Australian Doctor 14th July Issue 14JULY2023 issue | Página 33

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attenuation or disruption of the RPE of at least 250μm in diameter and evidence of overlying photoreceptor degeneration — all occurring in the absence of signs of an RPE tear .

In the absence of licensed treatments , potential clinical trials are discussed with Mary .

CONCLUSION

GPs have an important role in the management of AMD . First , they play a crucial role in informing patients of the natural history of the neovascular ( wet ) and atrophic ( dry ) forms of disease , as well as current and emerging treatments to slow disease progression . Most patients will not be aware that new treatments for atrophic AMD are imminent . The GP is the healthcare professional that is most likely to interact with the patient and thus is in a unique position to inform patients of these developments .

Second , these are chronic diseases , and the maximum benefit in terms of visual function is achieved with sustained therapy . GPs can educate patients about benefits of continued treatment and risks of early discontinuation . This can lead to better patient adherence and overall improved outcomes .

Third , GPs can support patients in efforts to stop smoking as this is the main modifiable risk factor for latestage AMD . Additionally , a diet rich in leafy green vegetables and multivitamins consistent with AREDS2 clinical trial can help slow progression of AMD .

This How to Treat will aid GPs in providing patients with information about warning signs ; treatment options , including clinical trials ; and available support services . Retinal imaging modalities have evolved to provide diagnostic and prognostic information — usually in a non-invasive manner .

There were no effective treatments for both neovascular and atrophic AMD 15 years ago ; the natural history was central visual loss , significant risk of falls and loss of independence . With the advent of intravitreal anti-VEGF therapy , it is possible to stabilise vision in patients with neovascular AMD . Newer treatments aim to provide the same efficacy but with reduced treatment burden . It is hoped that drugs currently being assessed in late-phase clinical trials will slow progression of atrophic AMD , providing another breakthrough to maintain patients ’ vision .

RESOURCES

• Macula Disease Foundation Australia bit . ly / 3RwELDB

• Vision Australia bit . ly / 3M1arA4

• Guide Dogs Australia bit . ly / 3ruYucy

• Australian New Zealand Clinical Trials Registry bit . ly / 3M4FVW7

• Royal Australian New Zealand College Ophthalmologists : Referral pathway for AMD management bit . ly / 3M4LPpV

Declaration of interest statement Dr Wong and Dr Mehta are on the advisory boards for Apellis , Bayer , Novartis and Roche .

References Available on request from howtotreat @ adg . com . au

GO ONLINE TO COMPLETE THE QUIZ ausdoc . com . au / how-to-treat

1 . Which TWO statements regarding AMD are correct ? a The disease affects central vision . b It is the leading cause of irreversible blindness in developing countries . c AMD is initially characterised by the development of drusen and RPE pigmentary changes at the macula . d Wet AMD is the more common late manifestation of AMD .

2 . Which THREE are risk factors for AMD ? a Sun exposure . b Smoking . c Hypertension . d Genetic variations .

3 . Which ONE statement about AMD is incorrect ? a AMD is increasingly common with an ageing population . b The prevalence of late AMD increases sharply in those older than 85 . c AMD is more common in males . d Cases of AMD are less prevalent in Asia than in Europe and North America .

4 . Which THREE may be presenting features of AMD ? a Distance vision more affected than reading vision . b Distortion of straight lines . c Asymptomatic . d Difficulty reading in dim light .

5 . Which TWO non-invasive modalities are useful in the diagnosis of AMD ? a FFA . b OCT and OCT angiography . c Indocyanine green angiography . d Autofluorescence imaging .

6 . Which TWO statements regarding the investigation of AMD are correct ? a OCT can determine the response to treatment and help guide treatment intervals . b Allergic reactions to the fluorescein dye are common . c Microperimetry is the gold

AGE-RELATED MACULAR DEGENERATION

standard for the diagnosis of AMD . d If diagnosis of neovascular AMD is confirmed on OCTA , this avoids the need for invasive FFA .

7 . Which THREE interventions may slow disease progression in AMD ? a A Mediterranean diet rich in antioxidants . b Increased physical activity . c Smoking cessation . d High doses of vitamin D .

8 . Which THREE statements regarding the treatment of neovascular AMD are correct ? a Intravitreal anti-VEGF injections can improve visual acuity . b Treatment with aflibercept , ranibizumab or off-label bevacizumab can always be extended to every 16 weeks . c Baseline visual acuity is the

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Figure 10 . Autofluorescence imaging of geographic atrophy five years later .

Figure 11 . OCT imaging of atrophic AMD .

strongest predictor of longterm visual outcomes . d Proactive treatment regimens have been associated with better long-term visual prognosis as opposed to reactive ones .

9 . Which TWO statements regarding the treatment of atrophic AMD are correct ? a Supportive measures can help maintain independence and quality of life . b Intravitreal anti-VEGF injections can slow progression . c Atrophic AMD has a slow evolution , causing significant central vision impairment . d Atrophic AMD progresses rapidly .

10 . Which THREE features on testing an eye with an Amsler grid are suggestive of neovascular AMD ? a Additional colours are identified on the Amsler grid . b Images appear larger than normal . c Images appear smaller than normal . d Straight lines appear more wavy .