Don’t let your patients fall behind: The future of AMD care

In September 2022, researchers in Spain¹ released results of a 270-eye study of patients with age-related macular degeneration (AMD) and the effects they experienced following the COVID-19 pandemic lockdowns and related social disruptions in 2020 and 2021. Not surprisingly, these patients were found to have suffered an increased rate of visual loss beyond what would be expected in normal times, but worse, that loss was not fully recoverable when the lockdowns ended and regular AMD treatments resumed.²

This research data align with our common-sense understanding that any delay in the diagnosis or treatment of a progressive disease will likely be bad for the patient. In this light, it is every eye care provider’s duty to help implement a care system that is robust, resilient, and flexible enough to endure fast-moving and long-term calamities, whether local, regional, or global.

AMD and COVID-19

AMD primarily affects people over aged 50 years but probably starts much earlier. It is a progressive, slow-moving inflammatory disease with a genetic predisposition component that can be activated by lifestyle factors such as diet and excessive sunlight. Changing these holistic factors can help, and choroidal neovascularization in the wet form of the disease can be medically controlled with regular injections of anti–VEGF, but the condition must be detected first.

The sooner treatment is initiated, the better the outcomes are likely to be, and this is where a disruption like a pandemic can really hurt. People may be reluctant or forbidden to leave their homes for a nonemergent health issue, so serious problems go undiagnosed and untreated with potentially devastating consequences for patients with a progressive disease.

Leveraging the genetic markers for AMD could also help identify those likely to develop it many years before symptoms or other signs are detectable, informing them so they can make changes and prepare for AMD earlier. This, in combination with technologies that bring diagnostic and treatment functions into the patient’s home, bypassing travel and crowds, could be an elegant solution to this pressing challenge.

Wearable devices

The good news is that parts of this new approach have already been developing in labs and start-ups around the world, with early versions in clinical use and becoming new standards of care. They can be categorized broadly as wearable medical devices: technologies that enable the diagnosis, monitoring, and treatment of disease and injury using compact and convenient electronic machines and internet connectivity.

The goal is to increase the frequency and sensitivity of patient interactions without the need for them to travel to specialized diagnostic or treatment centers or, in many cases, even to leave their homes. Once in widespread use, these technologies could eliminate many of the worst effects the pandemic response had on patient care, including excess vision loss in patients with AMD.

We’ve already started using the first of these devices. Fitness trackers, smart
watches, and wearable electrocardiogram, blood glucose, and blood pressure monitors are common, and we’ll see more soon as biosensors come online in the form of headsets using virtual reality/augmented reality, as well as smart gloves, clothing, and implants. They’ll be able to continuously monitor biological fluids, physical motions, and a valuable variety of other parameters. Wearable medical devices will provide remote, real-time, noninvasive diagnosis, monitoring, and even treatment capability.

A resilient, decentralized future of care

As devices become more capable, convenient, and connected, their functions will be liberated from traditional health care spaces and dispersed throughout communities, wherever patients live. With less need for diagnostic centers, the overall system and each patient’s treatment plan would be much less susceptible to disruptions such
as pandemics or even earthquakes and
natural disasters.

For example, a device I frequently use is a wearable augmented reality/virtual reality platform (Heru), which performs several vision exams including visual fields, contrast sensitivity, color vision, and now, dark adaptation. Its chief benefits for the eye care provider are convenience, consistency, and the huge reduction in floor space needed compared with big legacy diagnostic devices. In my practice, it also seems to foster a more streamlined and pleasant patient experience.

The multifunctional Heru device has a suite of tests designed to address AMD, including dark adaptation, contrast sensitivity, and the 10-2 visual field, which may aid in the detection of AMD-related changes years before drusen are seen in the retinal/macular evaluation. While it currently requires a technician to operate, there’s no hard reason those functions couldn’t be shifted to a 2-way video communication link with the patient. At that point, doctors and staff wouldn’t need to be in the same room when screening happens or even in the same hemisphere, for that matter. The critical medical data that are captured could be sent to any member of the health care team via a standard internet connection.

A dedicated home-use AMD monitor called the ForeseeHome (Notal Vision) is already available. By comparing its imaged results over time, doctors can quickly determine when the conversion from dry to wet AMD occurs and treatment is needed. There is also a home optical coherence tomography angiography machine in the works. Of course, many treatments for AMD and other retinal diseases still require a visit to the treating physician’s office.

Once treatment plans no longer involve frequent travel to a central facility for testing or monitoring, patients won’t have to choose between important eye care procedures and avoiding a pandemic infection, for example. Patients will likely be far more compliant with an AMD monitoring regimen when it involves just a few minutes of headset time at home rather than risky trips among people who may have active respiratory infections. This would, for example, help slow COVID-19 transmission rates not only for patients, but also for doctors, medical staff, and the general public, at the same time ensuring that changes in an AMD patient’s eye will not go unnoticed and untreated.

Beyond diagnostics and monitoring: remote treatment

Remote monitoring and diagnosis are powerful tools, but the holy grail of a truly resilient health care delivery system is remote treatment. The concept of a wearable or implantable device that can dispense therapeutic medication as needed has been around for a while, chiefly among medical futurists and science fiction writers. But the recent convergence of rapidly expanding networked computing power, internet connectivity, and the trend toward miniaturization in medical machines has enabled a new generation of devices small and light enough to be implanted or attached to the body with little to no discomfort.

For example, the wearable insulin pump has been in use for years to treat diabetes. The port delivery system (Susvimo; Genentech), which functions like the insulin pump but delivers anti-VEGF, is being developed for continuous and sustainable release of medication, reducing required patient treatment visits. There are also anti-VEGF eye drops being researched, which would turn wet AMD treatment into something closer to glaucoma management.

If such devices could be connected and controllable with a bit more functionality and in continuous communication with doctors, a simple liquid medication mini pump could become a new kind of diagnostic, monitoring, and treatment tool, unrestrained by the physical locations of the patient or doctor. Though this sort of functionality is in its infancy now, it is poised to deliver a bright future full of amazing, convenient devices that can bridge the gaps between face-to-face, hands-on interactions among patients and their health care providers.

As physicians, we owe it to our patients to imagine, discuss, and help build the structure of a more resilient system of health care delivery that can withstand even the most disruptive ongoing events. Pandemics and other disasters, predictable and unforeseen, will continue to challenge us and regular health care visits may once again become impossible. That’s when a new wave of wearable screening and treatment technologies could save eyes and lives.

References

1. Rego-Lorca D, Valverde-Megías A, Fernández-Vigo JI, et al. Long-term consequences of COVID-19 lockdown in neovascular AMD patients in Spain: structural and functional outcomes after 1 year of standard follow-up and treatment. J Clin Med. 2022;11(17):5063. doi:10.3390/jcm11175063

2. Valverde-Megías A, Rego-Lorca D, Fernández-Vigo JI, Murciano-Cespedosa A, Megías-Fresno A, García-Feijoo J. Effect of COVID-19 lockdown in Spain on structural and functional outcomes of neovascular AMD patients. J Clin Med. 2021;10(16):3551. doi:10.3390/jcm10163551