Treatment of AMD i Denmark Inger Christine Munch

Treatment of AMD i Denmark Inger Christine Munch, MD Roskilde Hospital Michael Larsen Glostrup Hospital

17 MAY 2010 Copenhagen, meeting at the Danish Society of the Blind

The president and vice president of the Danish Society of the Blind discussed whether a marked recent decrease in the number of new members was the result of changing referral practices among the Danish ophthalmologists

Årsag? Have the ophthalmologists stopped encouraging the newly legally blind to join the society?

- or is blindness decreaseing, perhaps as a consequence of better treatment of wet AMD, the leading cause of blindness in Denmark? - Let us look at the numbers …

Annual number of new members of the Danish Society of the Blind

Is there a national register of handicaps in Denmark? There is no such register The membership statistics of the Danish Society of the Blind is the only good source of blindness statistics in Denmark

- Membership censored; only by referral from an ophthalmologist - Not obligatory reporting

Criteria for membership • BCVA (best corrected visual acuity) in the best eye ≤ 0. 1 (6/60) • Visual field defects that cause an equivalent degree of disability, e. g. homonymous hemianopsia

Current study: Incidence and cause of blindness 2000 -2010 Dias 11

Denmark: dramatic reduction in AMD-associated blindness Annual incidence of legal blindness per 100, 000 inhabitants aged ≥ 50 years

Yearly incidence of blindness from AMD Aldersjusteret

Yearly incidence of blindness from other causes Year Incidensrate-ratio P 2000 17. 6 ref - 2001 19. 7 1. 12 . 16 2002 21. 6 1. 23 . 0079 2003 16. 5 0. 94 . 48 2004 13. 3 0. 76 . 0018 2005 15. 9 0. 91 . 26 2006 12. 8 0. 73 . 0004 2007 12. 7 0. 73 . 0002 2008 14. 4 0. 82 . 020 2009 13. 2 0. 75 . 0009 2010 11. 7 0. 67 <. 0001 Aldersjusteret

Do the changes in annual new members of the Danish Society of the Blind reflect changes in the incidence blindness? • Physicians’ referral practices may have changed • Patient preferences may have changed (Referral is not mandated by law)

Control study: Referral patterns at the Glostrup Hospital 2325 patients in current treatment with VEGF-inhibitors • 68 legally blind could potentially have been referred • 54 (86%) had actually been referred to the Danish Society of the blind

Israel • Population of 7. 3 mill. in 2008 • National register of the blind, obligatory referral • BCVA in best eye ≤ 0. 05 (3/60) • Visual field < 20° in best eye

Israel: Yearly incidence of blindness, all causes Et of Annual incidencefald legal blindness per 100, 000 inhabitants på 51% fra 1999 til 2008

Israel: Dramatic reduction in AMDassociated blindness Annual incidence of legal blindness per 100, 000 inhabitants

Change % in annual rate of blindness due to AMD %, adjusted for age and sex

Other causes of blindness

Israel, 4 most frequent causes of blindness

Number of new members >50 years of age Incident blindness in Danmark : AMD the most frequent cause

Wet AMD therapy: impact on health care system 2007 2008 2009 2010 2011

Denmark: dramatic reduction in AMD-associated blindness Annual incidence of legal blindness per 100, 000 inhabitants aged ≥ 50 years

AMD: It’s in your blood • Approximately 50% of the risk is attributable to genetic factors at the population level

Dry AMD Wet AMD Dry AMD with geographic atrophy Vision loss

Caveat! • Anti-VEGF therapy does not address the fundamental pathogenesis of AMD • It is foreseeable that the immediate benefit of wet AMD therapy may be overtaken in the long run by geographic atrophy of the RPE and the retinal photoreceptors

• No treatment for drusen-AMD • No treatment for geographic atrophy • No treatment for fibrosis • Need for repeated treatment in wet AMD: – cumulative risk of complications – discomfort – inconvenience – costs

Denmark: dramatic reduction in AMD-associated blindness Annual incidence of legal blindness per 100, 000 inhabitants aged ≥ 50 years