On this episode of Ready, Set, Retina, Daniel Epshtein, OD, FAAO, sits down with Mary Beth Yackey, OD, to review a case report of intermediate age-related macular degeneration (AMD) that converted to exudative neovascular AMD.
Dr. Yackey is an optometrist in a retina specialty practice at Cincinnati Eye Institute in Cincinnati, Ohio.
Overview of conversion from intermediate to advanced AMD
AMD is an acquired, degenerative maculopathy that can lead to irreversible central vision loss and is characterized by drusen, retinal pigment epithelium (RPE) changes, retinal and choroidal atrophy, and macular neovascularization.1
Of note, AMD classification by the Beckman Initiative for Macular Research Classification Committee is as follows:2
- No Disease: No pigmentary abnormalities are observed, and no or only a few drupelets (≤ 63µm drusen) are detected
- Normal Aging: Only small drusen (< 63µm) are present; no AMD pigmentary abnormalities are present
- Early AMD: No pigmentary changes are present; drusen are between 63µm and 125µm in size.
- Intermediate AMD: Large drusen (> 125µm) and/or any AMD pigmentary abnormalities are present.
- Advanced AMD: Neovascular AMD (nAMD, wet) and/or geographic atrophy (GA, dry)
For patients with intermediate AMD, it is critical that optometrists educate patients on the risk of converting to advanced AMD and understand which structural biomarkers to monitor for patients at high risk of progressing.
With this in mind, some imaging biomarkers that indicate a higher risk of progression to wet AMD include:3
- Color fundus photography
- Drusen volume
- Pigmentary abnormalities
- Optical coherence tomography (OCT)
- Subretinal drusenoid deposits
- Pigment epithelial detachment (PED)
- Hyperreflective foci
Case report of exudative neovascular AMD
Baseline
In September 2023, a 74-year-old white female patient was referred to the retina clinic for an AMD evaluation in both eyes (OU). The referring optometrist had already started the patient on AREDS2 vitamins and given her an Amsler grid to monitor for visual distortions.
The patient complained of mild blurry vision at near and reported needing to use good lighting to read small print for the past 5 months. She hadn’t noticed any distortion in her vision.
The patient’s best-corrected visual acuity (BCVA) was 20/25-2 in the right eye (OD) and 20/25- in the left eye (OS). The patient’s medical and ocular history were not remarkable for contributing factors.
Figure 1: Fundus autofluorescence (FAF) and OCT imaging OD at the baseline visit; the FAF shows granular and hyperautofluorescent defects near the retina, likely caused by drusen and photoreceptor damage, but no signs of geographic atrophy. The OCT scan shows a drusenoid PED and a hyperreflective foci directly above it.
Figure 1: Courtesy of Mary Beth Yackey, OD.
Figure 2: FAF and OCT imaging OS from the baseline visit; some areas of hyperautofluorescence can be seen on FAF, while reticular pseudodrusen can be visualized on OCT.
Figure 2: Courtesy of Mary Beth Yackey, OD.
It is worth noting that the presence of hyperreflective foci may indicate that the patient is at higher risk of converting to advanced AMD.4
At this visit, the patient was diagnosed with intermediate AMD OU and recommended to:
- Continue monitoring for visual distortions with the Amsler grid
- Continue AREDS2 supplementation (which can slow down dry AMD progression by ~55% over an average of 3 years)5
- Begin at-home visual acuity monitoring with the ForeseeHome AMD Monitoring Program (Notal Vision)
- Schedule a follow-up appointment for 6 months
To hear dietary and lifestyle changes that optometrists can recommend to AMD patients, watch the full interview!
ForeseeHome alert
The patient started using the ForeseeHome device in late January 2024 (despite being prescribed it 4 months prior), which is why it is important to give patients an Amsler grid as well, noted Dr. Yackey. Then, in mid-February (2.5 weeks after starting to use the ForeseeHome machine), Notal Vision alerted Dr. Yackey that the patient showed changes in her vision.
Figure 4: Screenshot of testing results OD from the ForeseeHome device; the blue lines indicate the dates that the patient used the device, and the heat maps in the center demonstrate AMD progression from baseline (left) to just a few weeks later (right).
Figure 3: Courtesy of Mary Beth Yackey, OD.
Prompt follow-up visit
The patient was immediately brought in for an evaluation; Dr. Yackey explained that, generally, her goal is to see the patient within 1 week of the alert. At this visit, the patient’s BCVA decreased to 20/40-2 OD (previously 20/25-2) and remained stable at 20/25- OS. She didn’t report noticing any changes in her vision.
Figure 4: FAF and OCT imaging OD; a large PED can be visualized on OCT, there is also hyporeflective subretinal fluid present to the left of the PED. On FAF, you can see hyperFAF to the left of the retina, which indicates there is likely exudation.
Figure 4: Courtesy of Mary Beth Yackey, OD.
Figure 5: FAF and OCT imaging OS; there wasn’t a significant change from baseline in the imaging.
Figure 5: Courtesy of Mary Beth Yackey, OD.
The patient was diagnosed with exudative neovascular AMD OD and intermediate AMD OS and referred to a retinal specialist for anti-vascular endothelial growth factor (VEGF) therapy within 1 week.
Anti-VEGF treatments
The patient was given an intravitreal Avastin (bevacizumab, Genentech/Roche) injection by the retina specialist to manage the neovascularization.
Figure 6: OCT image OD from April 2024 prior to the patient’s second Avastin injection—the first injection happened 6 weeks before. The subretinal fluid has mostly resolved. By the second injection, the patient’s BCVA improved to 20/40+2 OD.
Figure 6: Courtesy of Mary Beth Yackey, OD.
Figure 7: OCT scan OD from June 2024 after the patient had received three Avastin injections; the PED has started to collapse, though there is still a trace amount of fluid present, indicating the presence of an active lesion. The patient’s BCVA improved to 20/30-2 OD.
Figure 7: Courtesy of Mary Beth Yackey, OD.
After three injections of Avastin, the retina specialist decided to switch the patient to Eylea (aflibercept, Regeneron Pharmaceuticals) in the form of 2mg prefilled syringes (PFS), with the hopes of better resolving the exudation, of which she received four injections.
Figure 8: OCT image OD from November 2024 after four injections of Eylea; much of the exudation has been resolved, however, there are still trace amounts of fluid. The patient’s BCVA returned to 20/25-2 OD.
Figure 8: Courtesy of Mary Beth Yackey, OD.
Monitoring AMD patients with at-home testing
The ForeseeHome AMD Monitoring Program is an FDA-cleared, remote, artificial intelligence (AI)-enabled device used to assist eyecare providers detect conversion from dry intermediate to wet AMD.6
The device features a short, easy-to-use test for patients to perform on a regular basis, and once a test is finished, the data is automatically sent to a Notal Vision Monitoring Center that is run by practicing ophthalmologists.6 As highlighted in the case report, if the device’s AI algorithm detects a statistically significant change in the patient’s central visual field, their referring physician’s practice receives an alert.
Dr. Yackey noted that she recommends the ForeseeHome device to patients with vision 20/60 or better in each eye with intermediate AMD. If she receives an alert and sees that the patient has signs of exudative neovascular AMD, Dr. Yackey tries to get them to a retina specialist as soon as possible to begin treatment and minimize the risk of permanent vision loss.
Of note, Notal Vision recently received FDA De Novo clearance for its SCANLY Home OCT machine, which was designed to monitor patients with wet AMD.7 Dr. Yackey remarked that she is excited to see this technology develop, as at-home OCT imaging allows optometrists and retina specialists to understand a patient’s disease course on a more granular level. For example, it could be used to personalize treatment intervals between anti-vascular endothelial growth factor (VEGF) injections, based on the patient’s responsivity to medication.
Conclusion
There has been a recent explosion in research, technological advancements, and treatment options for AMD patients—making it easier for eyecare professionals to tailor the treatment approach for every individual’s unique disease course.
Optometrists can manage patients with intermediate AMD who are at high risk of converting to wet AMD by:
- Looking for biomarkers for AMD progression, such as:
- Color fundus photography
- Drusen volume
- Pigmentary abnormalities
- OCT
- Subretinal drusenoid deposits
- PED
- Hyperreflective foci
- Color fundus photography
- Offering patients multiple options for monitoring their vision, such as an Amsler grid or the ForeseeHome AMD Monitoring Program
- If patients experience visual changes or signs of progression to nAMD, aim to refer them to a retina specialist within 1 week, especially if they have subretinal hemorrhage
- Monitoring patients during and after anti-VEGF therapy for recurrence or signs of progression
