Home OCT: Providing More Personalized, Timely Treatment for Wet AMD

For patients with neovascular age-related macular degeneration (wet AMD), the number of anti–vascular endothelial growth factor injections needed to control disease activity varies widely, with some patients only needing 1 injection over a 2-year period and others needing 26 injections.

With no way to predict who will need just 1 shot and who will need 26, this tremendous variability means that clinicians must more closely monitor these patients and their disease, explained Daniel F. Martin, MD, chair, DRCR Retina Network; and chairman, Cleveland Clinic Cole Eye Institute; and Barbara and A. Malachi Mixon III Institute Chair in Ophthalmology, Cleveland Clinic.

During the Angiogenesis, Exudation, and Degeneration 2023 meeting, held virtually February 10-11, 2023, Martin and 2 others presented on the latest in home optical coherence tomography (OCT) and how the service can be used to manage wet AMD.

With a home OCT service, a retina specialist refers a patient to a monitoring center for home OCT. The monitoring center provides the patient with the device and necessary support for monitoring. The patient takes daily pictures, which are uploaded to an artificial intelligence (AI)–powered cloud service. Finally, the retina specialist reviews the images and fluid dynamics.

Martin explained that the AI is able to detect fluids, provide quantified spatial fluid maps, and map fluid volume trajectory. After viewing enough of these charts, it becomes clear there is a lot “going on between visits that we don't even know about, and that there's tremendous, tremendous heterogeneity in what happens to fluid after we treat,” he said.

The DRCR Retina Network is undertaking trials to better understand the use of home OCT monitoring to reduce visits and treatment burden, while maintaining visual acuity. The Protocol AK study is an observational study of 14 participants from 3 sites in which participants take daily home OCT scans for 6 months.

Protocol AO is a multicenter randomized clinical trial of 600 eyes from 80 sites in which home OCT is being compared with treat and extend. The coprimary outcomes were mean change in visual acuity and number of injections from baseline to 104 weeks. The goal is to determine if home OCT leads to better visual acuity outcomes and/or fewer injections over 2 years compared with treat and extend.

Another presentation reviewed the characteristics of disease reactivation, treatment responses, and the connection between the 2 as seen on results of home OCT. The purpose is to evaluate the effect of timely treatment and the implications and benefits of incorporating home OCT into patient care, explained Anat Loewenstein, MD, professor and director, Department of Ophthalmology, Tel Aviv Medical Center; president, Israeli Ophthalmological Society; The Sidney A. Fox Chair in Ophthalmology, Faculty of Medicine, Tel Aviv University, Israel.

A study of 35 treatment-reactivation episodes, revealed variability in the increase rate of reactivation, increased duration, and maximal fluid volume between different episodes in different patients, she explained. There was also variability in the decrease rate, response duration, and fluid volume at resolve.

While 1 week is considered the practical and desired response time, the study showed significant differences between patients treated less than and more than 1 week after fluid reappearance. Patients treated more than 1 week after reappearance had:

• > 100 nL difference in fluid volume at treatment
• An average of 10 days longer time to resolution
• An additional 700 nL/day of fluid exposure

Having the daily data from the home OCT showed that a patient with prompt treatment (1 day after fluid reappearance) had a prompt resolution (2 days after treatment). The more time that went by between fluid reappearance and treatment, the longer the response after treatment. A patient who received treatment 22 days when fluid started to show on the home OCT took 17 days for the fluids to resolve after treatment.

“There is a slower resolution after a longer delay in treatment,” Loewenstein said.

The home OCT also allows better insight into what happens with the patient between visits. For example, there may be 2 patients who have similar fluid levels during the office visits, but one of them responded better to treatment had a decrease in fluid that increased just prior to the office visit.

“We think that the home OCT might put new demands on timely office visits and [timely treatment] performed for neovascular AMD patients,” she concluded, and added. “I think [home OCT] will change significantly the way we manage the patient.”

Finally, Nancy Holekamp, MD, Pepose Vision Institute in St. Louis, Missouri, and visiting professor, Roche Pharmaceuticals, in Basel, Switzerland, reviewed 3 studies reporting on the progress toward implementing home OCT in the management of patients with wet AMD.

The first study was observational in nature, and Holekamp first presented the results at the previous year’s meeting. This study included 15 patients and 29 eyes, and patients received standard of care while also taking daily self-images. The study looked at the patient experience and the whole process of home OCT. The study highlighted the wide degree of heterogeneity in fluid dynamics and in response, just as Martin and Loewenstein had presented.

The median time for patients to complete the imaging was 40 seconds and 98% of the images were of a sufficient quality for AI grading.

“The implications for patient care are really startling in that we can actually better refine the office visits interval,” Holekamp said.

The second study paired standard of care with daily monitoring of home OCT scans from a manual grader. This was a subgroup analysis from a large-scale study of more than 150 patients. When the grader detected fluid, it triggered a visit for an in-office OCT scan and treatment as necessary.

Patients were seen a mean of 4 days after fluid detection, which allowed for timely treatment. There was also high compliance and a high degree of successful imaging acquisition rates in this study, Holekamp noted.

The final study was a physician monitored, longitudinal study of home OCT with weekly review. There were 3 categories of patients for this study: good responders who need fewer injections and have long treatment intervals; hard-to-manage patients; and candidates for drug switching. The patients performed daily home OCT imaging, a retina specialist set up a fluid volume notification threshold and reviewed the scans once a week, and there were mandatory clinic visits every 12 weeks.

She noted that all of the trials showcased that home OCT can allow for more personalized treatment and better manage complex cases.

“The one thing that I've learned from my experience with the home OCT: I learned how much I didn't know about what was happening with our patients [and] how they did after treatment,” Holekamp said. “So, I really think that this technology will not only help us take care of patients better, but it will help us understand the disease better.”