Continue Anti-VEGF Therapy with OCT-Guided Monitoring
For this patient with both glaucoma and neovascular AMD who has been receiving repeated intravitreal anti-VEGF injections (Eylea), the next step is to continue anti-VEGF therapy using OCT-guided monitoring to assess disease activity, while optimizing glaucoma management and considering treatment interval adjustments based on response 1.
Treatment Strategy
Anti-VEGF Management
- Continue intravitreal anti-VEGF injections (aflibercept, ranibizumab, or bevacizumab) as the mainstay of neovascular AMD treatment
- After initial loading doses, adjust treatment intervals based on clinical findings using one of three protocols 1:
- Treat-and-extend: Gradually extend intervals based on treatment response (most commonly used)
- PRN (as-needed): Based on presence/absence of subretinal or intraretinal fluid on OCT
- Fixed bimonthly: After three loading doses at 4-week intervals, aflibercept can be given every 8 weeks
Essential Monitoring at Each Visit
- Best-corrected visual acuity at distance
- OCT imaging to detect subretinal/intraretinal fluid, which is the primary indicator of disease activity 1
- Amsler grid testing for metamorphopsia
- Stereoscopic biomicroscopic fundus examination
- Fluorescein angiography when clinically indicated for disease progression assessment
Safety Considerations with Concurrent Glaucoma
Anti-VEGF therapy is safe in patients with concurrent glaucoma 2. Research demonstrates that intravitreal ranibizumab and aflibercept have no negative influence on the functional state of the visual pathway in patients with neovascular AMD and primary open-angle glaucoma, even in advanced stages 2.
Glaucoma Management Optimization
- Ensure IOP is adequately controlled with current glaucoma therapy
- Monitor optic nerve status given the dual pathology affecting vision
- Consider that brief IOP elevation during injection is generally well-tolerated but document baseline optic nerve status 3
When to Consider Treatment Modification
Switching Anti-VEGF Agents
If suboptimal response after 3-6 months:
- Consider switching between aflibercept, ranibizumab, or bevacizumab
- No significant difference in safety profile between agents 2
- Newer agents (brolucizumab, conbercept) may offer longer duration 4
Criteria for Treatment Discontinuation
Only consider stopping anti-VEGF therapy if 5:
- Disease remains inactive (no intraretinal/subretinal fluid on OCT) for at least three consecutive maximum treatment intervals
- No deterioration in vision
- No new retinal hemorrhage
Continue treatment if:
- Disease remains active despite stable vision
- Patient has only one good seeing eye
- History of disease recurrence
- Fellow eye has advanced AMD
Critical Pitfalls to Avoid
Do not discontinue anti-VEGF therapy prematurely - Vision often declines with disease progression even with treatment, but stopping too early accelerates deterioration 6
Do not rely solely on visual acuity - OCT findings of fluid are more sensitive indicators of disease activity than vision changes alone 1
Do not overlook the fellow eye - With advanced AMD in one eye, the fellow eye remains at exceptionally high risk and requires monitoring every 6-12 months even if asymptomatic 1
Consider AREDS2 supplementation - Can lower risk of fellow eye progression by up to 36% over 10 years 1
Additional Considerations
Given the moderate visual impairment (6/40 and 6/30):
- Refer to low vision services to optimize functional vision 3, 6
- Assess whether macular scarring, geographic atrophy, or glaucomatous damage is limiting visual potential 6
- Educate patient that while central vision loss is common, total blindness is extremely rare 1
- Instruct patient to report immediately any new symptoms: metamorphopsia, scotoma, decreased vision, or signs of endophthalmitis 1
The treatment burden is substantial, but anti-VEGF therapy remains the only evidence-based approach to preserve remaining vision in neovascular AMD 7, 4.