Preliminary guidance from NICE recommended that Lucentis (ranibizumab) should only be used for second eyes, that is, when the visual acuity in the fellow eye is worse than 6/12.1 Age-related macular degeneration (AMD) is the commonest cause of blindness in the western world in the over-50 group, with anti-VEGFs showing benefit in the slowing or prevention of visual loss.2, 3
We recently established the proportion of patients presenting with pathology and visual impairment, deemed as a visual acuity worse than 6/12, in the fellow eye.
A retrospective case note review of 166 patients with wet AMD was performed. Parameters recorded include diagnosis in the fellow eye and visual acuity at presentation. Of those with bilateral wet AMD, the index eye was determined as the most recently referred eye.
Of the 166 patients, 99 (60%) were female and 67 (40%) male. Of these, 45 (27%) had no abnormality in the fellow eye at presentation. Therefore, 121 patients had fellow eye pathology. Of those with pathology, the majority (86/121, 71%) had dry AMD, and 26 patients (21%) had wet AMD. The remaining nine patients had amblyopia (4/121), myopic degeneration (4/121) or previous rhegmatogenous retinal detachment (1/121).
Fifty-six (34%) patients presented with a visual acuity worse than 6/12 in the fellow eye. The commonest condition associated with visual impairment was dry AMD (29/56, 48.3% of all impairment), comprising 34% of all cases of dry AMD. Wet AMD was the second commonest (19/56, 34%), comprising 73% of all cases of wet AMD.
Although the majority of patients had fellow eye pathology, a relatively small proportion presented with an associated visual impairment. The preliminary recommendations from NICE would have excluded over 60% of treatable lesions, that is, those with wet AMD and visual impairment in index eye, but no visual impairment in the fellow eye. Importantly, of the patients ineligible for treatment, 15% (16/110) developed CNV in the fellow eye while under the care of the macular clinic. We welcome the NICE final appraisal document, which recommends treatment for all treatable lesions with acuities worse than 6/12, regardless of fellow eye visual acuity.
References
National Institute of Clinical Excellence. Pegaptanib and Ranibizumab for the treatment of age-related macular degeneration. (http://www.nice.org.uk/guidance/index.jsp?action=byID&o=12057.) (accessed on October 2008).
Amoaku WMK . The Royal College of Ophthalmologists interim recommendations for the management of patients with age-related macular degeneration. Eye 2008; 22: 864–868.
Klein R, Klein B, Linton RL . Prevalence of age-related maculopathy. The Beaver Dam Eye Study. Ophthalmology 1992; 99: 933–943.
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Raj, A., Alexander, P. & Puri, P. Retinal pathology in the fellow eye of patients presenting with wet age-related macular degeneration in the index eye. Eye 23, 1873 (2009). https://doi.org/10.1038/eye.2008.374
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DOI: https://doi.org/10.1038/eye.2008.374