Background: ARMD is a progressive degenerative disease of the macula and a leading cause of blindness in developed countries, primarily affecting people aged 60 years and older; risk increases with age and certain exposures (e.g., heavy alcohol use). The disease spectrum includes early (few medium drusen or pigmentary changes), intermediate (large drusen or geographic atrophy not involving the center), and late/advanced ARMD which may be non-exudative (dry, atrophic) or neovascular/exudative (wet).
Dry vs wet ARMD: The non-neovascular (dry) form causes slow, progressive macular deterioration with drusen and geographic atrophy. The neovascular (wet) form involves development of choroidal neovascularization (CNV) with leakage of blood and fluid, serous or hemorrhagic retinal pigment epithelial detachments, and scar formation, accounting for most cases of severe vision loss. Approximately 10–20% of patients with non-exudative ARMD progress to the exudative form.
Risk factors and natural history: ARMD risk rises with age; environmental and genetic factors contribute. Dry ARMD gradually worsens over years, while conversion to wet ARMD with CNV can cause rapid central vision loss.
Evolution of treatments: Historically, argon laser photocoagulation and submacular surgery were used but have limited roles due to harm or lack of benefit. Photodynamic therapy (PDT) with verteporfin limited visual loss in wet ARMD but typically does not improve vision. The advent of intravitreal anti-VEGF pharmacotherapies (pegaptanib, ranibizumab, bevacizumab, aflibercept, brolucizumab, and newer agents like faricimab) transformed management of neovascular ARMD, substantially reducing VA loss and providing VA gains with appropriate dosing regimens (e.g., VIEW trials for aflibercept; CATT comparing ranibizumab and bevacizumab).
Emerging and surgical options: For patients with refractory/end-stage central vision loss, intra-ocular devices such as the Implantable Miniature Telescope (IMT) have been developed and FDA-approved for selected older patients; IMT clinical trials (IMT-002 and follow-ups) demonstrated VA and quality-of-life improvements but also notable endothelial cell loss and potential corneal complications, informing strict selection and follow-up criteria.