Age-related macular degeneration (AMD) is divided into a “dry” form, which is hardly treatable, and a “wet” form, which is treatable.
In dry AMD, metabolic waste products from the photoreceptor cells (drusen) accumulate in the central retina (macula), which is responsible for sharp vision and reading. Depending on the size and location of these drusen, the disease can gradually affect visual acuity over time. At the same time, over many years, the density and regularity of the retinal pigment cells—which supply energy for the functioning of the sensory cells—decline, leading to deterioration of contrast sensitivity and increased sensitivity to glare.

Geographic atrophy (GA) is a late stage of dry AMD.
Here, cells in the outer retinal area lose their function. They degenerate (die) and eventually leave an empty, atrophic zone in which light and image processing can no longer take place.

Such an area manifests itself as what is called a scotoma, a blind spot, usually in the center of the central field of vision or very close to it. As the atrophic area expands, the disturbing spot increases in size and the visual function in the corresponding area decreases. Due to the resulting defects, light hits the retina without attenuation, which initially results in increased glare and light sensitivity.

AMD is now a fairly well-researched group of diseases, but the exact pathogenesis—the reason why some patients develop GA and others do not—has still not been fully clarified. It is assumed that various factors can promote its development.

One of the most important and unavoidable causes is advancing age; in addition, lifestyle factors and a genetic predisposition are discussed.

General risk factors include:

• Age
• Family history
• Smoking/past nicotine use
• High blood pressure and overweight
• Heart and vascular diseases, high blood cholesterol levels

Apart from a long-term vitamin supplementation according to the so-called AREDS 2 formula (lutein 10 mg, zeaxanthin 2 mg, vitamin E 180 mg, copper 2 mg, zinc 80 mg, vitamin C 500 mg, and unsaturated fatty acids), there is currently no recognized therapy. In recent years, the first treatment options for dry AMD have been developed: an injection therapy for advanced geographic atrophy – which has not been approved in Switzerland and Europe due to an unfavorable risk-benefit profile – and a light therapy, which is at least theoretically applicable to all advanced forms of AMD and is relatively safe.

SYFOVRE® (Pegcetacoplan, Apellis)
Injections against Geographic Atrophy

The FDA (U.S. Food and Drug Administration) approved in 2022 a drug for the treatment of geographic atrophy (GA), but not for other forms of dry AMD, under the name SYFOVRE® (active ingredient: pegcetacoplan). This product is to be injected every 6 to 8 weeks in all patients with GA. Over 2 years, it slows progression by up to 18%, which, for lesions threatening the fixation point, means a significant extension of usable vision. In principle, all patients with GA can be treated, including those in whom the fovea is already affected. The goal of treatment is not improvement, but a slowing of the deterioration in visual function. The most important side effect is a long-term up to threefold increased risk of conversion to wet AMD. For this reason, approval for the European and Swiss markets was not granted. Treatment can still be performed at the patient’s own expense, but the current risk-benefit ratio does not support it. 

Mechanism of action in the eye 

By injecting the medication into the inside of the eye—initially monthly, later every two months—the progression of GA is slowed and the disease temporarily stabilized. With a fine needle, the medication is injected, after local anesthesia and disinfection, under sterile conditions, and largely painlessly into the eye. The treatment takes a few minutes, the injection itself only a few seconds.

What is important to know – what should you expect?

 Outlook

• The time until vision deterioration occurs is extended.
• The therapy is not a cure for GA.
• An improvement in the situation is not possible based on current research.

Who is the therapy suitable for?

• Injections can be given in one or both eyes.
• Preference is given to eyes whose GA has NOT yet reached the fixation point and that still have usable vision, as improvement is not expected.
• Simultaneous injection therapy for wet AMD may be required in the same eye.

Duration of therapy

• The first three injections are given every 4–6 weeks.
• Thereafter, injections are given approximately every 2 months as long as usable reading function is present.
• If well tolerated, therapy can be continued long-term.

Cost

• There are no official prices for importing the drug into Switzerland, but pure drug costs are expected to be at least CHF 1,800 per injection. 

Most common side effects: 

• Irritation of the ocular surface (10%)
• Development of wet AMD (over 2 years: 5–7%; doubling the risk compared to untreated eyes)
• Vitreous opacities
• Superficial hemorrhage around the injection site (harmless)

Rare side effects (no more than with the conventional “macular injection”): 

• Intraocular infection (endophthalmitis) with risk of blindness (1:10,000)
• Inflammatory reaction to the injection or the drug (1:100)
• Short-term ocular pressure dysregulation (too high or too low, about 2%)
• Retinal detachment (1:100)

If injections are not an option: light therapy as an alternative?

Valeda Light Delivery System (LumiThera) – Photobiomodulation (PBM)

If an eye does not have GA or has non-central GA but shows age-related changes such as drusen and pigment irregularities, it does not qualify for injection therapy. In the case of large drusen, AREDS 2 supplementation can have a positive effect on the long-term course. More recently, there is also the possibility of light treatment (photobiomodulation).

Photobiomodulation (PBM) is a non-invasive, largely risk-free, low-level light therapy already used in many medical fields, for example in sports medicine to locally promote blood circulation and improve physical performance. A similar effect underlies its therapeutic action in advanced dry AMD. Light in the spectral range of near-infrared light (590–850 nm) is projected onto the diseased areas of the macula, stimulating the metabolic performance of the cells impaired by AMD. One treatment cycle consists of 9 sessions over 4 weeks.

What is important to know – what should you expect? 

The treatment should be carried out twice a year. A measurable therapeutic effect, usually in the form of disease stabilization, generally appears only with long-term use over at least two years.

In our practice, we usually treat only one eye, typically the better-seeing one, as long as the scientific data on efficacy are not yet conclusive.

Outlook

• This therapy also cannot cure dry AMD or GA.
• The aim of this treatment is likewise to slow the progression of age-related changes.

Who is the therapy suitable for?

• Men and women ≥ 50 years with advanced dry AMD and reduced visual acuity, with or without GA.
• When should the therapy not be performed?
• In the presence of or recent diagnosis of wet AMD
• In the case of central GA with already present loss of visual acuity
• Non-dilatable pupil (scar, suture, or adhesion)
• Neurological diseases (migraine, epilepsy)
• Sensitivity to intense light exposure (yellow, red, or near-infrared light)

Duration of therapy

• Therapy sessions per eye last about 5–10 minutes
• Each treatment cycle requires nine therapy sessions over 3–4 weeks, about three sessions per week
• The therapy must, according to current knowledge, be repeated every 4–6 months to achieve an effect

Cost

• Treatment costs in our clinic are CHF 400 (9 sessions per half-year; self-pay), not covered by supplementary health insurance.
• We are currently conducting a study on the efficacy of light therapy in daily practice. We appreciate your consent to include your data in this study to learn more about the effectiveness of this therapy. Your treating physician will be happy to provide more details during further evaluation.

Most common side effects: 

• Afterimages immediately after the therapy session
• Sensation of glare

Rare side effects: 

• Possibly a minimally increased risk of conversion to wet AMD
• No other serious side effects known to date

IN SUMMARY – IMPORTANT

None of the currently available therapies, neither intravitreal administration of the drug SYFOVRE nor light therapy, can prevent the progression of AMD with increasing age or the risk of conversion from the dry to the wet form.. 

No improvement in vision can be expected from the therapy. The aim is to temporarily stabilize vision and delay deterioration. Improvement is not expected.

WHAT CAN YOU DO YOURSELF?

The aging process in the central retina cannot be stopped, but depending on its severity, it can possibly be slowed by self-initiative, and everyday life with the disease can be made more tolerable through coping mechanisms. 

• Wear sunglasses 
  This not only reduces harmful UV effects on the retina but also alleviates sensitivity to glare. Seek advice from a specialized optician to determine which lenses, tailored to you, can provide optimal results. 
  
• Dietary adjustment
  Maintain a balanced, antioxidant-rich diet with:
  – green, seasonal vegetables,
  – natural vitamin supplementation (fresh fruit and vegetables),
  – little to no animal fats.

• AREDS/AREDS2 supplementation (lutein, zeaxanthin, zinc, unsaturated fatty acids)
  This is a dietary supplement (not a medication, hence not covered by insurance) with antioxidant vitamins and trace elements that can benefit vision in dry AMD. AREDS2 is also suitable for (former) smokers. 
  
• Daily living coping strategies
  Seek information from specialized groups and counseling centers, exchange experiences with patients in self-help groups on how to overcome daily obstacles, and maintain a good quality of life despite AMD. Addresses of information centers (e.g., Beraten B) can be found in the appendix.

For further questions, please feel free to contact us or make an appointment for an assessment of your situation and advice on treatment options tailored to you.