What is the recommended treatment for macular degeneration?

Treatment of Macular Degeneration

Anti-VEGF therapy is the first-line treatment for neovascular (wet) age-related macular degeneration, with agents such as aflibercept, ranibizumab, brolucizumab, or bevacizumab administered via intravitreal injection. 1, 2

Types of Macular Degeneration and Treatment Approaches

Non-Neovascular (Dry) AMD

• Currently no FDA-approved treatment for geographic atrophy
• Management focuses on:
  • AREDS/AREDS2 vitamin supplementation for intermediate AMD
  • Regular monitoring for conversion to neovascular form
  • Lifestyle modifications (smoking cessation, healthy diet)

Neovascular (Wet) AMD

• Characterized by choroidal neovascularization (CNV) with fluid leakage
• Requires prompt intervention to prevent vision loss
• Treatment algorithm:

First-Line Treatment: Anti-VEGF Therapy

1. Medication options:

   • Aflibercept (Eylea) - 2mg every 8 weeks after loading doses
   • Ranibizumab (Lucentis) - 0.5mg monthly or PRN
   • Brolucizumab (Beovu) - 6mg every 8-12 weeks after loading doses
   • Bevacizumab (Avastin) - 1.25mg (off-label use)
   • Faricimab (Vabysmo) - 6mg every 8 weeks 2

2. Initial dosing regimen:

   • Loading phase: Monthly injections for first 3 months
   • Maintenance phase: Based on treatment response using one of three approaches:
     • Fixed interval (every 4-8 weeks)
     • PRN (as needed based on disease activity)
     • Treat-and-extend (gradually increasing intervals between treatments if stable)

3. Treatment protocol selection:

   • The "treat-and-extend" regimen is frequently used in clinical practice and has shown similar efficacy to monthly dosing with fewer injections 1
   • PRN regimens may be slightly less effective in maintaining initial visual gains with longer follow-up 1

Monitoring Treatment Response

• Regular follow-up with:
  • Visual acuity assessment
  • Optical coherence tomography (OCT) to evaluate macular thickness and fluid
  • Fundus examination
  • Consider fluorescein angiography or OCT angiography for persistent cases

Special Considerations

Subretinal Hemorrhage

• Small subretinal hemorrhages can be managed with anti-VEGF therapy
• For larger submacular hemorrhages, pneumatic displacement procedures, tPA, or vitrectomy may be considered, though evidence is limited 1

Treatment Resistance

• If inadequate response to one anti-VEGF agent, consider switching to another
• In the CATT trial, approximately 50% of patients maintained visual acuity of 20/40 at 5-year follow-up 1

Potential Complications of Anti-VEGF Therapy

• Endophthalmitis (≤1.0% over 1 year)
• Retinal tear or detachment
• Intraocular inflammation
• Theoretical risk of systemic thromboembolic events, though clinical trials have shown inconsistent results 1
• Topical povidone-iodine is recommended before injection; routine antibiotic eye drops are not recommended

Treatment Duration

• Neovascular AMD typically requires ongoing treatment
• Interruption of treatment may result in disease recurrence and vision loss 2
• The CATT study showed that vision gains during the first 2 years were not maintained at 5-year follow-up, but 50% of patients maintained visual acuity of 20/40 1

Emerging Treatments

• Newer anti-VEGF agents like brolucizumab have shown promising results with potentially longer treatment intervals 1, 3
• Gene therapy approaches targeting VEGF production are under investigation 3
• Sustained-release implants and other drug delivery systems are being developed to reduce injection frequency 3

Anti-VEGF therapy has revolutionized the management of neovascular AMD, offering the first opportunity to improve visual outcomes in this previously devastating condition. The treatment approach should be guided by regular monitoring of disease activity with the goal of maintaining vision while minimizing treatment burden.