New approaches bring renewed vigour to the AMD battleground

Methods to improve therapeutic efficacy, enhance patient comfort and compliance and reduce side effects in the treatment of age-related macular degeneration were among the topics highlighted in the opening EURETINA session on AMD.

Chaired by Frank Holz and Anat Loewenstein, the symposium provided a broad overview of recent innovations in the field of AMD including advances in imaging technology, home monitoring devices, optimal treatment regimens, understanding persistent fluid in neovascular AMD, and updates on developments in dry AMD and geographic atrophy.

Francesco Bandello MD, PhD, opened the session with a discussion on the morphological and functional relationship between OCT angiography (OCTA), fluorescein angiography (FA) and indocyanine green angiography (ICGA) in AMD.

Although FA remains the gold standard for the diagnosis of choroidal neovascular vessels (CNV), it is invasive and time-consuming with relatively frequent adverse events and allergic reactions associated with its use. ICGA can improve the ability to detect CNV compared to FA alone but is also invasive and time-consuming. OCT-A is quick and non-invasive and renders structural and blood-flow information in the same scan, but is not able to show leakage and artefacts can be a problem due to eye movements or blinking, said Prof Bandello.

Using all of these technologies enables a more complete picture of what is happening in the eye, concluded Prof Bandello, who said that a good morphological and structural correspondence exists between all three approaches.

The possible benefits of moving directly into a treat-and-extend treatment regimen for neovascular AMD were then outlined by Martin Zinkernagel MD, PhD.

Prof Zinkernagel said that his clinic has adopted this approach of a mini loading phase of two injections and careful extension with regular OCT monitoring for the past decade with good functional outcomes.

“It reduces the treatment burden somewhat, saving one injection in the first year in patients with good response to anti-VEGF treatment,” he said. He added that the newer longer durability anti-VEGF drugs may be especially suited to a true treat-and-extend regime.

The causes and consequences of persistent fluid in neovascular AMD were discussed by Usha Chakravarthy MD, PhD. She noted that the persistence of fluid and fluctuations in retinal thickness due to changes in fluid volume is detrimental to visual function.

“Persistent intraretinal fluid is associated with worse visual outcomes. Data from large clinical trials confirm the higher risk of fibrosis in eyes with persistent fluid and suggest increased risk of macular atrophy,” she said.

Anat Loewenstein MD, PhD, described the functional and anatomical options for home monitoring in the era of long duration treatments for AMD. She noted the increasing need for novel diagnostic methods and outlined the promising results obtained in Tel Aviv, Israel, using a new digital health model, including home-based OCT, for remote patient monitoring.

“Home OCT works well and allows us to safely extend the retreatment intervals. The patients also show excellent compliance in real-world testing of the model,” she concluded.

Kourous Rezaei MD focused his talk on latest approaches to dry AMD treatment, noting that although the disease is a major public health concern, developing treatment options is particularly challenging for a number of reasons.

“The aetiology of AMD is not well known and may be multifactorial. Disease progression is slow and variable among patients and visual acuity is not an adequate efficacy endpoint. Moreover the efficacy signal requires large controlled studies and translatable animal models are lacking,” he said.

Steffen Schmitz-Valckenberg rounded off the session with a presentation on a novel monitoring tool for geographic atrophy progression and treatment.

He noted that the monitoring of geographic lesion size expansion represents a sensitive surrogate biomarker for progressive visual loss. The automated geographic atrophy grader provides a robust, reliable, validated and easy-to-use clinical tool to precisely quantify areas of geographic atrophy and can be implemented in routine clinical use.

All registered attendees will be able to view this session via playback on the virtual platform.