Selecting Initial Therapy in Newly Diagnosed Wet AMD

In this episode, "Selecting Initial Therapy in Newly Diagnosed Wet AMD," the expert retina specialists explore how presentation and patient priorities shape the first anti-VEGF decision.The panel makes a clear case that the first few anti-vascular endothelial growth factor (anti-VEGF) injections can set the course for a patient's long-term outcome in wet age-related macular degeneration (wAMD). Dr. Javaheri describes treating aggressively from the outset, reasoning that drying the retina and flattening pigment epithelial detachments (PEDs) quickly allows faster extension and fewer injections over time.Absent payer barriers, Dr. Javaheri uses second-generation agents first line in many patients. He notes that features such as hemorrhage, large or multiple PEDs, and extensive subretinal fluid shape less how he treats and more how he counsels patients about the likely course of their disease.

Dr. Kitchens prefers to start with what he calls the strongest and longest-acting option, particularly for patients with PEDs, which he views as tougher lesions to dry. Rapid drying allows him to skip a full loading series and begin extending as soon as the retina is dry. Asked about the belief that potent agents increase the risk of retinal pigment epithelium tears, he argues the opposite: large PEDs tend to tear when left untreated, so flattening them early is the priority.Dr. Kim frames her approach around the question patients often ask, namely what she would choose for her own mother. Because lost ground is not always recoverable, she starts with the best available agent whenever insurance allows, and especially for monocular patients, those traveling long distances, and people whose work demands near-perfect vision.The shared message is that the cost of undertreatment early can outweigh the convenience of starting with a less potent option.

The next episode in this series, "Extending Treatment Intervals in wAMD," features the panelists weighing how far they are willing to stretch dosing intervals with second-generation agents.