Management of Wet Age-Related Macular Degeneration - Episode 12
A panel of eye care specialists review challenges faced with the management of wet AMD when patients are put on an extended treatment regimen.
John W. Kitchens, MD: Roger, these patients, we’re talking every other month, or every month and a half, coming in. What are some of the challenges that you face, not just from a medical standpoint, but from a societal standpoint, from a familial standpoint, with treating these patients so frequently?
Roger A. Goldberg, MD, MBA: We talked a bit about this idea of a treatment burden, and there is a burden for the patient to have to come in, but it’s also an office visit burden. It’s a burden for their caregiver to have to drive them, particularly with the macular degeneration population, which tends to be an older population. Many of them don’t feel comfortable driving after they’ve gotten an injection. I would say, particularly in my AMD [age-related macular degeneration] population, most of them are coming to the clinic with a driver. They need to have somebody else come with them. The medicines, particularly the on-label medicines, are expensive. There’s a societal burden in terms of the cost of care to manage and control this disease. When you look at the cost, and they do cost-benefit analyses vs the millions of people who would have gone blind, had we not had these agents available to us. Both in AMD and diabetic retinopathy, in both of those indications, the societal cost of blindness is much greater than the cost of these medications. But the burden is still there just in terms of the ongoing effort required to come in and maintain that fairly regular and regimented treatment algorithm that’s necessary to maintain the vision over time.
It’s easy for patients in that first 1 to 3 injections because they’ve seen some vision gain. They look at the OCT [optical coherence tomography] that Dante talked about at the top of this program, and they see that the fluid is gone. What they’re experiencing with their vision and what they see in terms of the anatomic response, they’re excited and on board with treatment. Every 6 months though, after that when you’re talking about stability, which is to say, “Hey, we’re keeping your retina dry. We’re keeping your vision unchanged now.” Every once in a while, I have to pull up the original scan from when they first came in and say, “Remember, this is what we’re trying to prevent you going back to.” It can be tiring to come in when you’re not experiencing the benefit like you did during those first few injections.
John W. Kitchens, MD: It’s fascinating that you’ll have patients who have amazing responses, and after about a year, they’ll say, “Do I have to keep getting these shots, or I’d really like to take a break.” And sometimes I’ll say, and it’s always the patient’s choice, “OK, we’ll give you a little break.” And inevitably they’ll have a recurrence, where hopefully they don’t have hemorrhage. They’ll just have leakage and their vision will drop and they’ll realize, wait a second, it’s this aha moment. “These treatments are keeping me seeing. They made me better, and now they’re preserving my vision.” And you usually don’t have to have them go through that more than once before they go, “I get it. I’m going to stay on the shots.”
Roger A. Goldberg, MD, MBA: Certainly I think from a lot of the retrospective data from COVID-19, when some of these patients did miss their visits, and now it wasn't every patient who missed a visit or who lost vision, but a significant proportion of patients lost vision. And then yes, like knock on wood, and I'm knocking on wood here. But patients sometimes were able to get that vision back when we re-instituted treatment. Sometimes though patients weren’t able to get the vision back that they lost, and those are bad outcomes. So we kind of did this little bit of a mass trial in some patients who were either too afraid to come in, or whatever their COVID-19 situation was; sometimes the nursing home wouldn’t even let them out of the nursing home to come in and get their treatment. So it wasn’t always by choice or their choice, that they didn’t come in.
Transcript Edited for Clarity