Effectiveness of ranibizumab for neovascular age-related macular degeneration using clinician-determined retreatment strategy.
We read with great interest the article by Kumar et al. We have audited our 1-year results using a slightly different clinical model: a nurse-led optical coherence tomography (OCT)-guided macula service.
Following wet AMD diagnosis in the consultant-led macula clinic, three consecutive monthly ranibizumab injections are administered. Thereafter, patients are reviewed 4-6 weekly in the nurse-led clinic for 2 visits (visual acuity, fundus photography and spectral domain-OCT), and then in the consultant-led clinic, where dilated fundoscopy is also undertaken. After each nurse-led clinic, medical notes and scans are reviewed by the clinician in a 'virtual' clinic, only if any of the criteria below is met: 1. Reduced LogMar VA of >=5 letters. 2. Increased OCT intraretinal or subretinal macular fluid. 3. Increase in OCT central retinal thickness >=100 microns. 4. New macular haemorrhage on colour fundus photograph. 5. Persistent OCT fluid >=1 month after the previous ranibizumab injection.
85 patients (91 eyes) with a mean age of 81 (range 52-94) completed the 12-month follow-up in our audit. All patients were treatment naive for wet AMD. Patients attended a mean of 4 nurse-led clinics and 3 consultant- led clinics. The mean number of intravitreal injections was 4.8 (range 3- 9). The mean pre-treatment VA was 0.69 (range 0.2-1.2) and at 12 months was 0.58 (0.0-1.5). 31.5% of eyes gained >=15 letters, comparable to the PrONTO 1-year study, but in our audit 91.3% lost <15 letters compared to Kumar (97.4%).
Our results suggest that using vision and OCT scans can provide a basis for effective retreatment in year-1 outside of a randomised controlled trial. It is difficult to explain the differences in our results as our retreatment criteria are similar to Kumar et al, but perhaps using nurses and virtual clinics has necessitated strict protocols with less flexibility in retreatment decisions.
Conflict of Interest:
Dr Caroline Styles has been on an advisory board for Novartis.