Holiday treatment gap bad for AMD patients

Patients with age-related macular degeneration (AMD) may suffer a decline in visual acuity if they stop treatment for long summer holidays, according to researchers from France, Canada and Switzerland.

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‘It is important to convey the message of treatment adherence to patients, despite their need of holidays,’ the researchers wrote in a recent article for the journal Eye.

Study details

Visual acuity in patients who stopped treatment during vacation declined by 0.071 Logarithm of the Minimum Angle of Resolution (LogMAR), compared to a 0.003 improvement in patients who continued their treatments. The difference was statistically significant (P = 0.007)

France has a particularly strong tradition of long summer vacations, the researchers noted, dating back nine centuries to a decree by Pope Gregory II in 1231. So researchers at Cergy Pontoise Hospital in Paris, France, compared 23 patients who missed one injection during their summer holiday to 29 who received injections in this time.

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All the patients were getting 0.05 mg ranibizumab intravitreal injections pro re nata (PRN) at Cergy Pontoise. The treatment followed a protocol of three initial monthly injections followed by reinjection as needed.

Criteria for reinjection included a visual acuity loss of 45 ETDRS letters and/or an increase of central retinal thickness, presence of subretinal fluid, intraretinal fluid, or pigment epithelium detachment. If reinjection criteria were not met, patients were advised to return in 4 weeks.

In order to be included, patients had to be at least 50 years old, have a presence of subfoveal choroidal neovascularisation (CNV) secondary to AMD as evaluated by fundus biomicroscopy, fluorescein angiography (FA) and infracyanine green angiography (ICGA), and a presence of serous retinal detachment or pigment epithelium detachment detected on spectral domain-optical coherence tomography (SD-OCT).

All eyes included in this study showed evidence of exudation on OCT (subretinal or intraretinal fluid) during the visit preceding vacation.

Next: Findings and clinical implications

At baseline, the groups were similar in age, sex, CNV type, duration of follow-up prior to holidays, and previous number of intravitreal injections. The Best Corrected Visual Acuity (BCVA) at baseline was 0.83 for those who skipped in injection, and 0.89 for those who got an injection.

Findings and clinical implications

Among those who missed injections, BCVA decreased significantly in 48.5% of patients, remained stable in 40.1% and improved in 11.4%. By contrast, among patients who continued treatment, BCVA decreased in only 17.8%, stayed stable in 32.1%, and improved in 50.1%.

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Among those who skipped an injection, 61.8% had exudation on OCT after their vacations, compared to 27.6% of those who got injections while vacationing.

For patients with serous central detachment, 72.4% of those who skipped a treatment had a decrease in fluid after their holidays, compared to 38.2% of those who continued treatment.

The finding is consistent with other research into the effects of lapses in healthcare during holidays in diseases such as diabetes and hypertension, the researchers wrote. It also matches findings in AMD where treatment is delayed for other reasons, such as in countries where intravitreal injections have been withheld pending verification of clinical need.

Also, the rate of decline in BCVA in this study for the patients who missed injections was similar to previous research on patients delaying anti-vascular endothelial growth factor (anti-VEGF) AMD treatment.

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The investigators acknowledged several limitations to their study. The population of subjects was small and not representative of the French population as a whole. The two groups were not matched for health factors such as smoking status and the researchers did not look into the resources available to the patients for continuing treatment on holiday.

Next: Not depriving AMD patients of holiday, but....

Still, the researchers concluded that clinicians should emphasise the importance of continuing treatment. ‘The intention is certainly not to deprive AMD patients of holidays, but rather to increase awareness to consult and pursue their treatment on vacation in order to preserve their VA,’ they wrote. They suggested providing AMP patients with lists of available ophthalmologists in the areas they plan to visit on holiday, or prearranging treatment on the patients’ behalf.