Doc, how many more shots?” Regardless of your detailed, diagram-assisted discussions, this question and its derivatives frequently resurface. “Doc, you said three shots, right?”

Wrong, at least for more than 90 percent of wet age-related macular degeneration patients. Many of us tell patients that wet AMD is like hypertension; we have good treatments, but similar to pills for blood pressure, they are not a cure and need to be given repeatedly, in many cases indefinitely.

Many of our long-term wet AMD follow-up analyses are sobering. Most recently, the patients who were examined five years after CATT enrollment were reported to have lost 11 mean letters compared to the two-year endpoint. The authors summarized bluntly, “visual gains … were not maintained.”1

Possibly patients were under-treated after they completed the core two-year trial, because at five years 61 percent had intraretinal fluid and choroidal neovascular membrane area had grown by 59 percent while they received less than five mean intravireal injections annually. On page 28, Ivan Suñer, MD, MBA, and Marc Peden, MD, provide a perspective on optimizing long-term outcomes in this chronic disease: more frequent dosing translates into greater visual benefit.

While injection fatigue is often cited as a reason for reduced real-world treatment frequency, the majority of wet AMD patients appear to strongly prefer treatment regimens associated with the greatest amount of visual benefit, even if these involve a high treatment burden such as monthly injections.2 Rather, it may be payers who most directly encourage injection fatigue given recent audits of monthly dosing of approved agents for wet AMD—even in the context of persistent exudative disease activity causing visual acuity loss. Under such scrutiny and financial duress, it becomes more palatable for doctors to accept intraretinal fluid in wet AMD eyes and extend treatment intervals beyond what is likely ideal for patients.

Pursuing individualized medicine, retina specialists continue to optimize approaches aimed at limiting treatment burden while preserving optimal outcomes. On page 22, Carl Regillo, MD, Jeff Heier, MD, and David Reed, MD, provide their tips for employing treat-and-extend dosing.

I tell my wet AMD patients, “It’s not forever, forever. It’s just forever for now. Until we have something better.” Emerging treatments, including the novel VEGF-blocking agents brolucizumab (Alcon) and abicipar (Allergan), and dual-targeting therapies combining VEGF blockade with angiopoitin-2 and platelet-derived growth factor blockade hold great promise. Until new options are available, more frequent anti-VEGF dosing seems to be the best course to optimize long-term outcomes.

1. Comparison of Age-related Macular Degeneration Treatments Trials (CATT) Research Group, Maguire MG, Martin DF, Ying GS, et al. Five-year outcomes with anti-vascular endothelial growth factor treatment of neovascular age-related macular Degeneration: the Comparison of Age-Related Macular Degeneration Treatments Trials. Ophthalmology. April 20, 2016. [Epub ahead of print]
2. Mueller S, Agostini H, Ehlken C, Bauer-Steinhusen U, Hasanbasic Z, Wilke T. Patient preferences in the treatment of neovascular AMD: a discrete choice experiment. Ophthalmology. 2016;123:876-883.