The last 15 years have witnessed remarkable improvements in visual outcomes for patients with retinal pathology. Whereas many patients with diabetic eye disease, neovascular age-related macular degeneration, and retinal vein occlusion seemed to lose vision inexorably in the past, anti–vascular endothelial growth factor (anti-VEGF) therapy and occasionally corticosteroid therapy now help us preserve and even improve visual outcomes in individuals with these conditions over the long term.
These advances in care have been readily apparent when intravitreous therapy has been compared with previous standard care in phase 3 clinical trials. In eyes with diabetic macular edema, visual acuity gains of 2 to 3 lines have been demonstrated more frequently in eyes given intravitreous anti-VEGF compared with laser or sham treatment. Yet, there is the widespread perception that patients do not do as well in clinical practice with anti-VEGF treatments as they do in clinical research. Several platform presentations at national and international scientific meetings have addressed this issue, often noting high loss to follow-up rates and reduced frequency or numbers of injections in patients with common retinal conditions. The 5-year Comparison of AMD Treatment Trials (CATT) follow-up study documented a mean loss of 2 lines of visual acuity once patients being treated for neovascular age-related macular degeneration finished study participation at year 2 and were released to routine clinical care over the subsequent 3 years. Although it is possible that this decrease in vision was related to the natural history of the disease, it seems likely that undertreatment in the clinical setting may have played some role.
What can we do to address these concerns? As physicians, we need to make sure that our clinical practice patterns and retreatment algorithms faithfully reflect those used in clinical studies to achieve similar outcomes. This achievement can be challenging to implement in the hectic schedule of a busy clinic and as patients reschedule and cancel their appointments. Computer-assisted supports can be built into electronic health records and appointment management systems, but these are not routinely available at the moment. The field, and patients, would benefit greatly from standardized tools to ensure best practices that could be deployed across a variety of clinical sites worldwide. We also need to better address highly challenging issues of access and availability to therapies and specialty care so that more patients can benefit from clinical research advances. Finally, we need to continue to monitor real-world outcomes to understand what is being achieved in the clinic and how best to improve these results. Big data initiatives, such as the American of Academy’s Intelligent Research in Sight registry, may prove a useful tool in tracking treatment patterns nationwide. Although outcomes data obtained through this clinical practice registry could be messy owing to a lack of standardization, such data may in aggregate provide a useful glimpse into trends in vision or retinal pathology over time in response to changes in retinal practice.
The gap between clinical research and clinical care outcomes can seem disheartening at times. Nonetheless, patients with retinal pathology have overall benefited dramatically from therapeutic advances over the last few decades. Hopefully, future study results will be even more effectively translated into clinical practice to improve vision in eyes across the spectrum of retinal disease.