New prevention and monitoring strategies for neovascular AMD

Bethesda, MD-Nutritional supplements continue to be a viable prevention strategy for neovascular age-related macular degeneration (AMD), said Emily Chew, MD. 

With the original AREDS study conducted between 1992 and 2001, a combination of vitamin C, E, beta-carotene, and zinc created a 25% reduction in the progression to delay AMD after 5 years, but the combination “didn't work as well for geographic atrophy,” said Dr. Chew, deputy clinical director, National Eye Institute (NEI), Bethesda, MD.

“We've recommended this for patients with intermediate AMD. That means bilateral large drusen, or a late AMD in one eye,” she said.

Lutein and zeaxanthin-unavailable when the first study was initiated-were incorporated into the AREDS2 study, as were Omega-3s. The NEI had dietary data from AREDS that suggested they “may be very important, as well as Omega-3,” she said.

The AREDS 2 study was designed to determine what, if any, additive effect lutein, zeaxanthin, and Omega-3 would have to the original supplement.

The NEI also compared the addition of lutein and zeaxanthin versus the original supplement without it.

For advanced AMD and neovascular AMD, there is a protective effect. “It's specifically beneficial in reducing the risk of going to neovascular AMD, and less so for geographic atrophy,” she said.

“While we found there was a substitution for beta-carotene with lutein and zeaxanthin that was perhaps very important,” she said. “And omega-3 actually wasn't actually in any way successful or helpful.”

As most clinicians are now aware, the AREDS2 supplement substitutes lutein and zeaxanthin for beta-carotene as the former are better at reducing the risk of a cancer found in former smokers, Dr. Chew said.

The NEI also recommends the supplements for patients with geographic atrophy, because “30% of patients who have geographic atrophy will actually develop neovascularization,” she said. “It's important to actually prevent both groups with the oral supplements.”

Current monitoring strategies

Current monitoring strategies

Although the current anti-vascular endothelial growth factor (VEGF) injections are highly effective, in the long run, the vision doesn't always remain, Dr. Chew said.

People who begin treatment with good baseline vision are likely going to maintain their vision. However, those who start with worse vision (20/50 or worse) are likely to improve slightly, but not return to pre-diseased levels.

“The crucial predictor for good vision at one year following treatment is actually your baseline visual acuity,” she said.

Traditional monitoring strategies for neovascular AMD have been the Amsler grid and the Home Monitoring Of the Eye, which was used by the AREDS2 study using a telemedicine method.

“This was an ancillary study of the AREDS2 supported by the National Institutes of Health (NIH) with additional funding from Notal Vision,” she said. “We assessed whether a device [ForeseeHome, Notal Vision] plus a standard care versus a standard care would be better in actually identifying patients earlier with neovascular AMD.”

Patients using the device would look into a monitor, have their tests interpreted by a reading center, and be alerted by their physician when there was noncompliance or when the test indicated an alert.

Of the 1,520 participants, 51 in the device arm were noted to have neovascularization compared to 31 in the standard arm, Dr. Chew said.

Perhaps most interesting, however, is the change in visual acuity.

“Those who were given the device had only a 4-letter change, versus that of the standard arm, where there was a 9-letter change,” she said.

Neovascularization was also present in a smaller number of device users, she said.

“Our results were much better than we’ve seen in the previous literature,” she said. “The false-positive was about 2.4%, and this extrapolates to about a false rate every 4.2 per monitoring years. This means 80% of participants actually did not have a false alarm.”

Dr. Chew advised clinicians to talk to their patients with intermediate AMD who should consider taking AREDS or AREDS2 supplements for prevention.

Patients would also benefit from at-home monitoring with the device to detect neovascularization at an early stage, she said.

Patients who were monitored had better visual acuity-more participants with 20/40 or better- and the monitoring increased the likelihood of the maximum visual acuity results following the treatment of anti-VEGF therapy, she said.

She noted the NEI is still evaluating the cost-effectiveness of these devices and of various monitoring strategies.

Emily Chew, MD

E: echew@nei.nih.gov

This article was adapted from Dr. Chew’s presentation at the 2015 meeting of American Academy of Ophthalmology. Dr. Chew does not have any financial disclosures.