Race, age linked to anti-VEGF initiation for nAMD

One in five patients with neovascular age-related macular degeneration (nAMD) fail to start treatment within 1 year of presentation, reports a study. Factors associated with lower treatment initiation include Asian race, age <60 years, and low-vision status, among others.

“Our analysis identified that patients from racial and ethnic minority groups, as well as those with either normal vision or vision worse than hand movements, were more likely to remain untreated,” the investigators said.

“Although we defined treated as receiving at least 1 injection within the first year, effective management of nAMD requires repeated, timely injections, and this metric reflects only the initiation of therapy,” they added.

This retrospective cohort study included 918,759 patients with nAMD newly diagnosed between October 2016 and October 2021 from the American Academy of Ophthalmology IRIS Registry. Multivariable Poisson regression models were used to explore the associations between demographic characteristics, presenting visual acuity (VA), and the initiation of anti-VEGF treatment.

Of the participants, 61.5 percent were women and 82.3 percent were White. Male, Black, and Hispanic patients developed nAMD at younger ages (p<0.001). Among these patients, 719,204 (78.3 percent) initiated anti-VEGF treatment within 1 year, and 653,340 (71.1 percent) received the first injection within 1 month. [Ophthalmology 2025;132:1411-1421]

Racial disparity

Multivariate analysis revealed that Black (rate ratio [RR], 0.91, 95 percent confidence interval [CI], 0.89‒0.93; p<0.001) and Asian patients (RR, 0.95, 95 percent CI, 0.93‒0.97; p<0.001) were less likely to initiate treatment than White counterparts. Likewise, Hispanic patients were less likely to start treatment than non-Hispanic counterparts (RR, 0.96, 95 percent CI, 0.95‒0.98; p<0.001).

On the other hand, patients aged >60 years (vs those aged 50‒59 years) and those from the West (vs South) region were more likely to initiate treatment (p<0.001 for all).

Among participants with available VA data, those with VA worse than 20/40 to 20/200 were more likely to start treatment (RR, 1.14, 95 percent CI, 1.12‒1.15) than patients with 20/20 or better VA. In contrast, those with hand movements VA (RR, 0.72, 95 percent CI, 0.69‒0.75) and light perception or worse VA (RR, 0.49, 95 percent CI, 0.44‒0.54; p<0.001 for all) were less likely to initiate treatment.

“Racial and ethnic disparities were evident in both the presentation and initiation of anti-VEGF therapy among patients with nAMD,” the investigators said. “At the time of first presentation, Black and Asian patients on average were younger than White patients, and Hispanic patients sought treatment at younger ages than non-Hispanic patients.”

There were also differences in VA at presentation, with 17.1 percent of Blacks and 16.8 percent of Asians having severe vision impairment compared with 13.4 percent of White patients. Likewise, 19.6 percent of Hispanic patients presented with severe vision impairment relative to 13.2 percent of non-Hispanic counterparts.

Barriers

There are several barriers that contribute to undertreatment of nAMD, such as the perception of a long-term treatment burden, including frequent in-person visits requiring significant time and travel commitments that may discourage patients from initiating treatment. [Surv Ophthalmol 2024;69:160-164; Surv Ophthalmol 2024;69:160-164; Arch Soc Esp Oftalmol (Engl Ed) 2022;97:198-204]

Other barriers included fear or anxiety about intravitreal injections, financial constraints, socioeconomic status, and age-related comorbidities, especially among older patients. [Ophthalmology 2022;129:e114-e126

Notably, “[t]reatment interruptions exceeding 6 months can lead to irreversible VA loss in nAMD, even if treatment is resumed later,” the investigators said. [Ophthalmol Retina 2020;4:134-140]