Low Vision Intervention in the Anti-VEGF Era

JANET S. SUNNESS, MD

Five years ago, I became director of the Richard E. Hoover Low Vision Rehabilitation Services at the Greater Baltimore Medical Center. Although much of my previous research at the Wilmer Eye Institute at Johns Hopkins University had focused on scotomas caused by macular disease and the methods with which patients use their remaining vision, I was a medical retina specialist and only initiated the practice of low vision therapy formally in 2005. When I began, I found that I loved doing low vision, and I was particularly gratified at being able to do more for my patients with advanced age-related macular degeneration, whether due to choroidal neovascularization or to geographic atrophy, than could be accomplished medically at that time.

Fortunately, the treatment of CNV has vastly improved with the arrival of ranibizumab and bevacizumab, with stabilization of most patients' visual acuity, and with improvement in over one-third of patients. As a retina practitioner and a low vision specialist, I have a dual perspective on this. I share with you, wearing my “retina hat,” tremendous enthusiasm for the anti-VEGF agents that have reduced the visual impairment associated with AMD. But as a low vision specialist, I am aware that a patient with 20/70 visual acuity (the average VA at one year in the MARINA trial) will be unable to read newspapers and items with normal-sized print without some sort of low vision therapeutic intervention.

Gladly, for someone with this level of VA, it is often sufficient to increase the reading add to +4.00 or so, or perhaps to use a low-power magnifier. Also, patients treated with anti-VEGF agents do not develop the ugly-looking scars of the past that broadcast to us the fact that a central scotoma was present. Nowadays, there can be a scotoma present without the presence of an obvious scar. If there is a scotoma, training for scotoma awareness may often be necessary to get the patient back to reading fluently.

My perspective is that anti-VEGF treatments put the patient in the optimal condition for returning to normal daily visual activities with only a little “tweaking” with low vision intervention. My expectation was that we would see many people with moderate visual loss who could be helped with inexpensive devices and, in only one or two visits, could return to their prior activity level. But this expectation has not been fulfilled.

In a recent article in Retina,¹ we reported data that suggest that retinal specialists are often not referring patients with moderate loss of visual acuity and with central scotomas for low vision intervention. The data suggest that, surprisingly, the visual acuity of the patients with CNV referred now is worse when compared to the VA of patients with CNV who were referred in the past. This implies that retinal specialists may limit their referrals of CNV patients to those who have failed anti-VEGF therapy.

There may be several reasons for this. The retina may look good, without significant scarring, so it may not be appreciated that a scotoma is present. Or the patients are grateful for their preserved vision and may not report that they still cannot read the newspaper. There also may be the impression that, as long as the patient is being treated (and this may be indefinitely), there may be improvement, so why refer for low vision now?

It is amazing to me that many patients who have not been reading for three years can be restored to relatively normal reading with simply a higher add and better lighting. My perspective is that anti-VEGF treatment puts patients in the optimal condition for returning to normal activities with the help of relatively minor low vision intervention. I am writing to ask you to consider providing this service to your patients, either within your own practice, through the general ophthalmologist, or by referral to a low vision therapist. RP

REFERENCE

1. Sunness JS, Schartz RB, Thompson JT, Sjaarda RN, Elman MJ. Patterns of referral of retinal patients for low vision intervention in the anti-VEGF era. Retina. 2009;29:1036-1039.