COPHy 2023: Debating the value of home monitoring as a management option for AMD

The various aspects of home monitoring for patients with age-related macular degeneration are discussed in this point/counterpoint by Prof. Rufino Silva, University of Coimbra / Coimbra Hospital and University Centre, Portugal, and Univ.-Prof. Dr. med. Robert P. Finger, PhD, Department of Ophthalmology, University of Bonn, Germany. The two ophthalmologists outlined these perspectives with Sheryl Stevenson, Group Editorial Director, during the 14th annual Congress on Controversies in Ophthalmology in Lisbon, Portugal.

Video transcript

Editor’s note: This transcript has been edited for clarity.

Sheryl Stevenson: We're joined today by Dr. Silva at this year's Controversies in Ophthalmology meeting from Lisbon, Portugal.

Dr. Silva, welcome to you. We're delighted to have you join us as part of this debate regarding home monitoring: Will it be an important management option for patients with AMD? You will be presenting the perspective from the 'yes' side of this debate. We will also hear later from Dr. Robert Finger regarding the other side of the debate. I'd be curious to hear about the 'yes' side of the argument.

Prof. Rufino Silva:Okay, the question or the point of the debate is home monitoring. Will it be an important management option for our patients with AMD? As you know, the answer is yes. This is what I am going to show, the 'yes.'

We have a lot of unmet needs, so we are treating these patients for the last 15 or 17 years with anti-VEGF. We still have a lot of unmet needs to resolve. For example, one of the most important is related with baseline visual acuity. As we know, the baseline visual acuity is the most important factor for having a final good visual acuity. Patients that start with, for example, with low vision they never reach the level of driving vision. Patients who start being treated with, for example, 20/40, driving vision, they are more able to maintain this vision during the following years. As you know, they receive the same number of treatments of today's patients who started being treated, for example, with 20/200. We are losing a lot of resources for having bad results.

This is one point that is in favor of using the home monitoring OCT. This is very important because we can detect the fluid and treat the patients and offer the patients the treatment immediately after the onset of the fluid on the retina.

The other aspect is related with reducing the burden. We can't treat all the patients as we would like to do. For myself, I am frustrated with the results I have. It is impossible to have all the patients receiving, for example, 8 injections the first year; 6 injections the second year; 5 injections the third year. This is the minimum we need to do to at least maintain...during the first 3 years. This is almost impossible to do this, considering the number of patients we have.

Having this home monitoring system or the home OCT device, we can detect the fluid...and only when the fluid appears, to send the patients to be treated in the following at least 1 week, not more than 1 week, this can be done. This shows the fluid like we see at the office. It works very well and...the maps, the curves of fluid, and also we know that when we have the fluids for a short period of time, and we treat the patient with the fluid for a short period of time, the fluid disappears also in a short period of time. This is a great gain in terms of final visual quality outcome. This is very important.

Another point I would like to highlight is this. We treat the patients, then we observe the patients and we do the OCT at the office for 1 month or 2 months after the last injection and we feel that if we detect fluid and the sister protocol we use most frequently is that you don't extend so we reduce or we increase the time that we are restricted to. This is information that is given in only one point and in this point is related with interval. We are not sure.

For example, I am treating every month and I see the patients. It's good because no fluid, but if I don't know how it will be in 2 months or in 15 days more, I don't know. My decision is not based in reality. It is based on an assumption that probably the protocol I want to implement probably it will work. But it is an assumption. It's not reality. With OCT I have the reality, I have the real information. I think these are the most important aspects in favor of implementing the home OCT monitoring. I think that at the end, we will have better results, better outcomes for the patients, and reduce the burden for patients, for doctors, and for institutions and the costs.

Stevenson: Okay. Thank you for your insights. Appreciate that.

We're joined by Dr. Robert Finger today. Thank you so much for joining us. We've heard from Dr. Silva on the debate today regarding home monitoring for AMD. Is it important? Is it an important option for patients? And he's provided the 'yes' perspective. And we'd love to hear you providing the opposing view, the 'no' perspective. Can you take a few minutes and summarize your presentation?

Univ.-Prof. Dr. med. Robert P. Finger, PhD: Thank you, Sheryl. Yes, very happy to summarize my viewpoint on this, which is essentially, no, I don't think it's going to be useful to add home monitoring for neovascular AMD to our portfolio of different assessment techniques and monitoring approaches.

First of all, I wouldn't know where to add it in on top of what we're doing anyway. An add-on in diagnostic and functional testing. How would we do this? Do we provide everyone with a device that we have enabled to do either functional testing if this might be a smartphone, tablet, or something, or actually give everyone a home OCT, which I guess is very expensive to date, at least, where we don't have small-scale devices produced for home use yet.

This is a big hurdle in implementing home monitoring where we don't know with what device, how we will get the device to the patients, and then also operating any devices by patients. They're all older folks. They might not see well. They might not use much technology in their day-to-day life, and may not feel comfortable with operating this. Certainly, the doctors who would then—if we were talking about imaging—the doctors who would need to look at the images would want good images to be uploaded so that they actually can use those images. Do we train patients to do this? There's a lot of questions around this, which have not been answered to date. I haven't seen many studies, which aim to address this at all.

What we haven't talked about at all is reimbursement. Who's going to pay for this? As of today, I don't know any health care plan who would pay for ophthalmic home monitoring, certainly not in Germany where I'm based. This would either need to be the patient who then buys the device and kind of does the home monitoring just for themselves. If they then provide any data to the doctors, then the doctors wouldn't be reimbursed for looking at this because it's data that's not generated as a diagnostic procedure or monitoring procedure as part of the normal health care plan looking after patients with neovascular AMD. In summary, while it's technically fascinating to bring this closer to the patients, I think there's many, many unanswered questions as of now, which will for the foreseeable future stop us from implementing this for patients, and doctors, of course.

Stevenson: What is your take-home message for clinicians?

Finger: Essentially, don't worry about home monitoring because there's no way it's going to hit our practices within the next few years. We, of course, keep looking at options which might become available for home testing, home imaging, and these things. The take-home message is as of today it's not working—not because it's not technically possible, but because it's just not integrated into the health care system. The services delivered. The reimbursement structures. This is not going to be the case for the foreseeable future either.