Advances in the Treatment of Age-related Macular Degeneration
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Several emerging treatments will help preserve vision in older adults.
Even as the world was focused almost exclusively on the pandemic over the past two years, medicine was advancing in other areas. Among the most important advances were efforts to preserve our gift of good vision.
Age-related macular degeneration (AMD) is a common cause of vision loss as people age. AMD begins slowly; the degenerative process can take decades to cause blindness. This disease affects the macula, the part of the eye responsible for our central vision.
We need our central vision for driving, watching TV, seeing people’s faces, and other vital tasks.
We need to distinguish between the two types of AMD: “dry” and “wet .” Dry AMD develops before wet AMD, and wet AMD arises from dry AMD. The wet form of AMD happens when abnormal blood vessels grow and leak fluid and blood into the central macula.
The macula is the most important part of the retina because it is responsible for everyone’s best vision. While dry AMD will eventually cause vision loss, this loss can accelerate rapidly if wet AMD develops.
How is wet AMD treated?
Wet AMD is treated by periodically injecting a drug directly into the eye. Many of our Bascom Palmer patients require these injections every four to eight weeks. Fortunately, a new drug for treating wet AMD will require fewer injections.
On January 31, 2022, the Food and Drug Administration (FDA) approved faricimab, a drug for treating wet AMD. Known by the brand name Vabysmo®, this new medication joins other highly effective injectable drugs such as Avastin®, Lucentis®, and Eylea®. These drugs convert the wet AMD back to dry AMD, but the wet AMD frequently returns, and additional injections are needed.
At Bascom Palmer, our goal is to minimize the frequency of injections our patients have to undergo. Evidence from the Vabysmo Phase 3 clinical trials suggests that it lasts longer so fewer injections will be needed.
All the drugs we currently use inhibit vascular endothelial growth factor (VEGF), a substance in the body that promotes the growth of new blood cells. The Vabysmo drug has an added advantage – it also inhibits the angiopoietin-2 (Ang-2) growth factor. Inhibiting the development of both VEGF and Ang-2 is thought to have a more lasting effect on a patient’s vision. We are optimistic that Vabysmo will allow patients to have fewer injections, but we need to prove it to ourselves and our patients in the clinic.
If patients who need injections every four to eight weeks can be switched to Vabysmo, they may only need to be reinjected every 8 to 12 weeks or longer. That will be a great advantage for our patients.
The new drug should be available at Bascom Palmer by the spring of 2022.
A game-changing tool for earlier detection of wet AMD
While ophthalmologists treat wet AMD by injecting specific drugs into the eye, these injections usually don’t start until some vision loss has already occurred. The earlier we treat patients with wet AMD, the better their vision will be in the long run.
To achieve this goal, we use a breakthrough technology called swept-source optical coherence tomography angiography (SS-OCTA).
SS-OCTA technology allows ophthalmologists to detect the formation and growth of abnormal blood vessels in the macula months to years before wet AMD even develops. This will enable us to predict who will develop wet AMD and who will need treatment long before they actually need it.
The technology provides a clinical crystal ball that lets us identify high-risk patients who will need injections. I helped develop SS-OCTA at Bascom Palmer, and it is now available in most locations throughout the world.
The first step is to identify patients with dry AMD and take images of their eyes with SS-OCTA – a process that takes just minutes to perform.
Because we don’t know when the leakage from these abnormal blood vessels will begin, high-risk patients need to be seen every two months.
It’s key to get patients with dry AMD diagnosed through SS-OCTA because many still have good vision and are unaware that they have a potentially blinding disease. Once identified, these patients are asked to check their vision daily and tell their ophthalmologist if they notice any blurriness or distortion.
The next big breakthrough will happen when home-based OCT becomes available. Patients could take daily images of their maculas and then send the images into the cloud using this device. By using specialized algorithms in the cloud, we will detect the very beginnings of any leakage in the macula, even before the patient’s vision is affected.
Once identified, the patient’s ophthalmologist will be notified, and the patient can be seen the next day. While not yet commercially available, home-based OCT is being developed and should be in patients’ homes within one to two years.
Getting closer to a treatment for dry AMD getting closer
Currently, AMD can only be treated after the wet AMD develops. Even under the best circumstances, we only convert wet AMD back to dry AMD. Over time, patients still lose their vision from the dry AMD.
What if there was a treatment that could slow or stop the progression of dry AMD?
Such treatments are on the near horizon. According to first-year phase-3 results from studies of the drug pegcetacoplan, the drug significantly slows the progression of dry AMD. While the disease wasn’t stopped and any vision lost before treatment was not restored, the drugs did make a significant impact in slowing down the disease.
It’s clear from the studies that we will likely have a treatment for late dry AMD. If the year-two data show similar or better results, the drug should get FDA approval and be available at Bascom Palmer by 2023.
Other promising drugs are also being developed, so I’m optimistic that we will be able to prevent blindness in most of our patients with dry AMD.
Even though the pegcetacoplan treatment only slows disease progression, starting treatment as early as possible would preserve patients’ vision for much more extended periods. I anticipate even better treatments in the years ahead, so this is just the beginning of our battle against dry AMD.
As a 26-year veteran of ophthalmology, I find each of these developments encouraging.
To schedule an appointment at Bascom Palmer Eye Institute, call 800-329-7000 or click here.
Philip J. Rosenfeld, M.D., Ph.D., Board-certified Ophthalmologist and Professor of Ophthalmology, Bascom Palmer Eye Institute