Treatment of AMD i Denmark

Inger Christine Munch, MDRoskilde HospitalMichael Larsen

Glostrup Hospital

17MAY 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

Year Incidens-

rate Incidens-rate-ratio P

2000 52.2 ref -

2001 57.9 1.10 .023

2002 57.3 1.09 .052

2003 54.4 1.04 .35

2004 47.7 0.92 .077

2005 46.4 0.89 .020

2006 48.5 0.94 .16

2007 39.0 0.75 <.0001

2008 34.3 0.66 <.0001

2009 32.0 0.62 <.0001

2010 25.7 0.50 <.0001

Aldersjusteret

Yearly incidence of blindness from other causes

YearIncidens-

rateIncidens-rate-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 fald på 51% fra 1999 til 2008Annual incidence of legal blindness per 100,000 inhabitants

Israel: Dramatic reduction in AMD-associated blindness

Annual incidence of legal blindness per 100,000 inhabitants

Change % in annual rate of blindness due to AMD

-1.3

-12.2

-16

-12

-8

-4

0

1999–2003 2004–2009

%, adjusted for age and sex

Other causes of blindness

Israel, 4 most frequent causes of blindness

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