Learning About nAMD Treatment from Individual Responses

JULY 28, 2019
Tejus Pradeep, BA
Tejus Pradeep, BA

Tejus Pradeep, BA

Early treatment, meticulous follow-up, and maintaining treatment regimens are key to visual acuity improvements in neovascular age-related macular degeneration (nAMD).

David Boyer, MD, retina specialist with Retina Vitreous Associates Medical Group in Los Angeles, presented these important take-home points in his presentation, “The Average Patient Does Not Enter Your Office: What Can We Learn About Treating nAMD From Individual Patient Responses” at the 2019 American Society of Retina Specialists Annual Meeting this weekend in Chicago, IL.

He talked about results from a variety of clinical trials, including VIEW 1 and VIEW 2, and how patients in real life often do not respond the same as those in controlled study settings. Comparing patients who responded well to treatments to those who did not, he explained that decreases in central foveal thickness were poorly correlated to improvements in visual acuity.

Rather, he explained, the “groups of patients that did the best, the ones who ended up with 20/40 vision, were the patients that actually started with good vision, so early treatment is implied.”

Additionally, central subfoveal thickness was preserved more in the group whose vision improved to 20/40 — while those whose vision did not improve had 50 microns less of subfoveal thickness. The presence of intraretinal cysts were a poor prognostic indicator of visual improvements.

Treating patients until they are “dry”, or completely free of subretinal fluid should be goal for everyone, with “under-treatment representing the leading cause for decreases in visual acuity in the long term”.

A key takeaway is that barriers in access to care and issues with treatment adherence can have long-lasting functional impacts for our patients. As Dr. Boyer writes, “several large real-world studies show that dosing in perfect accordance with published trials is unsustainable in clinical practice, with a mean of 4.3 to 6.9 anti-VEGF injections given in the first year of treatment”. He furthers, “…data suggests that patients might not be aware that adherence to the treatment regimen is needed to achieve and maintain VA gains”.1

An Australian study showed that for patients with nAMD, loss in productivity due to attending appointments was 4.4 hours each month, not included time lost by caregivers.2 Data from a 10 country collaborative cohort study showed that those living in the most affluent 5% of areas had half the odds of AMD as those in more deprived areas (OR = 0.56, p = 0.02).3

Moving forward, it is essential that our screening efforts capture those at risk for AMD, that our interventions occur as early as possible, and that we address patients’ hurdles to continuity of care so that we may ensure optimal treatment outcomes.

If we work towards these targets as Dr. Boyer outlined, perhaps the results of patients in clinical trials will soon match those in our offices.   

Tejus Pradeep is a rising fourth-year medical student at Johns Hopkins University, School of Medicine in Baltimore, MD. In 2016, he graduated from Rutgers University with a Bachelor of Arts in cell biology and neuroscience, and a Bachelor of Arts in psychology. After graduating medical school, Tejus would like to pursue a career in the field of ophthalmology. The piece reflects his views, not necessarily those of the publication.

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