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

Treatment for Age-Related Macular Degeneration

For wet (neovascular) AMD, initiate intravitreal anti-VEGF therapy immediately with three loading doses at 4-week intervals using aflibercept, ranibizumab, or bevacizumab; for dry AMD with intermediate or advanced disease in one eye, prescribe AREDS2 supplementation (vitamin C, vitamin E, zinc, copper, lutein 10mg, zeaxanthin 2mg). 1, 2

Wet (Neovascular) AMD Treatment Algorithm

Anti-VEGF therapy is the primary treatment and must be started as soon as diagnosis is confirmed. 1, 2

Initial Treatment Protocol

• Administer three loading doses at exactly 4-week intervals with aflibercept, bevacizumab, or ranibizumab 1, 2
• Early treatment within 2 years of diagnosis significantly reduces legal blindness and visual impairment 2
• OCT imaging should be performed at each visit to assess for subretinal or intraretinal fluid 1, 2

Maintenance Regimens After Loading Phase

After the three loading doses, choose one of these evidence-based protocols 1:

• Aflibercept every 8 weeks: Comparable efficacy to monthly dosing in year one 1
• Treat-and-extend: Adjust injection intervals based on treatment response, extending when no fluid is present 1
• PRN (as-needed): Treat only when subretinal or intraretinal fluid is detected 1
• Monthly injections: A minority of retina specialists continue this approach 1

Important caveat: Some patients with persistent disease activity require continued 4-week dosing despite standard protocols suggesting longer intervals 3. If symptoms recur before the scheduled interval or fluid persists on OCT, maintain 4-week dosing until complete resolution is achieved for multiple consecutive visits 3.

Monitoring Requirements

• Biomicroscopic fundus examination at every visit 1
• OCT imaging to detect active exudation or disease progression 1
• Fluorescein angiography when clinically indicated 1
• Patients must report symptoms of endophthalmitis, retinal detachment, or decreased vision immediately 1, 3

Dry (Non-Exudative) AMD Treatment

AREDS2 supplementation is the only proven intervention to slow progression of dry AMD. 2

Who Should Receive AREDS2 Supplements

• Patients with intermediate AMD (bilateral soft drusen, confluent drusen, RPE changes) 2
• Patients with advanced AMD in one eye 1, 2
• This reduces progression risk by up to 36% over 10 years and could prevent disease progression in over 300,000 patients 2

AREDS2 Formulation Components

The specific formulation includes 1, 2:

• Vitamin C
• Vitamin E
• Zinc (25mg shown equivalent to 80mg in AREDS2) 1
• Copper (necessary to prevent copper-deficiency anemia from zinc) 1
• Lutein 10mg
• Zeaxanthin 2mg

Critical modification from original AREDS: Beta-carotene was replaced with lutein/zeaxanthin because beta-carotene increased lung cancer risk in smokers (relative risk 1.28,95% CI 1.04-1.57) 1, 2.

Potential Adverse Effects to Discuss

• Zinc at 80mg increased genitourinary hospitalizations (7.5% vs 4.9%, P=0.001) 1
• The patient's primary care physician should review long-term supplementation due to these risks 1

What Does NOT Work for Dry AMD

• No FDA-approved therapies currently exist to slow geographic atrophy progression 2
• Multiple agents are under investigation in clinical trials 2

Essential Lifestyle Modifications

Smoking cessation is mandatory and non-negotiable as cigarette smoking increases AMD progression risk proportional to pack-years smoked 2. This is the single most important modifiable risk factor 2.

Additional beneficial modifications include 4:

• Mediterranean diet pattern
• Physical activity
• Maintaining healthy body weight

Patient Education and Self-Monitoring

Amsler Grid Use

• Patients should monitor daily for metamorphopsia (wavy or distorted grid lines) 2
• Look at the central dot and evaluate if any lines appear distorted 2
• Report new symptoms immediately 1

Vision Rehabilitation

• Refer patients with reduced visual function to rehabilitation services immediately 2
• Optical/electronic magnifying devices, bright lights, and reading aids improve quality of life 2
• Reassure patients that central vision loss is common but total blindness is extremely rare 2

Follow-Up for Unilateral Disease

For patients with wet AMD in one eye, the fellow eye remains at high risk 1:

• AREDS2 supplements can lower risk by 36% over 10 years 1
• Patients must monitor vision in the unaffected eye and return promptly with any new symptoms 1
• Periodic examinations are necessary even without symptoms 1

Common Pitfalls to Avoid

• Do not delay anti-VEGF therapy for wet AMD—early treatment within 2 years is critical for preventing legal blindness 2
• Do not use two different anti-VEGF agents simultaneously—this is not evidence-based 3
• Do not prescribe AREDS2 supplements for early AMD or healthy adults—insufficient evidence for primary prevention 5
• Do not continue extended dosing intervals if fluid recurs—return to 4-week dosing until stabilization 3