The Retina TL;DR with Dr. Weng: Harnessing home OCT and Protocol AO for wet AMD with Christina J. Flaxel, MD, FARVO, and Noam Rudnick, MD, PhD

In this episode of The Retina TL;DR with Dr. Weng, powered by Modern Retina, host Christina Y. Weng, MD, MBA, FASRS, professor and the Alice R. McPherson Retina Research Foundation Chair in Ophthalmology at Baylor College of Medicine in Houston, Texas, welcomes Christina J. Flaxel, MD, FARVO, and Noam Rudnick, MD, PhD, for a discussion on the home optical coherence tomography (OCT) monitoring device (Notal Vision) and its role in the management of neovascular age-related macular degeneration (AMD).

Flaxel and Rudnick are two of the top recruiters for DRCR Retina Network Protocol AO, a randomized clinical trial evaluating home OCT-guided treatment in wet AMD. Flaxel is the Bula Buck Arveson and Charles C. Arveson Professor of Macular Degeneration Research and professor of ophthalmology at the Casey Eye Institute, Oregon Health & Science University, Portland, Oregon. Rudnick is a surgical retina specialist at Retina Consultants, P.C. in Hartford, Connecticut.

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Setting the stage: Why home OCT?

When asked for his “TL;DR" (“too long; didn’t read”), Rudnick summarized: Home OCT is a patient-operated device that allows physicians to monitor patients with wet AMD between office visits, paired with an AI-based algorithm that detects intraretinal and subretinal fluid—with the potential to personalize treatment and reduce both office visits and overall treatment burden.

Weng asked Flaxel to make the case for home OCT given how well anti-VEGF therapy on a treat-and-extend schedule already works. Flaxel pointed to real-world barriers—elderly patients, transportation challenges, and competing comorbidities—that make frequent office visits difficult, arguing that home OCT could enable truly personalized care: patients come in only when monitoring detects fluid. Both Flaxel and Weng noted that even their oldest patients have had little difficulty using the device. Rudnick added that with more durable agents on the horizon, smarter between-visit monitoring will only become more important—including for detecting new-onset wet AMD in the fellow eye.

Protocol AO: Design and implications

Weng outlined the Protocol AO trial, in which 600 treatment-naive wet AMD eyes are randomized to faricimab (Vabysmo; Genentech) on either a home OCT-guided or a standard treat-and-extend regimen, with co-primary outcomes of visual acuity change and number of injections at 2 years. (Update: Since the time of recording, Protocol AO has been fully enrolled, with topline results anticipated in 2028. See the ClinicalTrials.gov registry (NCT05904028) for current status.)

Rudnick noted that while fixed dosing, as-needed, and treat-and-extend regimens have shown broadly similar outcomes, as-needed monitoring has historically been limited to monthly visits—and some data, including from the CATT trial, have raised questions about whether monthly monitoring is adequate. Home OCT enables daily monitoring, potentially catching recurrence earlier. If results are favorable, he said, it could represent a new standard for managing wet AMD.

Workflow and real-world considerations

Weng asked Flaxel about the provider-side experience. Flaxel described the workflow as manageable with a strong team, noting that enrolled patients understand a phone call means they need to come in—though she acknowledged leaner practices may face greater challenges outside the trial.

Rudnick identified three hurdles for widespread rollout: determining the optimal fluid threshold for alerts; securing insurance coverage, as patients currently pay out of pocket outside clinical trials and payers will need to reimburse physician review time; and building clinic workflows for urgent visits. (Update: Notal Vision is actively collaborating with Medicare Administrative Contractors and private payers to establish reimbursement pathways; coverage has been granted with certain insurance plans.)

The device received FDA clearance in May 2024, but broader adoption will hinge on these questions—and on Protocol AO’s results.

Resources

For retina specialists and patients seeking additional information, Flaxel pointed to the DRCR Retina Network website, which includes resources for both physicians and patients. She also highlighted the work of Anat Loewenstein, MD, in addition to a recent editorial by Judy Kim, MD, and colleagues on the benefits and limitations of home OCT. For more information, please refer to the references below.

Christina Y. Weng, MD, MBA, FASRS, is professor and the Alice R. McPherson Retina Research Foundation Chair in Ophthalmology, and fellowship program director, vitreoretinal diseases and surgery, with Baylor College of Medicine in Houston, Texas. Weng serves as national protocol chair for DRCR Retina Network Protocol AO (research support) and has no relationships with Notal Vision.

Christina J. Flaxel, MD, FARVO, is the Bula Buck Arveson and Charles C. Arveson Professor of Macular Degeneration Research and professor of ophthalmology at the Casey Eye Institute, Oregon Health & Science University, Portland, Oregon. Flaxel has no relevant financial disclosures.

Noam Rudnick, MD, PhD, is a surgical retina specialist at Retina Consultants, P.C. in Hartford, Connecticut.

References

1. Blinder KJ, Calhoun C, Maguire MG, et al. Home OCT imaging for newly diagnosed neovascular age-related macular degeneration: a feasibility study. Ophthalmol Retina. 2024;8(4):376-387. doi:10.1016/j.oret.2023.10.012

2. Comparison of Age-related Macular Degeneration Treatments Trials (CATT) Research Group; Writing Committee:, Martin DF, et al. Ranibizumab and bevacizumab for treatment of neovascular age-related macular degeneration: two-year results. Ophthalmology. 2020;127(4S):S135-S145. doi:10.1016/j.ophtha.2020.01.029

3. Diabetic Retinopathy Clinical Research Retina Network. Protocol AO. Accessed August 10, 2026. https://public.jaeb.org/drcrnet/stdy

4. Korot E, Pontikos N, Drawnel FM, et al. Enablers and barriers to deployment of smartphone-based home vision monitoring in clinical practice settings. JAMA Ophthalmol. 2022;140(2):153-160. doi:10.1001/jamaophthalmol.2021.5269

5. Leng T, Leung EH, Mukkamala SK, et al. Longitudinal validation of the artificial intelligence algorithm in Home OCT for Age-Related Macular Degeneration-Report 3. Ophthalmol Sci. 2025;6(2):100907. doi:10.1016/j.xops.2025.100907

6. Nahen K, Benyamini G, Loewenstein A. Evaluation of a self-imaging SD-OCT system for remote monitoring of patients with neovascular age related macular degeneration. Evaluierung eines SD-OCT-Systems zur selbstgesteuerten Bildgebung und Fernüberwachung von Patienten mit neovaskulärer altersbedingter Makuladegeneration. Klin Monbl Augenheilkd. 2020;237(12):1410-1418. doi:10.1055/a-1271-6834

7. Okada M, Mitchell P, Finger RP, et al. Nonadherence or nonpersistence to intravitreal injection therapy for neovascular age-related macular degeneration: a mixed-methods systematic review. Ophthalmology. 2021;128(2):234-247. doi:10.1016/j.ophtha.2020.07.060

8. Rudnick ND, Blinder KJ, Friedman SM, Weng CY. History and current directions of the DRCR Retina Network. Retinal Physician. 2025;22:10-13. Accessed August 10, 2026. https://www.retinalphysician.com/issues/2025/june/history-and-current-directions-of-the-drcr-retina-network/

9. Weng CY. Understanding Protocol AO, the DRCR Retina Network's study of home OCT. Retinal Physician. 2025;22:18-21. Accessed August 10, 2026. https://digital.retinalphysician.com/articles/understanding-protocol-ao-the-drcr-retina-network-s-study-of-home-oct

10. Willis ET, Kim JE, Schneider EW. Home optical coherence tomography monitoring for neovascular age-related macular degeneration: transformative technology or cool toy? Ophthalmol Ther. 2024;13(6):1407-1416. doi:10.1007/s40123-024-00953-8

11. Weng CY, Blinder KJ, Hall EF, Rosenthal WN. Personalizing personalized medicine: the pursuit of optimal thresholds in the home OCT artificial intelligence algorithm for age-related macular degeneration. Ophthalmol Sci. 2025;6(2):101017. doi:10.1016/j.xops.2025.101017