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Carly Seidman, Keel Yeung, Joseph J Tseng, Kenneth J Wald; Parameters Influencing Clinical Decision Making in Anti-VEGF Therapy for Neovascular Age-Related Macular Degeneration. Invest. Ophthalmol. Vis. Sci. 2014;55(13):3941.
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Long-term management of neovascular age-related macular degeneration (nARMD) is the highest frequency, most labor-intensive activity of most retinal practices. Efficient treatment strategies must be adopted to remain economically viable. Approaches to follow-up include repeat treatment at fixed intervals, extended intervals (“treat and extend”), or on a pro re nata (prn) basis. Retreatment criteria include optical coherence tomography (OCT) or fluorescein angiography (FA) findings, clinical macula exam, and visual acuity changes. Despite other parameters, practice experience has led the authors to hypothesize that treatment decisions are almost always based on OCT.
This prospective observational study, based out of a private retinal practice, included 100 eyes that received an intravitreal injection of any anti-VEGF agent for nARMD as part of a “treat and extend” or prn program. All were status-post three consecutive monthly “loading” injections. The treating retinal specialists documented OCT findings, macula exam, peripheral exam (i.e. presence of retinal tears), visual acuity changes, and whether FA was performed. For each eye, the physicians also noted whether treatment decision was based on OCT or other parameters.
100 eyes of 98 patients, 62(63.2%) female and 35(35.7%) male were included. Since previous visit, visual acuity was improved in 11(11%), decreased in 20(20%), and stable in 69(69%). 46(46%) were on a “treat and extend” program and 54(54%) prn. OCT findings included subretinal or intraretinal fluid (SRF/IRF), retinal pigment epithelium (RPE) detachment, and scarring. Macula exam findings included SRF, IRF, RPE detachment, RPE changes, hemorrhage, exudate, and scarring. Zero eyes had a peripheral tear. Only 1 eye underwent FA. In 100(100%) of cases, physicians based their decision to treat primarily upon OCT.
The ongoing management of patients with nARMD was based primarily on OCT in our short-term study. FA was not routinely performed in our population. Visual assessment did not change therapeutic decisions, nor did macula exam. The yield of vision testing, macula and retinal periphery exam, and FA is likely very low. The implications of an expanding aging patient population and declining resources suggest the need for a larger study to determine the most efficient care for these patients.
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