Next-Level AMD Management
Advances have the potential to improve care and help patients maintain usable vision.
AT A GLANCE
- Age-related macular degeneration (AMD) remains one of the most common causes of vision loss among people older than 60 years of age.
- Home monitoring, genetic testing, and AI are helping to detect AMD and its progression earlier.
- Initiating treatment earlier in the disease course can help preserve vision. Last year, the FDA authorized the first treatment for dry AMD—a form of low-level light therapy known as photobiomodulation.
Age-related macular degeneration (AMD) is one of the most common causes of vision loss among people older than 60 years of age. AMD affects an estimated 18 to 20 million individuals in the United States, approximately 1.5 million of whom have advanced disease and are at risk of significant vision loss. As the US population ages, these numbers are expected to increase, potentially doubling by the year 2050.1
Fundus photography, OCT, OCT angiography, and Amsler grid testing have been the mainstays in AMD management for years. However, ongoing research and development may improve care and help patients maintain usable vision longer.
This article reviews various advances, including home monitoring systems, genetic testing, and a recently FDA-approved treatment using low-level light therapy, that may soon bring about a paradigm shift in managing this condition.
HOME MONITORING
Foresee Home Monitoring Program
The Foresee Home Monitoring Program (Notal Vision) is designed to help detect conversion from dry (ie, nonexudative) to wet (ie, exudative) AMD. Patients take a short daily test on the device, and the results are transmitted to a diagnostic monitoring clinic. If a statistically significant change in macular metamorphopsia is noted, the diagnostic monitoring center alerts both the patient and their eye care professional, and an appointment is recommended to determine if conversion has occurred and whether treatment is indicated. Home monitoring can catch conversion earlier than conventional monitoring alone, allowing treatment to begin while the patient’s baseline visual acuity is better preserved.
In an analysis of 306 eyes that experienced conversion from dry to wet AMD between October 2009 and 2018,2 the Foresee Home Program identified 69% of the conversions—similar to the 64% reported in the initial Age-Related Eye Disease Study 2 HOME study.2
More importantly, a retrospective study of patients in the AAO’s Intelligent Research in Sight Registry found that 83% of those whose conversion was detected early with the Foresee system maintained a VA better than 20/40 compared with only 34% of those who received the standard of care.3 These results highlight the Foresee system’s ability to catch conversion earlier, leading to improved visual outcomes.
Scanly Home OCT
In 2024, the FDA approved the Scanly Home OCT (Notal Vision). This compact home OCT device connects to a health portal, and an AI-based monitoring system scans OCT images for fluid that could signal a need for treatment. The physician can modify the amount of fluid on OCT that triggers a response, allowing for personalized monitoring.
A prospective, longitudinal pilot study found a 94.7% correspondence in accuracy between the Scanly system and manual graders.4 A prospective observational study assessed the feasibility of daily OCT imaging using the Scanly unit in patients with wet AMD and found that 13 of 14 were able to obtain a scan of sufficient quality for analysis. Overall, the quality of 99.3% of scans obtained with the Scanly system was rated as good, and fluid was successfully quantified on 86.5% of the images. Of 35 patients found to have fluid in the office, the Scanly system correctly identified 31 (89%). For 14 scans judged with in-office OCT to have no fluid, the Scanly system did not detect fluid on 10 (71%). For all cases in which there was disagreement, the volume of fluid involved was less than 10 µl, which has since become the threshold for the fluid alert.5
All participants in the study reported that instructions were clear and the device was easy and comfortable to use.5
The DRCR Retina Network is currently conducting Protocol AO (NCT05904028), a trial that is designed to compare the treatment for wet AMD guided by home OCT versus a traditional treat-and-extend strategy. While the device is not yet widely available, it is a potential option optometrists should keep an eye on for those who are interested in offering home monitoring.
GENETIC TESTING
Genetic tests for AMD are commercially available from at least two companies, Visible Genomics and Arctic Dx. A simple cheek swab is performed, and the sample is sent to a lab and analyzed for specific genetic markers associated with AMD. A report on the patient’s risk of conversion to advanced AMD is then generated. The information may be used to individualize care, increase the frequency with which high-risk patients are seen, and guide intervention.
PHOTOBIOMODULATION
Last year, the FDA authorized the first treatment for dry AMD, the Valeda Light Delivery System (Alcon, formerly LumiThera). The noninvasive device delivers a form of low-level light therapy, photobiomodulation (PBM), to enhance mitochondrial function and improve cellular energy production.6
The LIGHTSITE III trial evaluated the Valeda’s multiwavelength PBM treatment of dry AMD.7 The study’s primary endpoint was an improvement in BCVA of at least 5 letters or 1 line over 24 months. Overall, 58% of patients gained more than 5 letters, 18% gained more than 10 letters, and there was a mean gain of 13.4 letters. The treatment was found to be safe and well tolerated.6
PBM therapy with the Valeda system is intended for patients with dry AMD whose BCVA is 20/32 to 20/70 and who have at least three medium-sized drusen, one large drusen, or noncentral geographic atrophy (GA) without evidence of wet AMD or central GA. PBM treatment typically consists of nine sessions over a period of 3 to 5 weeks, two to three times per year.7
AI
Research has shown that deep learning—a form of machine learning that uses deep neural networks—can diagnose AMD and predict patients’ risk of exudation and their need for injections within the next 2 years.8 Deep learning has also been shown to predict patients’ responses to treatment with various anti-VEGF agents better than human counterparts.8 In addition, one study found that deep learning was able to predict the conversion to GA in 12 months.8
The iPredict (iHealthScreen) is an automated AI-based system designed to allow non-eye care specialists to screen individuals for AMD and predict which patients with early AMD are at risk of progression. A study found that the tool was able to detect referable AMD with 88% accuracy and predict individual risk scores for the development of late AMD within 1 to 2 years.9
The iPredict is available in several countries outside the United States. iHealthScreen has filed a 510(K) premarket submission for the iPredict device, making it the first company to apply for FDA clearance of an AMD screening tool.10
LOW VISION AIDS
Despite the advances in managing and treating AMD, many patients will, unfortunately, still lose vision. In such cases, the importance of low vision aids and a referral to an eye care provider who specializes in low vision cannot be overstated.
A MORE PROACTIVE MANAGEMENT APPROACH
New options for the early diagnosis and treatment of AMD and the detection of disease progression have the potential to improve patient care. Many of the new modalities will soon be available to optometrists, allowing them to play a key role in preserving patients’ vision through personalized monitoring and treatment.
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