32 HOW TO TREAT : AGE-RELATED MACULAR DEGENERATION
32 HOW TO TREAT : AGE-RELATED MACULAR DEGENERATION
14 JULY 2023 ausdoc . com . au has shown promising results in slowing the progress of geographic atrophy in the phase II FILLY study and for up to 24 months in the phase III OAKS and DERBY clinical trials . 40 , 41 As well as intravitreal approaches , systemically delivered treatments to slow the progression of geographic atrophy are being assessed for efficacy and safety . A number of these trials are open to recruitment in Australia .
CASE STUDIES
Case study one AMY , 86 , presents with a sudden reduction of vision in her right eye and complains that words are “ jumping around ” when reading with that eye . Her vision is reduced to a Snellen equivalent of 6 / 15 in the right eye and is maintained at 6 / 7.5 in the left eye . There is no family history of AMD , but Amy is an ex-smoker . Clinically , drusen are noted at both maculae but no intraretinal haemorrhage .
Imaging of her right macula identifies accumulation of intraretinal and subretinal fluid and some atrophy ( see figure 6 ). The left macula remains dry . An initial area of leak associated with a macula neovascular membrane is noted in the right eye ; fluorescein angiography identifies that this leaks over time and demonstrates foveal involvement in late phase . There is some atrophy noted nasal to the fovea , producing a bright window defect ( see figure 7 ). Amy is diagnosed with neovascular AMD .
After discussing the risks and benefits , Amy is started on a course of intravitreal aflibercept treatment for the right-eye wet AMD . Figure 8 shows an excellent response after three intravitreal aflibercept injections to the right eye four weeks apart . The intra- and subretinal fluid has cleared , and vision in the right eye has improved to 6 / 9 . The treatment interval can now be extended to eight weeks .
Figure 7 . Early and late phases of FFA imaging characteristic of neovascular AMD .
Figure 6 . Near infrared and OCT imaging of neovascular AMD in right eye .
Case study two Mary , now 75 , initially presented five years ago with gradually deteriorating reading vision in both eyes . Her visual acuity was recorded at 6 / 24 in the right eye and 6 / 7.5 in the left . She also had a history of sensorineural deafness . There was no family history of AMD , and Mary had never smoked . Clinically , drusen were present at both maculae . There was no evidence of neovascular AMD .
Autofluorescence imaging ( see figure 9 ) identified intensely dark areas consistent with geographic atrophy with foveal involvement in the right eye but foveal sparing in the left . The brighter areas indicate macula tissue under stress and at risk of developing geographic atrophy .
AREDS2 vitamin supplementation ( lutein , zeaxanthin , zinc and vitamins C and E ) was recommended , in addition to an improved , balanced diet to help slow disease progression .
Five years later , Mary ’ s visual acuity has reduced to 6 / 45 in her right eye and 6 / 12 in her left eye , with a small island of fovea spared in the left eye ( see figure 10 ). The five-year progression of the disease is also visible in the imaging . A larger area of geographic atrophy in the right eye and foveal sparing in the left eye explain the significant difference in visual acuity between the eyes .
The OCT ( see figure 11 ) meets the cRORA definition described in box 1 , with a region of hyper-transmission of at least 250μm in diameter , zone of
Figure 8 . Near infrared and OCT imaging of the right macula after intravitreal anti-VEGF treatment was initiated for neovascular AMD .
Figure 9 . Autofluorescence imaging of both maculae five years ago on initial presentation .