“We shall pay any price, bear any burden,” said John F. Kennedy, in one of the most stirring sections of his inaugural address in 1961. Kennedy’s foe was tyranny and threats to a freely democratic society, of course, but his whatever-it-takes doctrine reminds me a bit of how AMD was viewed by eye care practitioners a decade ago, at the advent of the anti-VEGF era.

After many failed attempts to halt the progression of visual loss associated with wet AMD, the approval of Macugen in late 2004 offered positive (though middling) evidence of an anti-VEGF drug’s ability to intervene in the disease’s pathophysiology.

When Avastin and Lucentis arrived on the scene in 2005 and 2006, respectively, the floodgates opened. So did a lot of wallets. The hefty price tag of Lucentis provided ample room for the just-as-good Avastin to take hold in the market, despite its off-label nature.

The caregivers of AMD patients were put upon too, often forced to take off work to bring an elderly parent to the ophthalmologist’s office for treatment. Inconvenient, sure, but worth it for the sake of restoring vision lost to AMD.

Everyone involved—Medicare, the eye care community, and AMD patients and families—appeared willing to sign themselves up for a monthly ritual that might very well never end: examine, inject, reimburse. Over and over and over. At the time, the visual gains were so ground-breaking that no one seemed to mind. Cost, logistics, inconvenience and infection risk all took a back seat. But add those up and you get the so-called treatment burden of AMD that now makes a once-exhilarating experience a bit less sanguine for all parties.

As we report this month in the feature “AMD Therapy: Battling the Burden”, the retina subspecialty is eager to break free of that endless loop. Researchers are hard at work in pursuit of the Next Big Thing—whatever it may be—simultaneously developing combination therapy, sustained-release drug delivery and even topical therapy, all with the goal of reducing the treatment burden.

The long-running sibling rivalry of Avastin and Lucentis has been riveting right from the start, and the blessing and curse that anti-VEGF injections represent shows no signs of abating, even as doctors seek a move to new modes of care.
Along with a thorough CE article on vitreomacular interface disorders and a refresher on congenital retinal abnormalities, this special issue on retina further explores AMD’s frontiers in a pair of thought-provoking articles.

First, Jeffry Gerson, OD, looks into technology for early AMD detection that might help patients be identified earlier in its course, allowing more options for vision preservation.

Next, Jay Haynie, OD, assesses the prospects for therapeutic intervention in dry AMD (“Arrested Development: How to Put the Brakes on AMD"). Should the Next Big Thing happen in that area instead of wet AMD research, it may very well negate (or at least diminish) the vaunted role that anti-VEGF therapy has played for a decade. Perhaps the best way to “bear any burden” is to avoid it entirely.