Management of neovascular AMD

Contemporary management of neovascular age-related macular degeneration (AMD) has evolved significantly over the last few years, with advances in imaging technology helping to enhance current knowledge about pathophysiological mechanisms that play a role in vision loss due to AMD, according to Edoardo Midena MD at a special session on the EURETINA Guidelines for Management of Retinal Disease yesterday. Choroidal neovascularization (CNV), the hallmark of ‘wet’, ‘exudative’ or ‘neovascular’ AMD, is responsible for approximately 90 per cent of cases of severe vision loss due to AMD. Dr Midena noted that previous models of disease in AMD were incomplete in that they did not encompass subretinal drusenoid deposits (pseudodrusen), subtypes of neovascularization and polypoidal choroidal vasculopathy. Recent work in this domain by Richard Spaide MD has proposed new aspects in the AMD construct to include specific lipoprotein extracellular accumulations, namely drusen and subretinal drusenoid deposits, as early AMD. The deposition of specific types of deposit seems to be highly correlated with choroidal thickness and topographical location in the macula. Dr Spaide’s work proposes that eyes with subretinal drusenoid deposits have a propensity to develop outer retinal atrophy, complete outer retinal and retinal pigment epithelial atrophy, or Type 3 neovascularization as specific forms of late AMD. Since Type 3 neovascularization may never involve the choroid, the term macular neovascularization has been suggested for the entire spectrum of neovascular disease in AMD. Dr Midena said that recent research has suggested that patients with better visual function at the end of treatment for choroidal neovascularization are those where the choroidal vessels are still present, rather than those where the vessels are not completely destroyed or fibrotic.