25% of normal 2/20/2018. Practical Guidelines for the Treatment of AMD 78% 22% Overview. AMD Information Overload

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Raymond Lambert
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1 I am a consultant / or have financial interest in: Practical Guidelines for the Treatment of Maculogix J&J Acuvue Vision Source Ocusoft Pogo Tech Jeffrey W. Jones, OD Longview, TX jjoneseye@gmail.com Overview Information Overload Current Standard of Care for Opportunity to Improve Outcomes Updated Disease Classification Using Dark Adaptation to Detect and Stage Treatment Guidelines for Nonexudative Disease Management 3 Even With All This Information, We Are Still Missing Too Frequently And Too Many Patients Are Diagnosed After Vision Loss Has Already Occurred 5% of normal patients had! 100% 80% 60% 40% 0% 0% 78% Legally blind in one eye BCVA worse than 0/50 Poor outcome Cervantes-Castañeda RA, et al. Eye (Lond). 008;(6): Olsen TW, et al. Ophthalmology. 004;111(): % Good outcome 5 6 1

This Committee Reviewed the Evidence and Developed Practical Guidelines Can We Do Better?

Karpecki, OD, FAAO Kentucky Eye Institute Lexington, KY Gary Kirman, OD Kirman Eye Hummelstown.

Lurking Below the Surface Photoreceptors Normal Early Intermediate Advanced No drusen No pigmentary abnormalities Medium drusen > 63 µm and 15 µm No pigmentary abnormalities 1 large druse > 15 µm

2 This Committee Reviewed the Evidence and Developed Practical Guidelines Can We Do Better? COMMITTEE CHAIR Jeffry Gerson, OD, FAAO Grin Eye Care Olathe, KS Glenn Corbin, OD Wyomissing Optometric Center Wyomissing, PA Steve Ferrucci, OD, FAAO Sepulveda VA Hospital Sepulveda, CA Paul Karpecki, OD, FAAO Kentucky Eye Institute Lexington, KY Gary Kirman, OD Kirman Eye Hummelstown. PA Kimberly Reed, OD, FAAO Ophthalmic Industry Consultant Tampa, FL Laurie Sorrenson, OD, FAAO Lakeline Vision Source Cedar Park, TX 8 Traditional Classification is Based on Retinal Structure Only is Lurking Below the Surface Photoreceptors Normal Early Intermediate Advanced No drusen No pigmentary abnormalities Medium drusen > 63 µm and 15 µm No pigmentary abnormalities 1 large druse > 15 µm and/or Any pigmentary abnormalities forms Geographic atrophy Neovascular Drusen Sclera RPE Bruch s Membrane Cholesterol accumulation leads to panmacular deposits (BlinD and BlamD). Peaks in these deposits eventually become clinically visible drusen. These extracellular cholesterol deposits affect photoreceptor health, causing inflammation and predisposing to CNV. In addition, they impair normal transport, including that of vitamin A, across Bruch s membrane. Ferris FL, et al. Ophthalmology. 013;10(4): The Beckman Committee Classifies Into 4 Stages 9 Curcio CA, Johnson M. Structure, function, and pathology of Bruch s membrane. In: Ryan SJ, et al, eds. Retina, Vol 1, Part : Basic Science and Translation to Therapy. 5th ed. London: Elsevier; 013: Retinal Function Is Impaired At Least 3 Years Earlier Than Drusen Are Visible ALSTAR Study Impaired dark adaptation identifies subclinical at least three years before it can be seen with imaging, OCT or clinical exam. Thus, Impaired Dark Adaptation is a Much Earlier Symptom of than Visual Acuity Normal night vision Subclinical to Early Impaired night vision Prospective Study of Subclinical Sample consisted of 35 adults without clinically detectable. At baseline, 4% of the subjects exhibited impaired dark adaptation. status determined at 3-year follow-up visit. Intermediate Late Owsley, C et al. Ophthalmology. 016;13():

This Research Leads to a More Comprehensive Disease Classification System: Structure + Function No Subclinical Early Intermediate No drusen No pigmentary abnormalities Normal dark adaptation No

abnormalities Using Dark Adaptation to Detect and Stage Advanced forms Geographic atrophy Choroidal Neovascularization 13 Clinical Testing of Dark Adaptation is Now Practical Multisite Study

3 This Research Leads to a More Comprehensive Disease Classification System: Structure + Function No Subclinical Early Intermediate No drusen No pigmentary abnormalities Normal dark adaptation No drusen or small drusen No pigmentary abnormalities Impaired dark adaptation +/- Small or medium drusen +/- pigmentary abnormalities Impaired dark adaptation 1 large druse > 15 µm Any pigmentary abnormalities Using Dark Adaptation to Detect and Stage Advanced forms Geographic atrophy Choroidal Neovascularization 13 Clinical Testing of Dark Adaptation is Now Practical Multisite Study Confirmed The AdaptDx is Highly Sensitive, Specific & Accurate The only objective test for measuring dark adaptation quickly and effectively in a clinical setting. High Sensitivity: Correctly identified 90.6% of confirmed cases High Specificity: Correctly identified 90.5% of confirmed normal cases High Accuracy: 90.6% overall accuracy Jackson GR, et al. Invest Ophthalmol Vis Sci. 014;55(3): The AdaptDx is Easy to Use and Administer No prior adaptation or pupil dilation required Low patient burden Automated analysis Objective output (Rod Intercept) CPT Code 984 for dark adaptation ($63.5 average national reimbursement) The AdaptDx Delivers a Simple, Objective Report Patient name, DOB, and ID number Eye tested and characteristics AdaptDx dark adaptation curves Rod intercept time and clinician assessment (>6.5 minutes consistent with )

Undetected is a Significant Problem 19 Sample of 100 consecutive older adults (over age 60) with normal retinal health based on clinical exam were tested using AdaptDx.

4 Undetected is a Significant Problem 19 Sample of 100 consecutive older adults (over age 60) with normal retinal health based on clinical exam were tested using AdaptDx. Jeffry Gerson, OD Grin Eye Care 39% (39 of 100) had previously undetected Primary Eye Care Has a Major Opportunity to Maintain Visual Acuity of Patients with 100% 80% 60% 40% 0% 0% CURRENT OUTCOMES w/o AdaptDx 78% Legally blind in one eye BCVA worse than 0/50 Poor outcome % Good outcome Cervantes-Castañeda RA, et al. Eye (Lond). 008;(6): Olsen TW, et al. Ophthalmology. 004;111(): % 80% 60% 40% 0% 0% IDEAL OUTCOMES with AdaptDx 10% Poor outcome 90% Good outcome It is Our Responsibility to Communicate Diagnosis with Our Patients Deliver a simple and objective message to your patients. No need to apologize. Help them understand why they may have trouble seeing or driving at night. Early diagnosis should be considered good news! We found something early and can do something about it! Treatment of Nonexudative 1 Primary Goals of Treatment Treatment Recommendations for All Stages of 1 Slow or Prevent progression to advanced Choroidal Neovascularization (CNV) Geographic Atrophy (GA) 1 3 Smoking cessation Nutritional supplementation Lifestyle modifications Effectively detect and manage CNV 4 Systemic disease management 5 Blue light / UVA / UVB protection 3 4 4

Prescribe Smoking Cessation SMOKING IS THE LARGEST MODIFIABLE RISK FACTOR FOR. Current smokers carry a.5 to 4.8 times higher risk than non-smokers for late 1. However 1 Chakravarthy U.et al.

Age-related macular degeneration and smoking cessation advice by eye care providers. Prev Chronic Dis. 011;8(6):A147 3 Handa S et al.

5 of patients with 90% were not advised to stop smoking <50% of smokers know that smoking may contribute to blindness 3 Evidence Strongly Suggests that Patients Should be Prescribed

Increased compliance with care 6 Which Supplement at Which Stage of?

supplement AREDS-based supplement Omega fatty acids Key ingredients Containing xanthophylls, such as lutein, zeaxanthin and/or meso-zeaxanthin Containing both xanthophylls and antioxidants,

5 Prescribe Smoking Cessation SMOKING IS THE LARGEST MODIFIABLE RISK FACTOR FOR. Current smokers carry a.5 to 4.8 times higher risk than non-smokers for late 1. However 1 Chakravarthy U.et al. Cigarette smoking and age-related macular degeneration in the EUREYE Study. Ophthalmology. 007;114(6): Caban-Martinez AJ et al. Age-related macular degeneration and smoking cessation advice by eye care providers. Prev Chronic Dis. 011;8(6):A147 3 Handa S et al. Awareness of blindness and other smoking-related diseases in eye patients. Eye. 011;5(9): of patients with 90% were not advised to stop smoking <50% of smokers know that smoking may contribute to blindness 3 Evidence Strongly Suggests that Patients Should be Prescribed Nutritional Supplements Patients treated with supplements have better outcomes than untreated patients due to: 1. Beneficial effects of the supplements. Increased compliance with care 6 Which Supplement at Which Stage of? Discuss Lifestyle Modifications with Respect to Diet and Exercise Our guidelines recommend nutritional supplementation for all stages of considering these options: Formulation Macular pigment supplement AREDS-based supplement Omega fatty acids Key ingredients Containing xanthophylls, such as lutein, zeaxanthin and/or meso-zeaxanthin Containing both xanthophylls and antioxidants, including zinc and vitamins E and C Mediterranean diet Exercise 7 8 Systemic Disease Management Retinal Light Protection Epidemiological evidence suggests that chronic sunlight exposure increases the risk of incident and its progression 1 Recommendations: Prescribe full-spectrum UV protection Consider High Energy Visible Light (HEVL) blocking [aka blue-light blocking] lenses 1 Sui G-Y, Liu G-C, Liu G-Y et al. Is sunlight exposure a risk factor for age-related macular degeneration? A systematic review and meta-analysis. Br J Ophthalmol. 013;97(4):

The AdaptDx Helps Detect and Monitor Patients as Their Disease Progresses Sample dark adaption progression over time (Rod Intercept in minutes) Disease Management Advanced Intermediate 0.0 18.0 16.

6 The AdaptDx Helps Detect and Monitor Patients as Their Disease Progresses Sample dark adaption progression over time (Rod Intercept in minutes) Disease Management Advanced Intermediate Baseline Worsening High risk Early Subclinical No Stable Screen Monitor & treat every 6 months, then 3 months Year 1 Year Year 3 Year 4 3 Key Takeaways Primary eye care is failing when it comes to, but we can do better! Functional testing complements structural exam for improved detection and staging There are proven, effective treatment options for all stages of, including subclinical. 33 6

Disclosures. Conclusion/Take Away. Further Disclosure. Start with a case.. Objectives 10/16/2018

Disclosures. Conclusion/Take Away. Further Disclosure. Start with a case.. Objectives 10/16/2018 : Better Outcomes Start with You Dark Adaptation in Dx of Jeffry D. Gerson, O.D., F.A.A.O. Disclosures I am/have been a member of an Ad board or speaker s bureau or been paid honoraria by/for Allergan,