April 14, 2025
5 min learn
Key takeaways:
- One presenter mentioned at-home OCT has the potential to enhance outcomes in neovascular AMD via personalised care.
- One other mentioned there are nonetheless limitations to beat with monitoring packages.
SEVILLE, Spain — Residence monitoring of neovascular age-related macular degeneration, an fascinating idea with many potential advantages, has entered the retina house within the U.S. with the Scanly Residence OCT monitoring program from Notal Imaginative and prescient.
However are sufferers, physicians and well being care techniques prepared for this paradigm shift within the administration of neovascular AMD? Two specialists supplied their views on the Congress on Controversies in Ophthalmology.
Two consultants debated the utility of at-home OCT monitoring for moist AMD on the Congress on Controversies in Ophthalmology.
For
Residence OCT has the potential to enhance outcomes in neovascular AMD, offering personalised affected person care, in accordance with Nancy M. Holekamp, MD. Her private expertise within the clinic and authorship in a potential trial just lately printed in Retina satisfied her that that is the way in which sufferers can be managed sooner or later.
She defined that upon request of the treating doctor, the affected person receives the OCT monitoring gadget with directions for operation. The affected person self-images at residence every day, and the information are despatched to the cloud, the place an AI algorithm reads the photographs for hyporeflective areas that correspond to both intraretinal or subretinal fluid. If abnormalities are detected, an alert is triggered, and each the doctor and the affected person are knowledgeable by a message {that a} go to to the clinic is required.
Nancy M. Holekamp
The retina specialist, nonetheless, stays “the captain of the ship,” Holekamp mentioned. It’s as much as the doctor to set the edge values that set off the alert. (Holekamp mentioned her threshold is 10 nL of intraretinal or subretinal fluid.) At any time, the well being care supplier can enter the cloud to view the scans and see how the affected person is doing. As soon as the affected person presents for the go to, the specialist critiques the scans and makes the choice on whether or not to deal with.
Holekamp’s potential research included 17 eyes of 15 sufferers identified with moist AMD, “however the fantastic thing about this know-how is which you can monitor each eyes,” she mentioned.
The sufferers scanned themselves every day for six months and have been seen by their doctor solely after they obtained the alert. Earlier than residence monitoring, the typical interval between injections was 8 weeks. Throughout the research time, it was prolonged to fifteen.3 weeks.
“The typical therapy interval was virtually doubled … and we did it with out dropping any imaginative and prescient. The change in imaginative and prescient was zero letters,” Holekamp mentioned.
Adherence was good: On common, sufferers carried out the scan six instances per week, and false alarms weren’t discovered to be a priority.
“Out of 40 triggered visits, 39 of them truly had fluid on the OCT, and 37 of them truly obtained an injection, and the others didn’t primarily based on investigator discretion and tolerance of subretinal fluid,” Holekamp mentioned.
Holekamp offered the case of a 76-year-old affected person who was handled with ranibizumab injections adopted by the port supply system (PDS, Roche) within the left eye; he additionally had a touch of intraretinal cystic change in the suitable eye. He started residence monitoring in December 2022, and in February 2023, the AI algorithm detected intraretinal fluid exceeding 10 nL of quantity. The affected person was seen, and the PDS was refilled.
“The fluid goes away by the subsequent day, by the subsequent time the affected person exams. So, we simply hold monitoring this affected person, and since he has steady supply, he’s doing very nicely till we see fluctuations in intraretinal fluid. And have a look at what we by no means noticed earlier than: You will get an accumulation of intraretinal fluid, after which it goes away after which it returns after which it goes away once more. We didn’t know that was occurring till we had every day monitoring. The quantity of knowledge is so instructive right here,” she mentioned. “We did a refill change once more, and the fluid was promptly resolved.”
Residence monitoring on this case was additionally a useful means for following up the intraretinal cystic change within the fellow eye.
“We see little tiny adjustments which might be under 10 nL … it ebbs and flows, and we hold following the affected person till we see a rise within the fluid that exceeds 10 nL. Then we name the affected person, give an injection of faricimab and see the fast decision of the intraretinal fluid with a single injection,” Holekamp mentioned. “We simply hold following the affected person, and the affected person doesn’t want one other injection till 7.5 months later.”
Residence OCT presents “actually personalised affected person care” that may lower therapy burden, Holekamp mentioned.
“What I’ve come to understand is that we’ve actually been managing our moist AMD sufferers at the hours of darkness with a paucity of knowledge factors,” she mentioned. “That is our restricted expertise in 15 sufferers and 17 eyes. However proper now, in the USA, there’s a a lot bigger scientific trial occurring, the DRCR Community Protocol AO. Preserve your antenna out for that.”
Towards
Residence monitoring is a promising idea, however the real-world outcomes are usually not considerably higher than the usual of care to justify the elevated value and doctor burden, the organizational issues, the stress of false alarms, and the restrictions of the know-how when it comes to picture high quality, in accordance with Rodrigo Abreu González, MD, PhD.
Within the workflow described by Holekamp, there could be failures and delays at virtually each level, he mentioned.
He juxtaposed myths and realities surrounding residence monitoring.
Rodrigo Abreu González
“The parable is that with one of these residence monitoring, we are able to detect early and stop imaginative and prescient loss, however the actuality is that visible acuity nonetheless declines regardless of the monitoring,” Abreu González mentioned. “One other fable is the excessive affected person engagement, however within the research, there have been solely 15 sufferers, and real-life proof is inconsistent. The third fable is that residence monitoring reduces the burden of clinics. What actually occurs is that it will increase the alerts and workflow stress and never just for the docs. Lastly, the parable is that AI ensures security and precision, but it surely nonetheless wants handbook overview and has false alerts.”
The ALOFT research (Mathai et al.) analyzed long-term outcomes of the AI-enabled ForeseeHome AMD monitoring program (Notal Imaginative and prescient). The proportion of conversions to moist AMD detected by the system was 52%, solely barely above the proportion detected by routine visits.
When evaluating the outcomes of residence monitoring with the usual of care, Abreu González mentioned that visible outcomes have been higher with residence monitoring, with a imply lack of 4 letters on common in contrast with 11 and 82% of sufferers sustaining 20/40 or higher imaginative and prescient as in contrast with 62%.
“Nonetheless, there was nonetheless a lack of imaginative and prescient, and 20% of the sufferers misplaced imaginative and prescient under 20/40,” he mentioned.
One essential downside of at-home OCT know-how is the inferior picture high quality in contrast with the excessive requirements of OCT within the clinic. One other pitfall is the necessity for technical help, coaching and follow-up.
“We have now sufferers who’re unable to make use of a smartphone, laptop computer or iPad, so simply think about if they’re utilizing the OCT at residence,” he mentioned.
Stress and burden are usually not lowered however multiplied, in accordance with Abreu González. Retinal fluid has fluctuations that don’t essentially point out an exercise that requires therapy. However these fluctuations would possibly set off an alert that generates nervousness within the affected person and additional work for the doctor.
Along with the sufferers the doctor is caring for within the clinic, there are alerts and messages from the sufferers at residence. This results in work overload and elevated infrastructure value. Relying on the nation and the system, there might also be reimbursement challenges, Abreu González mentioned.
He mentioned that residence monitoring techniques are, at current, not mature sufficient to be applied as there are nonetheless too many patient-, technology- and provider-related limitations that have to be overcome.
Latest knowledge confirmed the weaknesses of all at the moment accessible residence monitoring applied sciences.
“Present residence imaginative and prescient exams lack adequate diagnostic accuracy (Hogg et al.), virtually 30% of the sufferers can’t full the exams with out help (O’Connor et al.), and AI-generated alerts nonetheless require handbook overview (Willis et al.),” Abreu González mentioned.
Higher real-world proof from unbiased long-term research in addition to simplified, patient-friendly units are wanted, he mentioned.
References:
- Hogg RE, et al. JAMA Ophthalmol. 2024;doi:10.1001/jamaophthalmol.2024.0918.
- Holekamp NM, et al. Retina. 2024;doi:10.1097/IAE.0000000000004167.
- Mathai M, et al. Ophthalmol Retina. 2022;doi:10.1016/j.oret.2022.04.016.
- O’Connor SR, et al. Int J Environ Res Public Well being. 2022;doi:10.3390/ijerph192013714.
- Willis ET, et al. Ophthalmol Ther. 2024;doi:10.1007/s40123-024-00953-8.
Sources/Disclosures
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Holekamp N, et al. Debate 2: Residence monitoring has the potential to enhance affected person outcomes in AMD. Introduced at: Congress on Controversies in Ophthalmology; April 4-5, 2025; Seville, Spain.
Disclosures:
Abreu González stories no related monetary disclosures. Holekamp stories being an worker of Roche and holding shares or inventory choices in Nacuity, Notal Imaginative and prescient and Roche.
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