Treatment for AMD

My mother was diagnosed with macular degeneration this December. She has a "dry" eye and a "wet" eye. She had the steroid injection and laser therapy x1 to the wet eye in January (could have been photodynamic therapy). My question is what are the criteria for the use of these treatments? Are there different types of "wet" macular degeneration? We have read several conflicting articles about the criteria for the use of the steroids, such as previous use of laser, scarring or atrophy of 25%or more of the lesion, and different subtypes of lesions. These would disqualify her in some of the articles we researched. The FDA is now looking at using macugen along with laser/photodynamic therapy. What is your opinion about this and what do you do in your practice? Where can we find information about the latest studies that may help my mother.

Answer:

The treatments for wet macular degeneration are in a state of evolution just now. Macugen injections are better than no treatment for all types of wet macular degeneration as long as they are not greater than 12 disk areas in size. The various types - occult versus classic - depend on the way the vessels look when the fluorescein dye is injected into the vein and the pictures are taken. Photodynamic therapy is also better than no treatment for most types, but not all types. For very large vessels and for eyes with worse levels of visual acuity, the benefits of PDT become vanishingly small. There is no good evidence yet to say that Macugen is better than PDT, but the results of a comparison study are likely to be out before a year more. There are many new experimental treatments in trials now - VEGF trap (an injection into the eye), squalamine (an intravenous infusion), rhufab (an injection into the eye), and others. Combinations are being used, such as triamcinolone injected into the eye plus PDT, or Macugen injected into the eye plus PDT. I use these combinations at times, as do most retina specialists I know of, but the evidence base is still growing and we are making decisions in many cases based on inadequate data. A high percentage of scarring in a lesion does make the response to any kind of treatment less likely, and may lead to a recommendation against any treatment. The best recommendations really depend on particulars of the case, and there is no substitute for a consultation with a retinal specialist who will answer your questions. The best source for reliable information is PubMed (just google that word and follow the links), but most of it will be quite technical and daunting for the layman; nevertheless, I would encourage you to look it over. You will find a wealth of articles by searching on macular degeneration as a key word. This information is all peer reviewed, which cannot be said for much information that is circulated to the general public. Good luck. Addendum 1/18/2017: The above answer was written in 2004. In 2017 things are clearer, but the science continues to evolve. Now almost all patients receive one of three intravitreal injections as treatment: bevacizumab (Avastin), ranibizumab (Lucentis), or aflibercept (Eylea). They are approximately equal in efficacy, but differ by a factor of 20-40 in price. Avastin is used off-label. It has not been, and will never be, FDA approved for use in wet macular degeneration. It works, and Medicare pays for its use, and is the most commonly used agent for this purpose, but the pharmaceutical company has no interest in proposing it for FDA approval as they have a vested interest in Lucentis, which they designed specifically for use in wet macular degeneration and priced accordingly. Doctors co-opted Avastin, designed for use in cancer, and it is effective, and much cheaper, because one vial of the drug can be divided into 300 aliquots for ocular use. New drugs are being studied, and undoubtedly the landscape of therapy will continue to change.