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Can Anti-VEGF Therapy Keep Patients Driving Longer?
Evidence suggests you should mention this potential benefit of treatment to your patients.
By Sean McKinney, Contributing Editor

A recent study found that elderly drivers who have wet AMD may be able to hold on to their driver's licenses longer if they receive monthly injections of ranibizumab.1 The findings raise an important question: what are the best ways to manage a patient who gets behind the wheel between visits?

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Reason for Hope
"In Arizona, a patient must have best corrected vision of 20/40 or better in at least one eye to drive," says Pravin U. Dugel, MD, managing partner of Retinal Consultants of Arizona in Phoenix. "When patients don't meet that requirement, I face the difficult task of telling them they aren't legally permitted to drive, and I record it. But we know from the ANCHOR and MARINA studies that 30 to 40% of patients experienced improved vision with treatment.2,3 I have been surprised by how many patients below the legal limit for driving have their vision improved and drive again. So there's hope for improvement."

The recent study involved 1,126 patients over a 2-year period at the Wilmer Eye Institute in Baltimore. In the ranibizumab versus sham group, 85% of those receiving ranibizumab achieved the level of vision required for an unrestricted license. In the ranibizumab versus PDT group, 88% of those receiving ranibizumab achieved the necessary level of vision. Both groups reported higher confidence while driving.

Explaining the Benefits of Anti‑VEGF Therapy
"Typically when instituting anti-VEGF therapy, I tell patients they have a 70% chance of maintaining their baseline vision or improving, and up to a 40% chance of gaining three lines of vision," says Andrew Antoszyk, MD, partner at Vitreoretinal Service for Charlotte Eye Ear Nose and Throat Associates. "If patients have best corrected vision of less than 20/40, then I also emphasize that they have a good chance of achieving 20/40 vision (driving vision)."

Dr. Dugel says the stakes are high. "In the Southwest, where public transportation is poor, when you ask patients not to drive, you take away their way of life and their independence," he explains. "They're extremely motivated to keep their monthly appointments so they can hopefully avoid this outcome."

When to Discuss Driving
Dr. Antoszyk usually discusses driving if the patient has significant advanced macular degeneration in both eyes, such as geographic atrophy that surrounds the fovea. "I inquire about his night vision and ability to adjust to variable lighting conditions (dusk versus sunrise, rain, night driving, going from shaded streets to sunny streets). In situations where the patient has stopped driving due to poor function in the presence of dim illumination, I tell him that his impaired vision delays his ability to adapt rapidly to changing lighting conditions and places him at increased risk for hurting himself or someone else while driving. In patients with advanced geographic atrophy, I inform them of gaps in their vision of which they may not be aware. The brain automatically fills in the voids, giving them a false sense of a full field of vision. Thus, they don't know what they see and don't see."

Fortunately, Dr. Dugel notes, anti-VEGF therapy has made a major difference in outcomes for these patients. "Prior to these therapies, none of these patients had much hope of continuing to drive after being diagnosed with wet AMD," he says.

Vigilant Follow-up Is Needed
Despite the advantages of anti-VEGF, patients should be instructed to report any visual disturbances immediately, even after successful treatment.

"I stress the importance of being seen for increased distortion, blurred vision or onset of scotomas," says Dr. Antoszyk.

Dr. Dugel has his patients use Digisight apps, named "Sightbook" in the Apple Store for iPhones or iPads. The apps offer vision, contrast sensitivity and Amsler grid testing. "Patients love this because the walls of our office extend into their homes and they know they are being monitored on a daily basis and constantly in contact with our office. It's personalized, concierge service at the highest level … for free," he says.

Reference
1. Bressler NM, Chang TS, Varma R, et al. Driving ability reported by neovascular age-related macular degeneration patients after treatment with ranibizumab. Ophthalmology. 2013;120(1):160-168.
2. Brown DM, Kaiser PK, Michels M, et al. ANCHOR Study Group. Ranibizumab versus verteporfin for neovascular age-related macular degeneration. N Engl J Med 2006;355(14):1432-1444.
3. Rosenfeld PJ, Brown DM, Heier JS, et al. MARINA Study Group. Ranibizumab for neovascular age-related macular degeneration. N Engl J Med 2006;355(14):1419-1431.

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