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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: email@example.com
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/
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