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Retina Editorial What Is the Best Neovascular Age-related Macular Degeneration Treatment Regime for 2016? Richard P Gale 1 and Reema Gupta 2 1. Consultant Medical Ophthalmologist and Honorary Senior Clinical Lecturer, Academic Unit of Ophthalmology, York Hospital, York, UK; 2. Clinical Research Fellow, Academic Unit of Ophthalmology, York Hospital, York, UK Abstract The management of neovascular age-related macular degeneration (nvAMD) has evolved significantly over the last few years with a significant step forward being taken with the advent of intravitreal therapy. Many different treatment regimens can be used, and the goal of treatment is shifting away from just salvaging vision to include reducing treatment burden on patients, carers and healthcare systems. This editorial discusses the common treatment regimens and proposes a pragmatic way of treating patients in three steps: (1) initiating a treatment, (2) finding the appropriate re-treatment interval and (3) fixing the re-treatment interval. Keywords AMD, neovascular AMD, anti-VEGF, posology Disclosure: Richard P Gale has received consultancy, lecture fees, local Principles Investigator and/or research grants from Novartis and Bayer. Reema Gupta has nothing to declare in relation to this article. No funding was received in the publication of this article. Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any non-commercial use, distribution, adaptation and reproduction provided the original author(s) and source are given appropriate credit. Received: 30 October 2015 Published online: 21 December 2015 Citation: European Ophthalmic Review, 2015;9(2):157–8 Correspondence: Richard P Gale, Consultant Medical Ophthalmologist and Honorary Senior Clinical Lecturer, Academic Unit of Ophthalmology, York Hospital, Wigginton Road, York, YO31 8HE York, UK. E: Age-related macular degeneration (AMD) is the leading cause of central visual loss and legal blindness in patients over the age of 65 years. 1,2 The exudative or neovascular form of AMD accounts for over 90 % of the cases with severe visual loss. 3 Currently Available Regimens for Neovascular Age-related Macular Degeneration AMD is a highly complex disease with demographic, environmental and genetic risk factors. The pathogenesis of AMD lesions remains largely unclear and current evidence suggests that AMD results from genetic predisposition and a combination of metabolic and inflammatory insult to photoreceptors and retinal pigment epithelium (RPE). 4 Many studies used three initiation injections, on a monthly basis, to commence treatment. 6,7 This remains a pragmatic way of commencing therapy as the majority of patients in a one dose plus re-treatment- as-necessary regimen still required three doses to achieve a similar good outcome. 8 Regimens can be divided into an initiation and a stability/ maintenance phase. There is a need to find the best treatment regime for nvAMD that optimises visual outcomes and safety while minimising burden to patients, carers and healthcare providers (see Table 1). This editorial focuses on the pros and cons of current nvAMD treatment regimens and proposes a regimen appropriate for 2016. Once maximum control of activity and visual gain is achieved, ongoing disease suppression is required. The different approaches for managing this stability/maintenance phase can be considered as either ‘reactive’ or ‘proactive’ regimens. In the reactive form, treatment is given on a pro re nata (prn) basis whenever there are signs of activity and can be either ‘tolerant’ of a degree of disease activity or ‘intolerant’ of any signs activity. Disease activity is judged by taking a composite view of new symptoms, reduced measured visual acuity, dynamic evaluation with fluorescein angiography and most important morphology on optical coherence tomography (OCT). Intraretinal fluid and cysts, subretinal fluid and sometimes change in pigment epithelial detachment height are also considered. Studies directly comparing treatment regimens are often complicated by the usage of different drugs, a retrospective nature, single-arm design or cross-study comparison, so interpretation can be difficult. In the proactive form, treatment is given in a continuous manner, ideally before disease activity manifests. Proactive regimens can be further subdivided into ‘fixed’ or ‘variable’ form. The Seven Year Update of Macular Degeneration Patients (SEVEN-UP) study helped elucidate the challenges of long-term management of neovascular AMD (nvAMD), in particular that it is a chronic disease and that the patients remain at risk of vision loss many years after the treatment. 5 TOU CH MED ICA L MEDIA 157