It has been more than 10 years since the introduction of anti-VEGF therapy for neovascular age-related macular degeneration, and the number of patients approaching legal blindness has fallen significantly as a result. Our understanding of the best way to manage this disease state has changed drastically. We’ve moved from a mandated treatment approach to as-needed approaches and now to a treat-and-extend approach. Alongside this, our education of how fluid subtypes matter in neovascular AMD has also broadened.
There are three accepted subtypes of fluid in neovascular AMD: intraretinal, subretinal and subretinal pigment epithelial (sub-RPE). Each has differential effects on vision outcomes. For example, the persistence of intraretinal fluid has been shown to be a negative prognosticator for visual outcomes in the CATT/IVAN, VIEW 1/2 and HARBOR trials. Therefore, we are keen to treat this subtype as aggressively as possible. With subretinal fluid, the visual outcomes appear to be superior in those patients who persistently have it over those who do not. This was found in the HARBOR studies and most recently in the CATT/IVAN 5-year studies as well. Lastly sub-RPE fluid is still a little of a mystery. We don’t have any idea if alone it has a positive or negative correlation on final visual outcomes, but when paired with intraretinal and subretinal fluids, it has potentially a larger negative correlation.
Why do these fluid subtypes matter? They help us tell our patients what outcomes they hope to achieve. They also help us personalize the approach of treatment — we are less likely to treat until dry with patients with persistent subretinal fluid, but we are more aggressive with our intervals of treatment in those with intraretinal fluid.
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Disclosure: Singh reports he is a consultant to Zeiss, Novartis, Regeneron, Genentech and Alcon and receives grant support from Apellis and Graybug.