January 22, 2021
4 min read
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Real-world study highlights need to improve early wet AMD diagnosis

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A real-world analysis conducted on a large ophthalmology registry confirmed that best results with anti-VEGF injections in age-related macular degeneration are obtained in patients who initiate treatment when visual acuity is still good.

Unfortunately, these patients are a minority, and there are too many cases in which the onset of neovascular exudation is not detected promptly.

“Only 34.3% of eyes had 20/40 or better at baseline, and those were the eyes that maintained a mean VA of 20/40 or better in the long term with anti-VEGF treatment,” study co-author Allen C. Ho, MD, said.

Although it has long been proven that early diagnosis is critical for better visual outcomes, this is still a challenge in real-world clinical practice, and patients often present when significant vision loss has already occurred in the conversion from dry to neovascular AMD.

Allen C. Ho, MD
Allen C. Ho

This is happening even more frequently now because patients are afraid of COVID-19 and tend to cancel or postpone their appointments.

“Patients now come in and start treatment with a VA that is on average worse than in previous years,” Ho, an OSN Retina/Vitreous Board Member, said.

The study used the American Academy of Ophthalmology IRIS Registry, one of the largest clinical databases worldwide, to quantify baseline visual acuity in patients initiating intravitreal injection treatment for AMD and to determine how baseline visual acuity correlated with long-term visual outcomes in real-world settings. The authors performed a retrospective analysis of 162,902 eyes of 153,141 patients who entered the registry with a diagnosis of wet AMD in a time span of 4 years. The mean visual acuity at diagnosis was 20/80, with several eyes in the range of 20/200 to 20/320.

Eyes diagnosed too late

“If you start treatment at 20/80, you end up on average at 20/80, but if you start at 20/40 or better, then you are more likely to do better with time. It is like lane swimming: Whichever lane you are in, fast, medium or slow, that will remain your average speed. A patient starting at 20/200 VA is a swimmer who will never become fast. That’s why it is important to detect wet AMD early,” Ho said.

Delayed presentation often occurs because patients who start developing wet AMD unilaterally may not notice the change if the other eye has good vision.

“They may also underestimate the seriousness of their symptoms and postpone going to the doctor. Now, for fear of COVID-19, patients come even later and with worse vision,” Ho said.

Second eyes are not diagnosed much earlier, as shown in the study. Of the 21,838 patients who were diagnosed with wet AMD in the second eye, only 36% had a visual acuity of 20/40 or better as compared with 33.3% of first eyes, even though patients were, presumably, already taken care of by a retina specialist.

“Current methods of home monitoring, such as the classic Amsler grid, clearly fail to detect wet AMD early enough to maintain good vision in over 65% of patients, as shown by our study,” Ho said.

Home-monitoring system

The ForeseeHome system (Notal Vision) is available in the United States and may be a breakthrough technology for the early diagnosis of wet AMD. With a simple daily test, patients can check for even small changes in vision at home. The data are uploaded to the cloud, and an alert is sent to both patient and physician if any vision change is detected.

“It is a digital tool, but about two-thirds of our typical AMD population are able to use it. I ask my patients if they have an email address and a cell phone, and if they do, I expect there will be no problem. If they don’t have them, I don’t even discuss this option. Many patients are very interested and use it regularly. Since it detects problems in between visits, I see patients less frequently now, unless they have to come for injection in the other eye,” Ho said.

Because the costs of ForeseeHome are covered by Medicare, patients can have it for free or with a copayment of $15 per month. For those who do not have Medicare, the cost is $75 per month. The device is easy to use, to set up and to connect to Wi-Fi, with a few simple instructions provided by the company over the telephone.

“It looks like a microscope. You look through it and see a dotted line with a small bump moving to different locations on which you click with a mouse. It is like a video game. You do it one eye at a time, and it takes no more than a couple of minutes,” Ho said. “It should be used at least once a week, but most patients use it daily or every other day. It gives peace of mind, to you and to your patients, because you both know that any problem would be detected early.”

Timely method during pandemic

The COVID-19 pandemic has increased the demand for telemedicine and home monitoring.

“In the midst of a pandemic, remote surveillance with ForeseeHome is a timely and effective method to protect patients and health care workers from the risk of infection while ensuring regular monitoring. It is important to spread the voice that this tool is available and that it is free for most patients,” Ho said.

In the AREDS2-HOME study, 94% of patients who used home monitoring in addition to standard care had 20/40 or better vision when wet AMD was first detected.

“This was a clinical trial, but real-world data collected since the approval of ForeseeHome have shown that 83% of the patients are detected when vision is 20/40 or better, which is two and a half times more than in the IRIS Registry,” Ho said. “This means that if you use ForeseeHome plus your standard care with Amsler, it more than doubles your chances of getting better vision.”

In the study, 20/40 was used as an arbitrary cutoff for visual acuity, but it signifies that patients can read, drive a car and see their grandchildren’s faces. It means they are, and will remain, “in the faster swimming lane,” Ho said, making the most of what anti-VEGF therapy can offer. – by Michela Cimberle