What are the treatment options for Age-related Macular Degeneration (AMD)?

Treatment Options for Age-related Macular Degeneration (AMD)

The primary treatment options for AMD include AREDS2 nutritional supplements for dry AMD and anti-VEGF intravitreal injections for wet AMD, which should be initiated as soon as diagnosis is made to preserve vision and reduce the risk of legal blindness.

Types of AMD and Their Treatments

Dry AMD (85-90% of cases)

• Characterized by drusen and retinal pigment epithelial changes 1
• No specific treatment exists to reverse dry AMD, but progression can be slowed 2
• AREDS2 supplement formulation is recommended for patients with intermediate or advanced AMD in one eye 1
  • Contains vitamin C, vitamin E, zinc, copper, lutein (10mg), and zeaxanthin (2mg) 1
  • Reduces risk of progression to advanced AMD by up to 36% over a 10-year period 3
  • Beta-carotene should be avoided in current or former smokers due to increased lung cancer risk 3, 1

Wet AMD (Neovascular AMD)

• Characterized by abnormal blood vessel growth (choroidal neovascularization) 1
• Anti-VEGF therapy is the primary treatment, administered through intravitreal injections 1, 4
  • FDA-approved options include ranibizumab (Lucentis) 5, aflibercept (Eylea), and faricimab (Vabysmo) 6
  • Bevacizumab (Avastin) is commonly used off-label 3
  • Treatment should begin immediately upon diagnosis 1
  • Early treatment (within 2 years of diagnosis) reduces legal blindness and visual impairment 3

Treatment Protocols and Monitoring

Anti-VEGF Treatment Protocols

• Initial loading phase: Monthly injections for first 3-4 months 6
• Maintenance phase options:
  • Fixed interval: Monthly/bimonthly injections 6
  • Treat-and-extend: Gradually increasing intervals between injections if stable 6
  • PRN (as needed): Treatment based on disease activity 6
• Treatment intervals should be individualized based on clinical response 6
• Some patients may require continued treatment every 4 weeks if disease activity recurs before standard interval 6

Monitoring

• Regular comprehensive eye examinations are essential 3
• Patients should self-monitor using Amsler grid for early detection of metamorphopsia 1
• Optical coherence tomography (OCT) is useful for evaluating disease status 3
• High-risk patients (advanced AMD in one eye, large drusen with RPE changes in fellow eye) should be examined every 6-12 months 3

Supportive Care and Vision Rehabilitation

• Vision rehabilitation optimizes functional ability for patients with reduced vision 3
• Special optical or electronic magnifying lenses, bright lights, and electronic reading aids can help with reading 3
• Implantable Miniature Telescope (IMT) may benefit selected phakic, motivated patients with end-stage AMD 3
• Patients should be educated that while central visual loss is common, total visual loss is extremely rare 3

Risk Factor Modification

• Smoking cessation is strongly recommended as smoking is a key modifiable risk factor 3, 4
• Maintaining a healthy diet and weight may help reduce risk 1
• Protection from excessive UV light exposure may be beneficial, though total sunlight exposure effect remains uncertain 3

Treatment Complications and Management

• Potential complications of anti-VEGF therapy include:
  • Endophthalmitis and retinal detachment 6
  • Increased intraocular pressure 3
  • Thromboembolic events (rare) 3
• Regular monitoring for these complications is essential 6

Special Considerations

• Depression and visual hallucinations (Charles Bonnet syndrome) frequently accompany severe central vision loss 3
• Patients should be reassured that visual hallucinations do not represent psychosis or mental deterioration 3
• Loss of visual acuity increases risk of falls 3
• Family members or care assistants should help patients with cognitive impairment to self-test regularly 3