Treatment

of
Age-Related Macular
Degeneration (AMD)
• The various treatment options for AMD depend on the type and stage of
AMD that is present.
• At this time, the only treatment for dry AMD is high dose antioxidant
vitamin therapy.
 AMD – Non-Neovacular Therapy
• Education and follow up soft drusen and RPE hyperpigmentation are at
increased risk of developing GA and CNV.
• Macular laser photocoagulation can stimulate drusen resolution/reduction but
there is no associated changes in natural course of vision loss/CNV development.
• Inhibiting complement pathway using lampalizumab also are not effective in
preventing progression of the disease.
• One of the study called Age-Related Eye Disease Study (AREDS) was
initially conceived as a long-term multicenter, prospective study of the
clinical course of AMD.
• Micronutrients
• reduce risk of vision loss in nonexudative AMD
• 25% risk reduction for more- advanced stages of AMD 19% risk reduction
in rates of moderate vision loss (≥3 lines of visual acuity) at 5 years.
 AMD – Neovascular Therapy
• Laser photocoagulation (“thermal laser”) argon/diode only in very rare
instances, have poor outcomes high recurrence rates
• Photodynamic therapy (“cold laser”) – FFA classic predominant. Slows
progression, does not prevent significant vision loss. No visual
improvement.
• Antiangiogenic therapies : anti VEGF
• Pegabtanib slowed vision loss, but there
are more effective agents.
• Ranibizumab binds and inhibits all
active isoforms of VEGF- A as well as
their active degradation products
• Treatment effects declined in participants
undergoing quarterly (every 3 months)
ranibizumab dosing as opposed to
monthly dosing. These results suggest
that quarterly treatment is suboptimal
• Aflibercept VEGF Trap) acts as VEGF receptor decoy. Administered
every 2 months showed similar efficacy to ranibizumab administered
monthly
• Bevacizumab treatment of metastatic colorectal cancer. Used “off- label”
Was noninferior to ranibizumab therapy monthly but with 40- fold lower
costs.
• MARINA  the result demonstrate thet vitreal Ranibizumab is associated
w/ clinically and statistically significant benefits w/ respect to VA in
patients w/ minimally classic/occult lesions w/ no classic CNV associated
w/ neovascular AMD over a 2-year period
• ANCHOR  demonstrated efiicacy in patients w/ subfoveal,
predominantly classic CNV associated w/ neovascular AMD over 2-year
period
• HARBOR  benefits of Ranibizumab for neovascular AMD outweighed
the risk of macular athrophy development over 24 months.
• CATT  At the conclusion of the trial, the study demonstrated no
significant difference in visual acuity changes between the groups
randomized to Ranibizumab or Bevacizumab.
 Treatment Regimen

• Best outcome  fixed dosing (patient burden , compliance )

• Clinical practice  compromise, maintain best visual aquity (VA)
• PRN, treat & extend
 Pro-Re-Nata (PRN)
• PRN
• Treatment as-needed or pro re nata (PRN) treatment is one of these strategies where
patients receive fewer injections
• Treat on disease reactivation
• Monthly visit
• Injection is determined by a recurrence of the ME as assessed mainly by optical coherence
tomography (OCT)
• Retreat criteria is important (VA Protocol T > RESTORE)
• Reduce the stress and financial cost
 Treat & extend
• Treat & extend
• Proactive, prevent recurrence
• Injection every visit
• Interval between visit ~VA, OCT
• Reduced frequent of visit  manageable for patient
• As Needed Regimen Ranibizumab: 3 consecutive monthly injection of 0.5 mg
ranibizumab  follow up monthly  retreated if there is increase of 100
microns/loss of ETDRS VA 5 letters/more. 2nd year  retreatment if any
qualitative increase in amount of fluid detected on OCT. Mean VA at 1 year
increased 7 letters with mean injection of 5.3 (including 3 loading injection)
• Treat and Extend Regimen Ranibizumab: 3 loading dose and increasing treatment
of injection up to 12 week if not fluid is present. If there is fluid then we
decreased follow up time
• Comparing these 2 strategy : Treat and extend have better VA increased +10.8 vs
+2.3. With significantly more injection 7.8 vs 5.2.
• Avoid VEGF if there is high risk of recent stroke/heart attack. Have risk of
endophthalmitis.
• About 10% of patients might still lose significant amount of vision despite 2
years of monthly anti VEGF  these are called nonresponders. Signs :
aggressive form of wet AMD - RAP, tachyphylaxis to anti VEGF agents,
genetics.