Prof. Adrian Koh led a discussion touching on various aspects of the current management of patients with nAMD.

What is your understanding and definition of disease activity?

Robin Hamilton: Disease activity, for me, is based on the presence of fluid on OCT, including intraretinal fluid, subretinal fluid, and sub-RPE fluid. While there is some confusion about subretinal fluid being potentially beneficial, that is a dangerous message, and I aim to achieve a dry retina when treating my patients with nAMD. If that is not possible, then I look for unchanging fluid over three consecutive injections, implying that the eye is stable and the disease is no longer active.

Is vision important in driving your decision about disease activity?

Mr. Hamilton: In my opinion it is less important and less objective than OCT. However, I think it is still important that we measure VA at every visit, and those results will certainly influence me to treat, particularly if I see some fluid—even stable fluid—in combination with a drop in vision.

Is the fundus fluorescein angiogram (FA) becoming obsolete?

Prof. Kaiser: We are beginning to move away from FA, even for diagnosis, since clinical examination and an OCT will often suffice. However, in patients who are difficult to diagnose, adding FA is very beneficial to help avoid making a mistake and treating a condition that is not macular degeneration with anti-VEGF agents.

Does OCT angiography play a role in your management of patients in terms of determining disease activity and retreatment criteria?

Prof. Kaiser: OCT angiography can be a wonderful tool for helping to diagnose difficult cases. However, when used to guide retreatment, it can lead to confusion since the technique reveals large vascular fronds which can give the impression of disease activity where none in fact exists. For that reason, I think that looking at the structural OCT has more salient information for making retreatment decisions.

Do you treat all kinds of fluid in the same fashion?

Prof. Holz: We know that where the fluid is situated impacts the degree to which it interferes with normal retinal function. Intraretinal fluid seems to have the biggest impact in terms of causing functional loss. Subretinal and sub-RPE fluid appear to be better tolerated by the retina, but still the aim of treatment is to produce the ideal environment for these very sensitive retinal cells, namely the absence of fluid.

Are you concerned about overtreatment causing problems in the short or long term?

Prof. Kaiser: It is difficult to say whether repeated anti-VEGF injections promote the development of macular atrophy. Although the formation of atrophy has been observed in clinical trials of anti-VEGF agents, these studies were not designed to determine whether a causal relationship exists between the two. Regardless, our ultimate goal should be to improve vision and then maintain that improvement with the fewest number of injections possible, bearing in mind that most patients will need long-term therapy.