Delayed anti-VEGF start in nAMD linked to 3-letter loss vs 5-letter gain in US cohort of 94,912 eyes

Delayed initiation of anti-vascular endothelial growth factor (anti-VEGF) therapy in neovascular age-related macular degeneration (nAMD) is associated with poorer visual outcomes, according to a study in Ophthalmology Retina reported by endocrinologyadvisor.com. ophthalmologyadvisor.comendocrinologyadvisor.comophthalmologyadvisor.comOpen source ↗ The retrospective cohort drew on electronic health records from the Vestrum Health Retina Treatment and Outcomes database, which represents more than 360 retina specialists across the United States. The analysis included 94,912 treatment-naive eyes diagnosed with nAMD between January 2014 and October 2019, each with at least 1 year of follow-up.

Treatment timing and visual acuity

Prompt treatment was defined as initiation within 29 days of diagnosis, and delayed treatment as initiation 3 to 12 months after diagnosis. Among 45,478 first-diagnosed eyes, 44,318 received prompt treatment and 1160 received delayed treatment. At 1 year, promptly treated eyes gained an average of 5 Early Treatment Diabetic Retinopathy Study (ETDRS) letters, whereas delayed-treatment eyes lost 3 letters. Promptly treated eyes received approximately 7 injections during 8 visits, compared with 3 injections during 7 visits in the delayed group.

Visual improvement grew with injection frequency. Mean changes in visual acuity (VA) were −1.2, +0.6, +4.3 and +5.6 letters in eyes receiving 1 to 3, 4 to 6, 7 to 9 and more than 9 injections, respectively. Eyes with baseline VA worse than 20/400 gained up to 27.2 letters with more than 9 injections.

Factors associated with starting treatment

Of 90,681 eyes evaluated for treatment initiation, 75,638 received anti-VEGF therapy within 1 year and 15,043 remained untreated. ophthalmologyadvisor.comendocrinologyadvisor.comophthalmologyadvisor.comOpen source ↗ Higher odds of treatment were seen with baseline subretinal fluid (odds ratio [OR], 4.97; 95% CI, 4.75-5.20), macular edema (OR, 3.26; 95% CI, 3.11-3.42) and subretinal pigment epithelium fluid (OR, 1.64; 95% CI, 1.56-1.72). Lower odds were seen with geographic atrophy (OR, 0.76; 95% CI, 0.72-0.80), baseline VA worse than 20/400 (OR, 0.29; 95% CI, 0.27-0.30) and simultaneously diagnosed bilateral nAMD compared with first-diagnosed eyes (OR, 0.32; 95% CI, 0.31-0.34).

Among first-diagnosed eyes, geographic atrophy was associated with higher odds of delayed treatment (OR, 1.59; 95% CI, 1.35-1.87), while subretinal fluid (OR, 0.37; 95% CI, 0.33-0.42) and macular edema (OR, 0.44; 95% CI, 0.38-0.51) were associated with lower odds.

The authors list several limitations: the retrospective observational design, the lack of standardized treatment and VA assessment protocols, and possible inaccuracies or incomplete information in electronic health records. They state that physicians should strive for a more regimented approach to nAMD treatment in routine clinical practice.