THENew therapies and innovative drugs dedicated to patients with maculopathy, and capable of significantly improving the quality of vision and life of approximately 1 million Italians. Top international experts have spoken about it last December at Floretina ICOOR 2023 in Rome. Here is what is useful to know, what symptoms should be reported to the ophthalmologist and why around the age of 50 it is a good idea to undergo a targeted vision check.
What is maculopathy
Doctor Tommaso Nuzzo, ophthalmologist and medical director at the San Paolo hospital in Milan.
«Maculopathy or macular degeneration it is a pathology that affects the macula, the central area of the retina. It is progressive and irreversible, but it is possible to slow down or even block its progress if identified in time; hence the importance of an early diagnosis. Among the main symptoms: distorted and blurry central vision. A revolution that in Italy should change the lives of patients as early as 2024″, explains the Doctor Tommaso Nuzzo, ophthalmologist and medical director at San Paolo hospital in Milan.
There are two forms, the “dry” one, the most common (about 90%), and the wet or exudative one. Wet maculopathy was not considered curable until a few years ago, but i therapeutic advances in recent years have made it possible to slow down its progression.
«Maculopathy is a pathology that significantly compromises the quality of life of patients and is very widespread: it concerns 2% of Italians and increases with age. It is now a social disease and represents the most frequent cause of low vision and visual disability after the age of 50 years in the Western world”, he adds Stanislao Rizzo, president of Floretina ICOORdirector of the Ophthalmology Clinic of the A. Gemelli University Polyclinic IRCSS, Full Professor of Ophthalmology at the Catholic University of Rome.
What are the risk factors
Among the risk factors of macular degeneration are important:
Maculopathy: why after the age of 50 a targeted screening visit is needed even without symptoms
“Unfortunately many patients arrive at the diagnosis late, because they do not undergo eye check-ups after the age of 50. You should undergo check-ups even before the age of 50, and they become even more important as the years go by”, explains Doctor Nuzzo.
«After the age of 45/50, whether there is a family history of glaucoma or senile macular degeneration, a first screening visit even in the absence of symptoms because some early pathologies manifest themselves without giving specific symptoms. If instead you take the time and make one early diagnosis of maculopathy or glaucoma, the progression of diseases can also be greatly slowed down thanks to new drugs”, advises Nuzzo.
Two important tests to do at home (and then go to the ophthalmologist)
The importance of early diagnosis of maculopathy remains the first step to preserve and extend visual health. An initial piece of advice is offered by Doctor Nuzzo, a small test to be done comfortably at home and then reported to the eye doctor.
1. Check your field of vision
«It is important to pay attention if there is a new alteration of the visual field both in the central part of the visual field. Few people do this test, if there are changes compared to usual it is advisable to be examined by an ophthalmologist as soon as possible”, warns Doctor Nuzzo.
2. The Amsler Test
The Amsler test, used since 1945, it is a grating with vertical and horizontal lines useful for easily checking your central field of vision.
Amsler grid (fondazionemacula.it)
There grid is a diagnostic tool which helps detect visual defects caused by imperfections of the retina, in particular the macula, the optic nerve and the transmission of visual impulses to the brain. «Closing first one eye then the other with glasses closelymust observe whether they are straight or slightly warped. Even a lined or squared notebook or online is enough. If there are deformations of the contours of the squares, it is also a good idea in this case to contact your ophthalmologist”, recommends Doctor Nuzzo.
Watch out for the first “hidden” symptoms
It is not easy to identify the first symptoms of maculopathy, such as the slightly distorted vision of the images. Especially if one of the two eyes is healthy, it is not noticed immediately and the disorder progresses in the meantime, until it reaches appearance of a potentially irreversible and indistinct dark spot in the middle of the visual field. «The goal of research in recent years has therefore been to find drugs that could be more effective in delay the progression of visual lossalso acting on other growth factors involved, and which would make the treatment easier by reducing the need for intravitreal administrations”, explains Doctor Rizzo.
Symptoms
“Those who suffer from maculopathy usually report the following symptoms:
- impaired color perception
- reduced central vision (scotoma)
- photophobia (discomfort in light)
In particular, the most indicative symptom is the presence of metamorphopsia, i.e. the images are distorted. But as was said above, if the two eyes have different visual capabilities, self-diagnosis is more difficult.
How is the diagnosis made?
The course of the disease is initially quite slow and for this reason it is easy to delay the diagnosis, increasing the possibility of degenerating into more serious forms of maculopathy.
This is why it is essential to undergo the eye examination. After a comprehensive examination of the eye and ocular fundus, it is necessary to subject the patient to some exams:
What is dry maculopathy
Dry maculopathy is due to formation of yellowish deposits under the macula with atrophy of the retinal tissue and the decrease in central vision is usually rather gradual. «Until now there have been no real therapies for this type of maculopathy, other than food supplements. But now it was a new drug approved in the USA. Consists of an injection with a new active ingredient. It will be used only after a careful examination and selection of the most suitable patients. An innovation that opens the way to new therapies that were not available before”, explains Nuzzo.
«But there is important news to combat this disease which currently has no treatment available. In fact, approval is expected by 2024 of theEmma following the approval of the‘FDA of 2 new drugs, the Pegcetacoplan and theIzervay».
«In patients with dry maculopathy, in the most advanced forms, currently orphan of therapies, the drugs injected intravitreally inactivate the inflammation mechanism which is mediated by the “complement cascade”, i.e. a linked series of inflammatory events responsible for the photoreceptor degeneration. The drugs slow down the evolution of the disease in a good percentage of patients without unfortunately restoring sight,” he adds Donald J. D’Amico, Professor of Ophthalmology at Weill Cornell Medical College and Director of Ophthalmology at New York Presbyterian Hospital .
What is wet maculopathy
«Wet maculopathy is caused by one abnormal growth of new blood vessels under the macula, the central part of the retina responsible for vision, and vision impairment in this form can also be very rapid. For some years, wet form therapy has made use of special drugs, the so-called anti-VEGF therapies which are administered directly into the eye through intravitreal injections. I am monoclonal antibodies that slow the progression of the disease inhibiting the formation of new blood vessels in the fovea, where they usually do not exist”, explains Nuzzo. “This intraocular injections are very scarybut actually thanks to the anesthesia we have (a special eye drop) and at the speed of the procedure with a very small needle the pain is very limited.” Injections are usually given once a month or every two months, with a time commitment for the NHS, the patient and their carers.
Maculopathy: what are the new long-lasting drugs
With the arrival of faricimab, a drug with long-term administration, up to 4 months, the therapy becomes more long-lasting and less demanding. It has been available for a few months and will be available soon reimbursable by the National Health Service. According to recent studies published on The Lancet, in 60% of patients it can be administered every 4 months, instead of 2 as the current therapeutic standard.
Available in Italy from this year
Also in 2024, it will also arrive in Italy, a monoclonal anti-VEGF antibody already used, ranibizumab, to counteract wet senile maculopathy and diabetic macular edema. Inserted into a small refillable reservoir, implanted in the wall of the eye and which delivers small amounts of the drug daily. A cutting-edge treatment that has been pioneered in the United States since Doctor Carl Coolin Awh, present at the Floretina ICOOR Congress.
“There new therapeutic strategy is that of surgically implant small reservoirs into the eye that gradually release the drug inside of. This could extend the retreatment interval to six months, simply by refilling the tank and thus reducing the number of injections needed per year,” explains Coolin Awh.
Gene therapy: in which cases can it be useful?
The most advanced therapy is gene therapy and can be decisive for the treatment of some rare retinal diseases. «It is now consolidated and approved gene therapy for a form of hereditary retinal dystrophy, theLeber congenital amaurosis (LCA)while clinical trials are currently underway for other variants of retinitis pigmentosa, Usher syndrome, and Stargardt disease,” adds Dr. Rizzo.
Gene therapy also for other forms of maculopathy
«Today, a gene therapy is also being studied for the treatment of wet senile maculopathyfor the rdiabetic etinopathy And other chronic retinal diseases. In these cases it is not a question of replacing a diseased gene or correcting a defect, but of modifying the genome of the retinal cells by inducing them to produce anti-VEGF substances, which act like the same drugs that until now we have injected from the outside once a month” , concludes Coolin Awh.
Artificial intelligence: an aid for diagnosis
An Italian clinical study conducted in Piedmont and Veneto demonstrated the effectiveness of one specific algorithm, Dairet (Diabetes Artificial Intelligence for RETinopathy) for first level screening of diabetic retinopathywhich affects 30% of diabetic patients.
The study, published in the journal Diabetes & Obesity International Journal, demonstrated high effectiveness of the algorithm in detecting mild and moderate cases of retinopathy, with a sensitivity ratio (ability to detect cases) of 91.6% for mild retinopathy and 100% for moderate retinopathy.
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