Treating the Whole Patient: When to Switch (and Why)

Caroline R. Baumal, MD: There’s a factor that’s not captured in studies, and that's taking everything together as a whole and the patient factors. There are certain patients who say, ‘I hate these injections. I don't want to do them.’ While we want to do what's best for their eye, the way that they feel about this does influence how we feel about it.

There's certain patients who always come in late or they just don't want to come in. There is something like in a study protocol you're stuck to a strict study protocol, but in the real world you deal with all the other factors where people say, I just don't want to come in. Or you might look clinically and realize this eye doesn't have a good visual prognosis, so I don't have to push it as hard. Maybe that's not the way to be because in the studies you don't have that option. So we do have these biases that we don't really think about when we see patients that affect how we treat them.

David Eichenbaum, MD: Or if you see your patient and they're doing great, they don't mind the shots as much as the average patient — no one ever comes in and says ‘Dr. Eichenbaum, I can't wait for this shot. Can we do one next week, a bonus shot?’ No one does that, but some of them don't seem to mind if we go out of our way to make them as comfortable as possible, and you're more likely to give that sort of easy patient the frequent injection and we’ve all had the hard patient.

They ask every time. After their 70th shot they ask, ‘Doctor, is this my last injection?’ And you have to say, ‘No, we’ve gone over this 70 times.’ It's hard to bring that patient in just because of the human factor, and you're exactly right, that's omitted from the clinical study data. So what we do, we try treat and extend. We try switching. I switch between commercially available agents and the clinic population. Do you switch?

Dr. Baumal: If I switch, I like to have a reason. Typically, I use all of the medications, and a lot of my preliminary choice depends on what's available. Sometimes it depends on insurance. There haven't been huge differences shown with regard to what you start with, so sometimes we have to consider patient's insurance. I don't like them to incur a cost if they don't have to, but fortunately we have a lot of choices, and I think that's a very good thing. Sometimes I switch if I don't see a response to one agent. I wanted to ask you what makes you decide to switch, and then I'll tell you what makes me decide to switch. Since you are a fellow with me, I'm curious to see if it's the same thing.

Dr. Eichenbaum: It goes back to training. We had basically bevacizumab and ranibizumab when I was a fellow. You need a reason to switch, and my reason to switch is almost always image-based. It’s rarely vision-based. It has to be either the inability to extend beyond a reasonable interval, or the inability to dry the retina. I would contend that almost nobody with wet macular degeneration is an anti-VEGF non-responder.

They’ll all respond to some extent to any of the agents, but do they respond enough is the question, or do they respond completely, or can I get them an extra week or 2 weeks or 4 weeks if I switch them to an agent with a higher potency or more volarity or whatever you want to call it that makes it stickier to the VEGF and perhaps dries them out longer? It has to be a reason, and for me that reason is almost always the recurrence or persistence of fluid.

Dr. Baumal: I think that's the reason why most people switch is because we want to have drier OCTs or see if we're leaving any vision on the table. To see if we can get any more visual improvement, that's a tougher bar to cross because these patients are often chronic, and we don’t do ETDRS vision in the clinic, so it's hard for us to know, but the OCT is something we can look at and measure every time. I like how you said even an extra week to these patients means a lot. We think ‘Oh, what's a week?’ but it really does mean a longer time between injections.

I would say that—I like to do this thing to see if patients are responding to the anti-VEGF injection. There are people who we see, and they do have persistence of retinal fluid. I try to go through this exercise: Is that just residual subretinal fluid or is it actively leaking subretinal fluid? I'll often treat the patients with an agent, and I'll try to see them a week later and make sure that they're responding.

Often, you'll see them a week later and the fluid's gone, just the agent that we're using isn’t lasting four weeks. Those patients, although very rarely, I’ll find that patients like that often fluid doesn't go away with any agent, and then you have to decide if you're going to try to inject them more frequently, which I find is very hard for people to tolerate. So that's why there is this quest for more durability in the agents, and agents hopefully that can improve our vision results as well.

Dr. Eichenbaum: There are those really hard patients, the more-than-monthly patients. We sometimes try other things. Sometimes I will get an indocyanine green (ICG) and look for something to PDT. We'll sometimes add some sub-tenon depot steroid. You do different things when you're desperate, but none of that is stuff that has good scientific guidance.

Those are kind of your macular degeneration train wrecks. Fortunately, in my practice and in the clinical trials those patients are few and far between which is good, but you're right about the extra week or 2 weeks meaning a lot of these patients. If you add 2 weeks to their interval, you reduce their lifetime number of injections substantially, which means a lot to a patient who may have another 5 to 10 years of life left and is going to require lifelong treatment or treatment until something better comes out that's truly, truly different than what we're doing.

Dr. Baumal: Patients do better when they switch, but it's just not a lot of patients who really need to switch in my experience.

Caroline R. Baumal, MD: Hello and welcome to this discussion presented by Modern Retina and Ophthalmology Times titled, “Treating Age-Related Macular Degeneration in 2020. I'm Dr. Caroline Baumal. I'm a Professor of Ophthalmology at Tufts University School of Medicine in Boston. Please welcome—okay.

Please join me in welcoming my colleague, and not only my colleague but an ex-fellow from Tufts and a good friend of mine, Dr. David Eichenbaum, who is currently a partner at Retina Vitreous Associates of Florida in Tampa Bay. In today's discussion we'll talk about available therapies and some that are still in development as well as practical considerations in treatment of wet AMD during the post-pandemic era.