Advancement in the management of wet AMD - Episode 2

Identifying a typical patient with Wet AMD

Caroline Baumal, MD: Aleksandra, what is the typical patient that you see with macular degeneration in your practice, an example of a patient who has not yet been treated for macular degeneration?

Aleksandra Rachitskaya, MD: We [at Cole Eye Center] are seeing so many more patients. The big point is that our patients are getting older and older. As we see older patients, we see more advanced stages of the disease, be it neovascular AMD [age-related macular degeneration] or even geographic atrophy. I am seeing more geographic atrophy than ever before.

When we talk about macular degeneration, our standard patient is a female Caucasian, typically in her 70s. The studies show that, as time passes, gender becomes less of a risk factor as we go into later stages of AMD. We also know that patients who have a history of smoking, or are actively smoking, are at a higher risk, and we usually see patients who also have a history of hypertension and cardiovascular disease. The other subset of patients might not be as strong, but BMI [body mass index] has been considered and if the patient has been diagnosed with other vascular diseases.

The standard patient is usually coming in, in my clinic, with vision somewhere between 20/40, 20/60, and I’m actually glad when they come in with that state of vision because a lot of times the treatments we have are very effective. Unfortunately, we still see patients, some of whom are older and have problems with their nondominant eye, when they come in with very advanced wet AMD, we often cannot bring the vision back as much as we could have if we had seen them earlier.

Caroline Baumal, MD: That’s interesting because it seems that the word is out there that we do have treatments for wet macular degeneration. People, on the average, compared to a decade ago, do tend to come in earlier. However, due to COVID-19 [coronavirus disease 2019], I feel like I have been seeing patients later again. Maybe it is the patients with later stage AMD that really stick in your mind.

Dr Singer, I know you are in a busy practice [at the University of Texas at San Antonio]. On the average, how many injections do your patients get a year for neovascular AMD? Do you have any insight into that?

Michael Singer, MD: It is about 8 or 9 [injections] a year. I typically start with 3 loading doses. Depending on whether they are dry, I will extend them out every 2 weeks with typical treatment extensions. If I start seeing increasing fluid or decreasing vision, I may contract by 2 weeks, and obviously, if I happen to see a huge hemorrhage, then I am going back to monthly injections until we get this stabilized.

Caroline Baumal, MD: Do you treat differently if it is intraretinal fluid versus subretinal fluid?

Michael Singer, MD: I do. Essentially, my initial goal is to get rid of all the fluid. From lots of studies that have been conducted, such as the work we [at the University of Texas at San Antonio] have done with the VIEW trial, and what Nancy Holekamp, [MD,] in Boston has done with HARBOR, we can see that there are patients who have chronic subretinal fluid who actually have no effect on vision. The reality is subretinal fluid is something I am going to end up with. If I have given you 3 shots and I see the same subretinal fluid at a month and it has not changed, if your vision is the same, I’ll try extending it out. I also use the patient as the guide because they look at the OCT [optical coherence tomography] at every visit. By that time, they’re starting to get shot fatigue because it’s about the fifth or sixth injection. They are then pushing me to go out a little bit and I am pushing to go out, but if anything changes, then I contract back.

Caroline Baumal, MD: That is great. You teach your patients how to read the OCT. That is a good skill.

One thing you mentioned is shot fatigue. It is very hard for patients to keep up the treatment regimens that are in a lot of clinical studies. We do not stop following patients at 1 or 2 years; we follow patients for decades.