At-Home Monitoring for Age-Related Macular Degeneration Gets High Marks

SAN FRANCISCO — At-home monitoring of age-related macular degeneration (AMD) with optical coherence tomography (OCT) cut office visits in half with no deterioration in visual acuity, a small study showed.

After 6 months of daily evaluations, visual acuity did not differ significantly from in-office evaluations before the study. At the same time, the average treatment interval increased from 8.0 to 15.3 weeks. The at-home imaging schedule detected early disease activity and afforded protection for the non-study eye.

“This study demonstrates for the first time treatment experience with home OCT-guided management,” said Lloyd Clark, MD, of Palmetto Retina Center in West Columbia, South Carolina, during the American Academy of Ophthalmology meeting. “Home OCT was easy for subjects to use, resulting in good compliance and early detection of recurrent and even new disease.”

During a panel discussion, ophthalmologists said they found the home-based monitoring intriguing and something that could be a valuable aid in clinical practice.

“I think it’s actually a good tool,” said Lihteh Wu, MD, PhD, of Asociados de Macula Vitreo y Retina de Costa Rica in San José. “For the most part, we’ve been compromising with treat and extend. With this, maybe we can actually be doing more like PRN [pro re nata, or ‘as-needed’]-type treatment for these patients, really individualizing the treatment for each person.”

Demetrios Vavvas, MD, PhD, of Mass Eye and Ear in Boston, praised home OCT technology, though he added, “I don’t know if it’s there yet, if it is mature. I think it’s the future, personalized medicine, seeing exactly what we saw here. Some patients may need [treatment] a little earlier, some may need it a bit later. You can detect the uninvolved eye much more promptly and you can have a much better outcome. I really like it lot.”

However, David Zacks, MD, PhD, of the Kellogg Eye Center at the University of Michigan in Ann Arbor, said the enthusiasm should be tempered by several factors, beginning with the potential for motivational bias.

“If they just tested themselves every day with an Amsler grid, would they not have gotten the same results?” he asked. “The other thing is, wouldn’t you have gotten to 16 weeks if you had these patients on treat and extend?”

“It’s an intriguing technology, but it will be expensive to deploy and implement, so that has to be figured in as well,” Zacks added.

Dimitra Skondra, MD, of the University of Chicago, noted that despite the results in this study, compliance with the daily testing will still be a concern. Additionally, the impact of the technology on daily work flow in an ophthalmology practice and electronic health record messaging and communication with patients could also be problematic.

“I think we need to keep logistics in mind,” she said.

Clark reported findings from the first study of home OCT-guided management of neovascular AMD. Participants in the study used an OCT device developed by Notal Vision. Previous observational studies provided insights into fluid exposure and dynamics between office visits, but treatment decisions were based solely on in-office visits.

“This study takes it a step further,” said Clark. “The study was designed to understand the feasibility and impact of home OCT imaging on neovascular AMD management.”

Patients perform OCT imaging at home, and the device transmits images to a monitoring center. A cloud-based artificial intelligence platform evaluates the images for evidence of active disease, which is verified by a retina specialist who decides the next course of action. Providers receive email notifications when fluid parameters or at-home monitoring interval exceeds a prespecified threshold.

In-office assessments were triggered by retinal fluid parameters. Regardless of findings, each patient had in-office safety assessments at 3 and 6 months.

The study involved 15 patients and 27 eyes, and patients were instructed to use the home OCT device daily for 6 months. The results showed that testing frequency averaged 6.3 tests per week, ranging from 6.1 during the first month to 6.4 during month 6. Baseline visual acuity was Snellen 20/34 and did not change significantly from baseline to 6 months.

“These were patients currently under care for neovascular AMD and were stable clinically,” Clark told MedPage Today via email. “We didn’t expect to see visual acuity improvements and we hoped not to see any deterioration.”

The mean treatment interval almost doubled from baseline to 6 months (P<0.01). The 15 patients had a total of 40 in-office visits triggered by OCT findings. In all but one case, fluid accumulation was confirmed by in-office OCT, and patients received treatment during 37 of the 40 visits.

“The data offer valuable information on disease status between office visits,” said Clark. “In one subject, new-onset neovascular AMD was diagnosed through routine fellow-eye imaging, prompting early asymmetric treatment. Another patient had a ranibizumab port delivery device [Susvimo], and the investigator opted for as-needed refills given current circumstances. Recurrence was identified at 10 months and treated promptly.”

Clark acknowledged limitations to the study, including the small number of patients and eyes, the nonrandomized nature of the study, treatment variation according to investigator discretion, and use of Snellen visual acuity measurements.

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