A coherent overview of the current situation in neovascular AMD

Dr Jennifer Arnold speaking at the EURETINA symposium on neovascular age-related macular degeneration The EURETINA symposium on neovascular age-related macular degeneration (AMD), entitled ‘Novel Insights and Lessons Learned’, was very well attended – and for good reason. Held on the opening day of the 16th EURETINA Congress in Copenhagen, the symposium featured a series of presentations that provided both a coherent overview of the current situation in neovascular AMD and a detailed examination of what has been learned to date. Chaired by Prof Ursula Schmidt-Erfurth, Austria, and Dr Jennifer Arnold, Australia, the symposium began with a comprehensive look back at the treatment results in “the real world”, outside the highly controlled settings of large trials. “We need data from real life to see whether these treatments work long-term,” said Dr Paolo Lanzetta, Italy. For this purpose, the LUMINOUS study was set up. Designed to provide five-year safety and efficacy data for all licenced indications of ranibizumab, the LUMINOUS study was an observational, non-interventional, multicentre study of over 30,000 patients. What struck the researchers was the vastly greater patient diversity from this “real-world” study than those seen in large randomised controlled trials (RCTs). Patients were generally older, ethnically more diverse and had more comorbidities. “Data coming from big RCTs and those from real-world evidence complement each other,” said Dr Lanzetta. The combination should help guide clinicians, who primarily treat patients outside the confines of strict study protocols. Dr Schmidt-Erfurth spoke next. Her presentation, ‘The future outlook: precision medicine in anti-VEGF therapy’, included a detailed examination of the prognostic value of pathognomonic lesions of neovascular AMD, as seen in spectral domain-optical coherence tomography (SD-OCT) images. These included intraretinal (cystoid) fluid (IRF); subretinal fluid (SRF); and pigment-epithelial detachment (PED). “There is a linear correlation between IRF and best corrected visual acuity (BCVA) at treatment-naïve presentation,” said Prof Schmidt-Erfurth, with greater IRF volume correlating with lower BCVA. “Further, reduction in IRF correlates with BCVA gain.” “On the other hand, SRF area may have protective effects on BCVA,” she said. These markers can be analysed via a technique called “machine learning”, computer algorithms which might then recommend personalised treatment regimens based on what is seen on OCT. WHAT KEEPS RESEARCHERS BUSY Prof Patricia D’Amore, USA, then provided delegates with a fascinating update of what currently keeps laboratory-based AMD researchers busy. “Neovascularisation associated with AMD is the endpoint of injury to the retinal pigment epithelium (RPE), and reflects a chronic hypoxic and inflammatory process,” said Dr D’Amore. “So, although VEGF neutralisation provides symptomatic treatment, it does not impact the processes that underlie the development of AMD, including RPE injury and breaks in Bruch’s membrane.” Prof Eric Souied, France, brought delegates up to speed regarding angio-OCT in the management of AMD, which he finds very encouraging, despite the currently bewildering series of new, difficult-to-interpret findings. “Are we simply impressing each other with fancy, yet useless information?” he asked. “No, I believe the that the detailed findings will become increasingly useful in the treatment of patients.” Dr Arnold compared and contrasted ‘treat-and-extend’ regimens with standard PRN treatment, concluding that treat-and-extend can achieve good results if we treat intensively until lesions are unactive, and remain vigilant to detect recurrences early. Dr Marco Zarbin, USA, concluded the symposium with a look at the drugs in the pipeline, including Fovista and other pathway-specific, potentially synergistic anti-AMD treatment modalities.