Age-related macular degeneration (AMD) is one of the most important conditions we manage as retina specialists, and it will likely become even more important as the population ages and more patients come into the clinic.

Prior to the availability of anti-VEGF drugs, the best that could be hoped for was to slow the disease's progression and attendant vision loss. Laser therapy could be destructive to the surrounding tissue, sometimes inducing the same visual acuity loss the treatment was meant to prevent. The first anti-VEGF agent to come to market in ophthalmology (pegaptanib sodium; Macugen, Valeant) offered the promise to preserve baseline visual acuity. When ranibizumab (Lucentis, Genentech) was approved by the US Food and Drug Administration in 2006, it was the first on-label therapeutic intervention available to treat wet AMD that offered a chance to actually improve visual acuity. Fast forward to the present and anti-VEGF therapy is the standard of care, basic science research has provided new insights into the pathophysiology of AMD, and we are aided in the clinic by a wealth of technology that permits earlier diagnosis and, hence, earlier intervention.

But the AMD story is still incomplete. For instance, much work needs to be done to refine how we use these medications in daily practice. There have been additional agents to enter the market (aflibercept [Eylea, Regeneron] and the off-label use of compounded bevacizumab [Avastin, Genentech]). New information has surfaced about inadequate and incomplete responses to treatment. We are learning that some patients may respond better to particular agents.

The implication of all of this is obvious: We should be moving away from an era of homogenized treatment courses and schedules and toward individualized regimens. Such a thought may be entirely optimistic, however. The first hurdle we will have to navigate is the burden and complexity individualized treatment will add for following patients. The second, and perhaps more ominous and uncertain element, is whether cost-conscious health care reform might dictate the particular agents and treatment regimens used in the clinic. Hopefully, doctors will be able to continue to treat patients as individuals.

There is an age-old dichotomy in medicine where clinical practice rarely mirrors experiences in controlled clinical trials. The literature is replete with evidence of the safety and efficacy of anti-VEGF drugs, but as Carl Regillo, MD, points out in an article in this issue, there is uncertainty regarding the optimal timing of dose delivery. Treating AMD exacts a toll on the patient and the provider, and we need better means to deliver needed therapy.

Another unknown is what, if anything, can be done for dry AMD. As Pravin Dugel, MD, points out in this issue, the cupboard is depressingly bare when it comes to interventions for dry AMD. Perhaps novel targets like the one described by Brian Berger, MD, and colleagues in this issue will offer a promise of treatment options for dry AMD.

There have been remarkable strides in the recognition and treatment of AMD, and now the work is in tweaking our processes to make outcomes even better for our patients. This issue of Retina Today features top clinicians and researchers explaining how new understandings are advancing the art and science of AMD management. We hope readers will gain insights not only into how to better manage patients in the clinic, but also glean where we may be going with the future of AMD management.

Robert L. Avery, MD,
Associate Medical Editor

Allen C. Ho, MD,
Chief Medical Editor