February is Age-Related Macular Degeneration Awareness Month. Rishi Singh, MD, Vice President and Chief Medical Officer of Cleveland Clinic Martin Health, spoke with Ophthalmology 360
Question:
February is Age-Related Macular Degeneration (AMD) Awareness Month. How can ophthalmologists contribute to the education and conversation around AMD and general eye health?
Rishi Singh, MD:
Ophthalmologists serve as the frontline caregivers for a lot of patients with eye-related diseases such as age-related macular degeneration, and one of the things that they distinctly do is detect things like bruising or retinal pigment epithelium changes, the earliest signs of macular degeneration. We know at those stages that it’s modifiable in the sense that we can reduce the progression to advanced forms of AMD, and we’ve learned a lot about AREDS vitamins in the past few years. The Age-Related Eye Disease Study has really been helpful.
Having that conversation, at least initially with the patients, about their need for these vitamins, as well as screening and annual visits, it’s really the first and foremost thing that they do with their patients in the population.
Question:
Can you talk about the importance of early detection of AMD? How do you recommend other eye care providers educate patients and the wider community on the risks and symptoms of AMD?
Rishi Singh, MD:
Yeah. When we talk to patients about this condition, we really discuss the blurriness of the vision that might occur. Some of those signs are really subtle. It does require, again, that in-person conversation and in-person evaluation for that matter. Thankfully, with the advent of things like optical coherence tomography or OCT testing, that has become far more commonplace in all practices, optometric practices, ophthalmology practices, [and] retina specialists have them. We can learn a lot about some patient’s progression to advancing forms of the disease. Those have been very valuable techniques.
I think when you talk to the patients individually, having a conversation around the risk factors that they can modify themselves is really an important conversation. Things like dietary changes, low cholesterol diets, low fatty acid diets, certainly low lipids in their profile, and also making sure that they have the other items which are avoiding smoking at all costs to really reduce the progression of disease in those patient populations.
Question:
Can you talk about the treatment options for AMD? How do you determine the best course of treatment for each patient? What are the important factors you consider when determining a care plan?
Rishi Singh, MD:
Well, it’s really tailored, as you said, to the individual patient, and it’s based upon their stage. If they’re in an early-intermediate stage, we recommend the vitamin therapy, [and] we recommend Amsler grid monitoring. We recommend annual follow-ups to make sure there’s no progression in their disease state. When they’re in advanced forms of disease, so for example, the wet form of the disease, there are lots of different treatment options available. Back in 2005 is when we first had our anti-VEGF therapies come to market. They’ve been fabulous at reducing the overall progression of vision in those conditions, and certainly improving vision in many of those patients. More recently, we’ve had some new drugs come to market, which we can speak about as well, but those have been valuable at increasing the durability between the treatments. It’s really helpful to increase that duration that we can dose patients between.
In addition, we are also thankful that we have now complement inhibitors for geographic atrophy, which is an advanced form of the dry disease, and those geographic atrophy drugs now can reduce the visual progression of patients by reducing the tissue loss that occurs from geographic atrium.
Question:
What are some important advancements or things on the horizon that you think are important to highlight regarding AMD?
Rishi Singh, MD:
In the neovascular form of AMD, there have been some really significant advances in the past couple of years. The first is faricimab. It’s a bispecific molecule inhibiting both angiopoietin-2 as well as VEGF-A together. That in itself has a lot of value and benefit in reducing some of the angiopoietin-2 effects of the eye, which are things like inflammation, hyperreflective foci, [and] fibrosis formation. On the VEGF side of things, we also have a high dose of aflibercept molecule now, 8 mg of aflibercept, which is 4 times the molecular dose. It decreases the amount of VEGF that’s available in the eye and improves VEGF suppression, and as a result, can be very valuable at overall reducing the need for frequent injections in a patient population.
Then in addition to this, we have gene therapy products, which are coming to market hopefully soon. Gene therapy has been the holy grail about giving a patient 1 injection, either intraretinaly, subretinaly, or even the supracortal space, and then having that biofactorily produce the product over time. That can reduce the need for these injections and decrease the burden of those injections in those patient populations.
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