for care outside the optometric clinic. I find these three steps useful when referring patients to an ophthalmic colleague.
1. Explain the referral.
I tell my patients that I am referring them to a retina specialist whose career has been dedicated to their particular disease. I reassure them that this is not the end of the patient-optometrist relationship.
2. Mentally prepare the patient for treatment.
I explain to a patient that the usual treatments for AMD require an injection into the eye. I find that when not explained appropriately, this creates more anxiety than the diagnosis itself. If I don’t tell the patients about the forthcoming intravitreal injection, they may research on their own and decide against visiting a retina specialist out of fear. Which brings me to a third step…
3. Serve as an educator for the patient.
Patients are navigating unfamiliar and scary territory when they hear that they have wet AMD. Arm them with information, and use your education to comfort them. Commonly, patients are scared of injections. Reassuring them that intravitreal injections are among the most commonly performed procedures and are generally minimally (if at all) uncomfortable will help assuage their fears.
THE SOONER, THE BETTER
Patients with wet AMD must be treated promptly. As optometrists, we have the opportunity to identify disease patterns and set up patients for success with referral. Let’s get to work.
Deciding on the Best Treatment Regimen for Wet AMD Patients
By Christina Weng, MD, MBA
The pharmacologic standard of care for wet AMD is highly effective: the decade-plus body of evidence that anti-VEGF agents can effectively treat this disease shows this. The challenge retina specialists often encounter, however, concerns treatment frequency—specifically, if a patient should be treated monthly, as-needed (prn), or via a treat-and-extend (TAE) schedule.
MONTHLY THERAPY
Major clinical trials evaluating the safety and efficacy of anti-VEGF therapy for wet AMD treatment show that monthly therapy is very effective.1-3 However, not all patients require monthly injections, and unnecessary injections put patients at risk for complications such as endophthalmitis and retinal detachment. Furthermore, the burden of visiting the office on a monthly basis is significant, particularly for patients who need someone to accompany them to the clinic.
PRN THERAPY
In the strictest sense, prn regimens require monthly visits in which a patient receives treatment only if there is indication of disease activity; in reality, many patients do not follow this visit regimen and may present less often. Several clinical trials have demonstrated that prn therapy leads to inferior visual acuity compared with monthly therapy.4 Therefore, despite the potential decreased treatment burden offered by this regimen, I generally do not treat my patients on a prn basis, although patients who have been stable and inactive for a long time can do well with this approach.
TREAT-AND-EXTEND THERAPY
When a patient is newly diagnosed with wet AMD and a TAE regimen is decided upon, he or she typically receives three monthly loading doses with an anti-VEGF agent. When the patient returns for the fourth monthly visit, OCT imaging is performed, and an injection is administered. If no fluid is present on OCT, then the patient returns in 6 weeks for the next injection. If fluid is observed on that visit, then an injection is administered, and the patient is advised to return in 4 weeks. If there is no fluid, however, then an injection is administered and the patient is asked to return in 8 weeks. Note that with the TAE regimen, a patient receives an injection and OCT at each visit; the treatment intervals are typically extended or shortened by 2 weeks, guided by presence or absence of fluid on OCT.
The TREX-AMD study showed that TAE regimens led to visual and anatomic gains that were comparable to those of monthly treatment regimens in the treatment of wet AMD.5 The burden of office visits and injections may be reduced if a TAE course is initiated.
WHICH REGIMEN IS BEST?
The personalized nature of wet AMD therapy requires retina specialists to weigh the costs and risks of treatment against the potential benefits.
Although I do not typically treat patients on a fixed monthly regimen, there are exceptions. For example, if a monocular patient with wet AMD were to present to my clinic, I would prefer to use this more aggressive strategy in lieu of one that places less burden on the patient.
At present day, retina specialists often opt for a TAE regimen, as it represents a marriage of the benefits of monthly and prn regimens while mitigating the risks of undertreatment and excessive burden. It essentially allows the physician to individualize treatment for each particular patient, maximizing the likelihood of success, and minimizing the risk of treatment-related complications and noncompliance.
CONCLUSION
Each patient’s needs are unique to them, and the art of medicine requires health care providers to tailor therapy to each individual. Given the body of data we have on different treatment regimens, optometrists and retina specialists can make an informed choice when the time comes for referral and treatment.
1. Brown DM, Kaiser PK, Michels M, et al; ANCHOR Study Group. Ranibizumab versus verteporfin for neovascular age-related macular degeneration. N Engl J Med. 2006;355:1432-1444.
2. Rosenfeld PJ, Brown DM, Heier JS, et al; MARINA Study Group. Ranibizumab for neovascular age-related macular degeneration. N Engl J Med. 2006;355(14):1419-1431.
3. Heier JS, Brown DM, Chong V, et al; VIEW 1 and VIEW 2 Study Groups. Intravitreal aflibercept (VEGF trap-eye) in wet age-related macular degeneration. Ophthalmology. 2012;119(12):2537-2548.
4. Schmucker CM, Rücker G, Sommer H, et al. Treatment as required versus regular monthly treatment in the management of neovascular age-related macular degeneration: a systematic review and meta-analysis. PLoS One. 2015;10(9):e0137866.
5. Wykoff CC, Croft DE, Brown DM, et al; TREX-AMD Study Group. Prospective trial of treat-and-extend versus monthly dosing for neovascular age-related macular degeneration: TREX-AMD 1-year results. Ophthalmology. 2015;122(12):2514-2522.
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