Strategies for improving early detection and diagnosis of neovascular age-related macular degeneration

Abstract

Treatment of the neovascular form of age-related macular degeneration (AMD) has been revolutionized by the introduction of such agents as ranibizumab, bevacizumab, and aflibercept. As a result, the incidence of legal blindness occurring secondary to AMD has fallen dramatically in recent years in many countries. While these agents have undoubtedly been successful in reducing visual impairment and blindness, patients with neovascular AMD typically lose some vision over time, and often lose the ability to read, drive, or perform other important activities of daily living. Efforts are therefore under way to develop strategies that allow for earlier detection and treatment of this disease. In this review, we begin by providing an overview of the rationale for, and the benefits of, early detection and treatment of neovascular AMD. To achieve this, we begin by providing an overview of the pathophysiology and natural history of choroidal neovascularization, before reviewing the evidence from both clinical trials and “real-world” outcome studies. We continue by highlighting an area that is often overlooked: the importance of patient education and awareness for early AMD detection. We conclude the review by reviewing an array of both established and emerging technologies for early detection of choroidal neovascularization, ranging from Amsler chart testing, to hyperacuity testing, to advanced imaging techniques, such as optical coherence tomography.

An Eye on Age-Related Macular Degeneration: The Role of MicroRNAs in Disease Pathology

“…The hallmark of NV AMD is the growth of new blood vessels generally sprouting from the choroid, penetrating the overlying Bruch’s membrane, and growing within the subretinal pigment epithelium space or the subretinal space [36, 37]. In NV AMD the growing neovascular membrane is initially capillary-like [36], and these fenestrated and friable vessels frequently leak serous fluid, lipid, and blood into the retina and surrounding spaces.…”

“…Macrophages release a range of other mediators, including pro-inflammatory and proangiogenic factors. At some point, the balance between growth factors and inflammatory mediators shifts toward an antiangiogenic, anti-proteolytic, and anti-migratory state, and the CNV lesion becomes fibrosed [36, 37]. This process is known as disciform scar formation, and is associated with irreversible visual loss [36].…”

The Finnish national guideline for diagnosis, treatment and follow‐up of patients with wet age‐related macular degeneration

“… In the TER, the maximum follow-up interval with anti-VEGF treatment has been reached and the adequate treatment response has been maintained, which after followed without anti-VEGF treatment for the past 6-12 months (with no signs of active wAMD).  The Amsler grid can be used in self-monitoring (Yannuzzi 1982;Augustin et al 2005;Keane et al 2015) as well as patients monitoring their symptom (e.g. changes in visual acuity, distorted vision or increased difficulty in reading).…”

Performance, usability and comparison of two versions of a new macular vision test: the handheld Radial Shape Discrimination test

“…The observation that patients with advanced macular disease, in particular neovascular AMD, often reported their vision as distorted led to the development of the Amsler grid (Amsler, 1953) which remains widely used as a means of detecting metamorphopsia (Faes et al, 2014; Keane et al, 2015). More recently, alternative methods of measuring visual distortions based on various hyperacuities have been developed (Pitrelli Vazquez & Knox, 2015).…”