I have been fortunate enough to practice 30 years in what I would characterize as the “Golden Age of Therapies for Vitreoretinal Diseases” and this is most relevant in the treatment of Age-Related Macular Degeneration. As the leading cause or irreversible blindness among elderly patients in developed countries, it affects more than 1.75 million individuals in the US. Nearly 2 million Americans over the age of 55 are diagnosed with AMD each year. As the population ages, AMD is projected to affect the sight of over 10 million people by 2030.
Loss of vision in patients with AMD can be secondary to geographic atrophy of the retinal pigment epithelium (RPE) and choriocapillaris called “non-exudative AMD,” or secondary to the development of abnormal blood vessels under the retina that result in leakage of fluid or blood called “exudative AMD.”
Treatments have been available since the early 1980’s, however the last ten years have seen an explosion of newer and better treatments resulting in preservation of vision in millions of elderly patients for both wet AMD and now we have the first ever treatment for dry AMD with geographic atrophy.
The first approved treatment for exudative AMD was in 1982. Laser photocoagulation was used. The laser was focused on the abnormal blood vessels and a burn was applied to destroy the source of bleeding. Unfortunately, this could leave a scar with a noticeable “blind spot” near the central vision and recurrences were common.
Photodynamic Therapy was introduced in 2000 and involved using a drug called Verteporfin and a cold laser in combination. The drug was injected into the bloodstream and accumulated in the abnormal blood vessels under the retina. A “cold” laser was then applied to the retina which created a reaction to destroy the blood vessels. Unfortunately, although vision was preserved initially, the long term loss of vision continued.
The most revolutionary treatments for wet AMD are injections of drugs into the eye which are described as anti-VEGF agents. VEGF is a protein in the eye that promotes the growth of abnormal vessels and with regular injections, this protein is blocked and the vision can be preserved for years. The first drug was Macugen introduced in 2004, followed by Avastin (2005), Lucentis (2006) and Eylea (2011). More recently, Vabysmo (2022) was approved and has both anti-VEGF properties as well as a blocker of a secondary pathway (Ang-2) that appears to be more effective with longer duration of action.
Finally, the first treatment for dry AMD with geographic atrophy, Syfovre was approved just recently which will now offer hope to selected patients who can look forward to a reduction in the rate of vision loss.
The future remains bright with clinical trials (here at RAWNY and at other sites around the country) involving gene therapy, biosimilars (drugs which can replace Lucentis, Avastin and Eylea at lower cost) and other drug formulations. The future is indeed bright for our patients.
