Treatment Options for Macular Degeneration
Anti-VEGF therapy is the primary treatment for neovascular (wet) age-related macular degeneration, with multiple FDA-approved options including aflibercept, ranibizumab, and brolucizumab, while nutritional supplements are recommended for non-neovascular (dry) AMD. 1
Types of Macular Degeneration
Non-Neovascular (Dry) AMD
- Characterized by atrophy of retinal layers and retinal pigmented epithelial cells 1
- Treatment options include:
Neovascular (Wet) AMD
- Characterized by development of abnormal blood vessels in the choroid layer beneath the retina 1
- Primary treatment options include:
Anti-VEGF Therapy for Neovascular AMD
FDA-Approved Anti-VEGF Agents
- Aflibercept (Eylea): Can be administered every 8 weeks after initial loading doses, with comparable efficacy to monthly dosing in the first year 1
- Ranibizumab (Lucentis): Typically administered monthly or as needed (PRN) 1
- Brolucizumab (Beovu): Received FDA approval in October 2019; demonstrated non-inferiority to aflibercept with superior reductions in central subfield thickness 1
- Bevacizumab (Avastin): Used off-label, shown to be effective but may be slightly less effective than other monthly anti-VEGF regimens 1, 2
Administration Protocols
- Initial treatment: Typically begins with three loading doses at 4-week intervals 1
- Maintenance regimens:
- Fixed monthly: Most effective for visual acuity but requires more frequent injections 1, 2
- Extended-fixed: Injections every 2-3 months after loading phase; similar efficacy to monthly with fewer injections 2
- PRN (as needed): Treatment based on presence of subretinal or intraretinal fluid; requires fewer injections but may not maintain initial visual gains with longer follow-up 1
- Treat-and-extend: Interval between treatments gradually increased if stable; comparable efficacy to monthly dosing with fewer injections 1, 2
Efficacy Considerations
- Monthly regimens are slightly more effective than PRN regimens (approximately 1.7 letters better visual acuity) 2
- Treat-and-extend regimens show similar efficacy to monthly injections while reducing treatment burden 1, 2
- Long-term outcomes show that 50% of patients maintained visual acuity of 20/40 at 5-year follow-up 1
Other Treatment Options
For Wet AMD
- Photodynamic therapy: Combines verteporfin (photoreactive agent) with low-level laser light; less commonly used since anti-VEGF introduction 1
- Laser photocoagulation: Older treatment associated with blind spots; no longer in common use 1
For Large Submacular Hemorrhages
- Options include pneumatic displacement procedures, tissue plasminogen activator (tPA), and/or pars plana vitrectomy, though evidence is limited 1
Emerging Treatments
- Newer anti-VEGF agents: Extended duration of effect with injection intervals as long as 12-16 weeks for some patients 3
- Sustained-release implants: Release drug regularly over extended periods 3
- Gene therapy: Targeting genes involved in producing anti-VEGF proteins intraocularly 3
Potential Complications of Anti-VEGF Treatment
- Endophthalmitis: Infection risk of approximately 0.019-0.09% per injection; lower risk with PRN regimens compared to monthly injections 1, 2
- Non-infectious inflammation, retinal tear, or detachment 1
- Theoretical risks for systemic arterial thromboembolic events, though clinical trial results remain inconclusive 1
- Retinal pigment epithelium tears/rips: May occur but not a contraindication to continued therapy 1
Monitoring and Follow-up
- Regular examinations using biomicroscopy of the fundus 1
- Optical coherence tomography (OCT) to detect signs of active exudation or disease progression 1
- Fluorescein angiography and fundus photography as clinically indicated 1
- Patients should report symptoms of endophthalmitis, retinal detachment, or decreased vision promptly 1
- Fellow eye monitoring is crucial as it remains at high risk for developing advanced AMD 1