Specialist Referrals and Therapy Goals for Patients With AMD

Karl Csaky, MD, PhD: Carl, that was fantastic, and there are challenges in terms of the diagnosis. Lloyd, when you go out into the community and you talk to your other health care providers and optometrists who are in the community, what do you tell them? What do you think are reasonable guidelines that would prompt other health care providers who provide eye care to say, “Dr Clark, I need to send you a patient.” What are the things that you tell them?

Lloyd Clark, MD: In terms of what we tell health care providers when there’s a concern for progression of macular degeneration include: a sudden change in vision, distortion, a lot of the symptoms that we talked about earlier. The good news is that our colleagues in primary eye care have gotten the message. We’re 15 years into anti-VEGF therapy for wet AMD [age-related macular degeneration]. If you look at clinical trial data, the presenting vision in the study cohorts has improved as the years have gone along, which means we’re getting better as clinicians at identifying these patients earlier, specific disease characteristics as have been described by my colleagues, and we’re seeing the patients sooner. There’s a significant increased awareness among our patients as well as a significant increased awareness among our referring colleagues in terms of getting these patients in with the troubling signs of wet AMD. We’re doing a much better job with wet AMD certainly than we were doing when many of our current agents were under development and approval for treatment.

Karl Csaky, MD, PhD: I agree; let’s move on. Say a patient comes into your clinic, you make the diagnosis of age-related macular degeneration. Carl, what do you think about in terms of treatment? How do you tell the patient, what are the goals, especially if it’s a patient with wet AMD? How do you discuss the goals of their therapy, and how do you go about it in terms of explaining the various options that you might have with this patient?

Carl Regillo, MD, FACS: Treatment options are limited, but the good news is, it’s already been mentioned, anti-VEGF therapy for wet AMD has changed our world for the better considerably. We’re going back about 15 years that we’ve had these drugs in our hands. As Nancy mentioned, if caught early, we can definitely change the natural course of things in such a favorable way that we can prevent severe vision loss and often improve vision if it is decreased at presentation, and it often is.

Taking a step back, there is a treatment for the dry, early/intermediate stages, and that’s the AREDS 2 vitamin supplements. These supplements do decrease the risk. It’s not a big reduction, but nonetheless there’s a slight reduction in the risk of progression to neovascular or wet AMD. Most patients with dry AMD, in the hands of the general eye care provider and not having any symptoms, should be on such a supplement that will help to decrease the risk of the advanced form, particularly the wet form. If they do convert to the wet form, as mentioned, that does prompt a referral. I recommend that the patient get seen within a week ideally, that way we can get early anti-VEGF treatment on board.

I tell patients when they first present, often there is some degree of decreased acuity, and I tell them when we start these treatments, there’s a high chance we can stop further progression and further worsening of the vision. There’s a good chance we can improve the vision to some degree, and if caught early, we can get good absolute vision outcomes, but caught later, if the disease has been around for a few months, we often can’t get quite the vision gains we hope to, to get them into a good vision range. I tell patients, this is not a cure, this is disease control, and we have to start the treatments, we do it on a frequent and regular basis indefinitely in order to get the best vision gains and keep them over time. There’s no stopping treatment unless it’s a futile situation where vision is lost terribly and there’s scarring, and then it’s not beneficial, but that’s an unusual patient.

As Lloyd mentioned, there’s a trend that we catch wet AMD earlier, when the vision is not as decreased as it used to be when patients used to present. We can get great results, but you have to keep on top of the condition. I stress to patients the importance of compliance and that it’s going to be a challenging type of treatment to come into the office on a frequent and regular basis. At this time there’s no treatment for the advanced dry form, geographic atrophy, but hopefully that will change soon. For those patients, there’s not much we can do other than help to support the way they function by having them be evaluated by doctors who specialize in low vision aids, for example. But specifically on what we can do medically as a retina specialist to treat wet AMD, it’s a challenging task for both us and our patients to keep on top of therapy.

This transcript has been edited for clarity.