Letting the Good Times Roll in Retina

American Academy of Ophthalmology 2013

Carl D. Regillo, MD; Allen C. Ho, MD; Sunir J. Garg, MD

Disclosures

December 04, 2013

Editorial Collaboration

Medscape &

In This Article

Developments in Dry AMD

Dr. Regillo: Let's move on to dry AMD, because now we are also seeing some developments in dry AMD. Sunir, what do you think is the top news in dry AMD?

Dr. Garg: There is a lot of interest in dry AMD. One of the most interesting things to come out is an in-home monitoring system that patients can use. We found that when patients present earlier, we can treat them earlier and they generally do better.[4] There is a product called ForeseeHome™ (Notal Vision; St. Louis, Missouri) that shows great promise in detecting these lesions earlier than we have otherwise been able to catch them.

Dr. Regillo: This is a home monitoring device that people use instead of the usual way they follow their vision at home -- for example, with an Amsler grid?

Dr. Garg: Exactly. So when patients go home, we tell them to cover one eye at a time, look at a piece of paper with some lines on it, and tell us whether they saw any changes; whereas this system will alert the patient that there has been a change even before they notice a change at home when they are reading.

Dr. Ho: It's a very refined detection system. It transforms the paper to technology. They stopped the study early because patients who were in the monitored technology arm actually had improved visual outcomes.

Dr. Regillo: It's a big deal to stop a study early, especially for something positive. Patients were being detected with choroidal neovascularization (CNV) when their vision was only minimally affected, compared to the standard, in which patients had more vision loss. That was presented at this meeting. It is a big development.

What about treating dry AMD, in terms of slowing the progression of atrophy? What came out of the meeting here?

Dr. Ho: We learned 2 things about dry AMD. One was the AREDS2[5] information that has been discussed before. There has been a formulation change. The big controversy at this meeting (and I don't know that it will be resolved in the future, because we are probably not going to do another large-scale prospective trial) is whether you can individualize therapy based on a patient's genetics. Carl Awh[6] gave a compelling presentation, as did Emily Chew.[7] I don't know how we are going to resolve this, but certainly time will tell. I do believe, however, that the force of personalized medicine is present in other specialties. At some point down the line, we will need to address this.

Dr. Regillo: So there is some controversy about whether genetic testing at this time plays a role in fine-tuning the way we manage dry AMD?

Dr. Garg: That's exactly right. The question is, is personalized medicine right for dry AMD with our current therapy? Over time, we will find that there are certain indications for it. But right now, for the dry AMD patients, I don't see it happening.

Dr. Regillo: Are we going to have resolution to this controversy anytime soon?

Dr. Garg: Not in the near future, and not for dry AMD as we understand it today.

Dr. Ho: Retina specialists will determine how they practice. Currently, I'm still not doing genetic testing routinely in my patients with dry AMD.

MAHALO: Slowing the Progression of Dry AMD

Dr. Regillo: Let's discuss anti-factor D, the MAHALO study.[8] It received quite a bit of attention at the American Society of Retina Specialists (ASRS) meeting a couple months ago. Here at this meeting, we saw an additional genetic analysis. What does it mean to you?

Dr. Ho: This study is making an impact, because whenever you have a list of different strategies to approach a disease -- for example, atrophic AMD -- you don't want to have just one good treatment. This is the first treatment to show some slowing of progression of the growth of geographic atrophy. The vitamin studies didn't -- AREDS 1 and 2 did not show this. So, it's the first study. You can consider it a little surprising because other complement studies have failed to show this to date.

The study that you presented, Carl, was very important because we finally have some hope -- although the differences weren't great. A 20% reduction in growth of the area of geographic atrophy at 18 months is not great. The genetic subtype at 44% difference is potentially significant and could have traction for our patients with atrophy and for the practicing retina doctor.

Dr. Regillo: I'm very excited too. This is the first time that a drug has slowed the progression of dry AMD and shown a benefit in clinical testing. This is a small phase 2 study. Take it with those caveats. The genetic analysis seems to make sense. It seems to amplify the effect of the drug. The genetic polymorphism that was identified in this study is complement factor I. Those patients seem to be driving the results. The medicine is called lampalizumab; it's a humanized antibody fragment injected in the eye that targets factor D. So we will see.

Dr. Ho: As important as that genetic specific complement factor I was, the fact that it was found in more than half the patients in the study means that it could be meaningful in terms of numbers for our patients. So I'm excited about the possibilities.

On the other hand, I will balance that statement by saying that if you are a patient with geographic atrophy and you are losing vision, when your doctor presents you with this medication down the line, you will be saying, "I'm still losing vision." We will be in the situation of having to say, "Let's do this treatment because you will be losing less." Recall our early treatment days in wet AMD.

Dr. Regillo: It's still a promising development.

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