What are the management options for macular degeneration?

Management of Macular Degeneration

For neovascular (wet) AMD, initiate intravitreal anti-VEGF therapy (ranibizumab, aflibercept, or bevacizumab) immediately upon diagnosis with three loading doses at 4-week intervals, as early treatment within 2 years significantly reduces legal blindness and visual impairment. 1

Risk Stratification and Prevention

Identify High-Risk Patients

• Patients with intermediate AMD or advanced AMD in one eye (approximately 8 million Americans ≥55 years) require AREDS2 supplementation (vitamin C, vitamin E, zinc, copper, lutein 10mg, zeaxanthin 2mg), which can prevent progression in over 300,000 patients and reduce risk by up to 36% over 10 years 1, 2
• High-risk features include: bilateral soft drusen ≥125 μm, confluent drusen, RPE clumping or atrophy, and family history 1
• Smoking cessation is mandatory as cigarette smoking increases AMD progression risk proportional to pack-years smoked 1

Early Detection Protocol

• AMD is typically asymptomatic in early stages, making comprehensive eye examination the best opportunity for early diagnosis 1, 2
• Patients should self-monitor with Amsler grid for metamorphopsia (distorted lines indicate urgent evaluation needed) 2
• High-risk patients (advanced AMD in one eye with large drusen/RPE changes in fellow eye) require examination every 6-12 months to detect asymptomatic CNV 1

Treatment Algorithm for Neovascular (Wet) AMD

Immediate Intervention

The standard of care is to treat neovascular AMD as soon as diagnosis is made—do not delay 1

Anti-VEGF Therapy Protocol

• Initial treatment: Three loading doses at 4-week intervals with aflibercept, ranibizumab, or bevacizumab 1, 3
• Maintenance regimens (choose one based on clinical response): 1
  • Aflibercept: Every 8 weeks after loading (comparable efficacy to monthly dosing in year 1)
  • Treat-and-extend: Adjust intervals based on presence/absence of subretinal or intraretinal fluid on OCT
  • PRN (as-needed): Treat when fluid recurs on OCT
  • Monthly injections (minority of specialists use this approach)

Monitoring Requirements

• OCT at each visit to assess for subretinal/intraretinal fluid 1
• Fluorescein angiography at baseline and selected follow-up visits for neovascular AMD 1
• OCTA may be useful for evaluating high-risk fellow eyes 1
• Patients must report immediately if symptoms of endophthalmitis, retinal detachment, or decreased vision occur 1

Management of Dry (Non-Neovascular) AMD

Nutritional Supplementation

AREDS2 formulation is the only proven intervention to slow progression 1, 2

• Components: Vitamin C, vitamin E, zinc, copper, lutein (10mg), zeaxanthin (2mg) 2
• Indicated for intermediate AMD or advanced AMD in one eye 1, 2
• Lutein/zeaxanthin replaced beta-carotene due to lung cancer risk in smokers 2

Geographic Atrophy

• No FDA-approved therapies currently available to slow atrophy progression 1
• Multiple agents under investigation in clinical trials (complement inhibitors, neuroprotective agents, visual cycle inhibitors, gene therapy, cell-based therapies) 4
• Monitor with multimodal imaging: OCT, fundus autofluorescence, and color fundus photography 1

Patient Education and Rehabilitation

Critical Counseling Points

• Central vision loss is common, but total blindness is extremely rare 1
• No harm in using eyes for normal visual tasks 1
• Smoking cessation is non-negotiable as it is the key modifiable risk factor 1
• Fellow eye remains at high risk when one eye has advanced AMD 1

Vision Rehabilitation Referral

Refer patients with reduced visual function to vision rehabilitation services immediately 1

• Optical/electronic magnifying devices, bright lights, and reading aids optimize remaining function 1
• Implantable Miniature Telescope (IMT) may benefit screened, motivated phakic patients with end-stage AMD 1
• Address depression and Charles Bonnet syndrome (visual hallucinations), which frequently accompany severe vision loss 1

Common Pitfalls to Avoid

• Do not delay anti-VEGF treatment while waiting for "better" timing—early treatment (within 2 years) has superior outcomes 1, 2
• Do not forget to discuss bevacizumab's off-label status during informed consent 1
• Do not overlook cognitive impairment in AMD patients—involve family members in self-monitoring instructions 1
• Do not miss the fellow eye—unilateral neovascular AMD patients need continued surveillance and AREDS2 supplementation for the unaffected eye 1
• Ancillary staff must understand that new metamorphopsia, scotoma, or vision loss requires same-day examination 1