Evolving Treatment Patterns and Outcomes of Neovascular Age-Related Macular Degeneration Over a Decade

PURPOSE: Management of neovascular age-related macular degeneration (nAMD) has evolved over the last decade with several treatment regimens and different medications. This study describes the treatment patterns and, importantly, visual outcomes over ten years in a large cohort of patients. DESIGN: Retrospective analysis of electronic health records from 27 National Health Service (NHS) secondary care healthcare providers in the UK. PARTICIPANTS: Treatment-naïve patients receiving at least three intravitreal anti-vascular endothelial growth factor (VEGF) injections for nAMD in their first six months of follow-up were included. Patients with missing data for age or gender and those aged less than 55 were excluded. METHODS: Eyes with at least three years of follow-up were grouped by years of treatment initiation, and three-year outcomes were compared between the groups. Data were generated during routine clinical care between 09/2008 and 12/2018. MAIN OUTCOME MEASURES: Visual acuity, number of injections, number of visits. RESULTS: A total of 15,810 eyes of 13,705 patients receiving 194,904 injections were included. Visual acuity (VA) improved from baseline during the first year, but dropped thereafter, resulting in loss of visual gains. This trend remained consistent throughout the past decade. Although an increasing proportion of eyes remained in the driving standard, this was driven by better presenting visual acuities over the decade. The number of injections dropped substantially between the first and subsequent years, from a mean of 6.25 in year 1 to 3 in year 2 and 2.5 in year 3, without improvement over the decade. In a multivariable regression analysis, final VA improved by 0.24 letters for each year since 2008, and younger age and baseline VA were significantly associated with VA at three years. CONCLUSION: Our findings show that despite improvement in functional VA over the years, primarily driven by improving baseline VA, patients continue to lose vision after the first year of treatment, with only marginal change over the past decade. The data suggest that these results may be related to suboptimal treatment patterns, which have not improved over the years. Rethinking treatment strategies may be warranted, possibly on a national level or through the introduction of longer-acting therapies.