Late stage AMD: can we do better?

Both late, vision threatening forms of age-related macular degeneration (AMD) still present major unmet needs. In neovascular AMD (nAMD) there is still significant research activity underway in trying to improve our interventions. However, it is likely that by looking at how current treatments are being used, we will gain a better understanding of how to improve outcomes for all patients. Clinicians use different treatment protocols and have different optical coherence tomography defined goals of treatment, which potentially impacts outcomes. Real-world outcome study in nAMD, such as the Voyager study aim to identify treatment patterns and determine the best strategies to improve outcomes globally.In geographic atrophy (GA), there is an extraordinary effort underway to find treatments for this late form of AMD, which until now has had no interventions available to slow its progression or prevent its occurrence. In 2023 the first two treatments for GA received approval in the United States. As treatments become available, for patients with established areas of cell loss, the focus will turn to the possibility to using these interventions earlier in the disease process. Earlier intervention trials however, require different trial design to ensure greater feasibility in terms of cost and length. Earlier surrogate trial endpoints for GA have been proposed, such as nascent GA (nGA), which could help trial design, but additional natural history studies in AMD need to be undertaken, such as the HONU study. In addition, when considering the possibility of novel early intervention, different AMD sub-phenotypes may well need to be considered as they may respond differently to the intervention being investigated, such as was the case in the LEAD nanosecond laser study.