Management of Wet AMD Progressing to Dry Atrophy
Stop anti-VEGF therapy if OCT confirms absence of active exudation and the backshadowing represents fibrotic scarring or geographic atrophy, then transition to AREDS2 supplementation and vision rehabilitation services. 1, 2
Immediate Diagnostic Confirmation
Your patient's clinical picture—vision decline from 6/18 to 6/60 with backshadowing on OCT but no fluid—suggests either:
- Fibrotic scarring from previously treated wet AMD (most likely given the backshadowing)
- Geographic atrophy (dry AMD progression)
- Occult persistent CNV beneath the scar (less likely but must be excluded)
Perform these studies at the next visit: 1
- OCT imaging to definitively confirm absence of subretinal or intraretinal fluid
- Fluorescein angiography if there is any clinical suspicion of occult CNV activity beneath the scar
- OCTA may help distinguish between inactive scar and persistent low-grade neovascularization 1
The backshadowing you describe on OCT typically represents dense fibrotic tissue or RPE/photoreceptor loss blocking deeper visualization—this is characteristic of end-stage scarring from treated wet AMD or geographic atrophy. 1
Treatment Algorithm Based on OCT Findings
If No Active Exudation is Confirmed (Most Likely Scenario)
Discontinue anti-VEGF injections immediately since there is no treatable component and continued injections provide no benefit for fibrotic scarring or geographic atrophy. 1, 2
Initiate AREDS2 supplementation (vitamin C, vitamin E, zinc 25mg, copper, lutein 10mg, zeaxanthin 2mg) to reduce risk of progression in the fellow eye by up to 36% over 10 years. 2
Refer to vision rehabilitation services immediately for optical/electronic magnifying devices, bright lights, and reading aids to optimize remaining functional vision. 1, 2
If Occult CNV Activity is Detected
Resume anti-VEGF therapy with treat-and-extend or PRN protocol based on presence of fluid. 1, 2
Critical Management Points
Monitor the fellow eye aggressively since patients with advanced AMD in one eye remain at exceptionally high risk—examine every 6-12 months even without symptoms to detect asymptomatic CNV at a treatable stage. 1
Enforce smoking cessation as this is the only modifiable risk factor that significantly impacts disease progression. 1, 2
Set realistic expectations: Counsel the patient that central vision loss is common but total blindness is extremely rare, and that vision rehabilitation optimizes existing function rather than restoring lost vision. 1, 2
Screen for depression and Charles Bonnet syndrome (visual hallucinations), which frequently accompany severe central vision loss—refer for professional evaluation if present. 1
Common Pitfalls to Avoid
Do not continue anti-VEGF injections indefinitely without documented fluid on OCT—this exposes patients to unnecessary injection risks (endophthalmitis, retinal detachment) without therapeutic benefit once the disease has burned out into fibrotic scarring. 1, 2
Do not assume the fellow eye is safe—the 10-year risk of developing advanced AMD in the fellow eye can be as high as 36% without AREDS2 supplementation, and patients must self-monitor with Amsler grid testing. 1, 2
Do not delay vision rehabilitation referral—patients with 6/60 vision qualify for low vision services and benefit significantly from early intervention with adaptive devices. 1, 2