Macular degeneration of the elderly, from examinations to treatments: the answers of the experts

How is age-related macular degeneration diagnosed? Which patient is at risk of the disease? What are the treatment options? These, in short, were the questions to which some of the most authoritative specialists in ophthalmology were asked to answer, during the webinar held recently within the training course of Floretina 2021, on the theme ‘Neovascular Amd in real life’, chaired by Edoardo Midena, professor of Diseases of the visual apparatus and director of the School of Specialization in Ophthalmology of the University of Padua, and by Stanislao Rizzo, director of the Ophthalmology complex operating unit of the A. Gemelli Irccs University Hospital in Rome , organized with the unconditional contribution of Bayer. Age-related macular degeneration is a disease of great social and health importance and is the leading cause of severe central low vision in industrialized countries, in people over 65 years of age. In Italy 50 thousand new cases are registered every year. Patients with the neovascular (wet-wet) form of maculopathy should undergo intravitreal injections (anti Vegf drugs), a treatment that not only prevents further vision loss but, in many cases, regains acuity. lost sight especially when it is possible to intervene in time. An eye examination, however, is not always sufficient to make a correct assessment. In fact, to confirm the diagnosis and frame the disease, some instrumental tests are necessary, such as optical coherence tomography (Oct), a modern technique that has made it possible to analyze retinal structures with ever-increasing detail and resolution. “The simple Oct, however, does not allow – explains Midena – a study of the retinal microcirculation, guaranteed instead by the angiographic techniques with dye (fluorescein angiography, Fa) and now by the new diagnostic method represented by the Oct angiography (Octa) which, thanks to an innovative imaging technique, increases the already considerable diagnostic possibilities of the Oct and also provides information on the vascular network, based on the analysis of signal changes during repeated retinal scans “. The choice of the exam is therefore up to the specialist, who will decide, based on the clinical picture found and the therapeutic needs, to perform a single exam (for example only Oct or Fa) or a combination of several exams (for example Oct plus Fa) . “Starting from the assumption that anti-Vegf drugs, which have now entered clinical practice for about 20 years, are effective and represent the gold standard for the treatment of AMD – continues Midena – over time we have verified that the absolute efficacy is correlated to the number of intravitreal injections carried out during the year and the efficiency of this treatment is certainly linked to the characteristics of the treatment regimen we choose “. There are two broad categories of treatment schemes, proactive and reactive. Among the proactive treatments we mention the ‘fixed’ one and the Treat & Extend (T&E), which have as their main feature that of treating patients regardless of the neovascularization activity. “These therapeutic treatments, supported by clinical evidence, however require an ad hoc organization – continues the expert – In the specific case, the T&E allows us to reduce the number of injections, limiting the number of visits (a need particularly felt in this pandemic period), with the benefit of obtaining an increase in visual acuity “. “But in order to carry out this therapeutic strategy – specifies Midena – there is a need for a well-structured organization of the reference specialist center, with the possibility of evaluating the activity of neovascularization, practicing the intravitreal injection and planning the subsequent treatment. based on the results, possibly in a single day. This facilitates the planning of the therapeutic path, also adapting it to the patient’s needs “. An objective that could be achieved more easily through the creation of Units dedicated to the management of macular pathology within hospitals where the maculopathic patient is taken care of, being able to carry out everything he needs in a single day. : from the eye examination, to the instrumental diagnosis, to the delivery of the injection procedure.