Firstly, I would question the accuracy of the diagnosis.
AMD is typically a bilateral condition with symmetrical clinical features, so it would be unusual to have advanced AMD in one eye but no sign of AMD in the fellow eye. Conditions that mimic AMD (e.g. myopic, traumatic, post-inflammatory or post-central serous chorioretinopathy maculopathies) should be excluded.
Assuming the diagnosis is correct, the decision whether or not to commence anti-VEGF treatment is complex. I would base my decision upon consultation with the patient, her family and carers, and careful consideration of the following questions:
1. Is treatment likely to improve or maintain her quality of life?
This depends upon multiple factors, including;
a) the extent of permanent structural macular damage present
- this is related to the duration and severity of wet AMD
b) the risk of further loss of vision if treatment is withheld
- this depends upon the current visual acuity (VA) e.g. if the VA of
the affected eye is hand movements, it cannot deteriorate much further,
but if it is 6/9, it is likely to deteriorate markedly without treatment
c) the risk of the fellow eye losing vision due to wet AMD or unrelated ocular disease
- based upon prospective data from the Age Related Eye Disease Study
(AREDS), her risk of developing advanced AMD in the fellow eye
approximates 12% within 5 years and 25% within 10 years (assuming
that she currently has no signs of AMD in the fellow eye).
d) The presence of ocular co-morbidity (e.g. cataract, glaucoma, diabetic retinopathy or amblyopia).
- this will influence her visual potential and prognosis
2. What is her life expectancy?
According to actuarial life tables, the life expectancy of a 94-year-old Australian woman is between 3 to 4 years. This may be longer if she is in excellent health or reduced if significant medical morbidity is present e.g. cancer or cardiovascular disease.
Age per se is not a reason to withhold treatment because good vision is increasingly important to maintaining independence with increasing age. However, life expectancy does influence the likelihood of developing visual loss in the fellow eye, an important consideration when weighing up the risks and benefits of anti-VEGF therapy.
3. What is her social situation?
This is relevant to the logistics of attending for anti-VEGF treatment e.g. does she have family or social support to help her attend for regular anti-VEGF treatments and eye examinations, does she live in an urban centre or rural setting located a long way from ophthalmic care?
Social habits also determine visual demands e.g. someone who enjoys needlework, drives and has an active lifestyle has greater binocular visual demands than someone who has dementia, is housebound and spends their time listening to the radio.
Ultimately, my decision on whether or not to commence anti-VEGF therapy would be highly dependent upon the desires of the patient after she has been provided with sufficient information to enable her to make an informed decision.