The evolving role of vascular endothelial growth factor inhibitors in the treatment of neovascular age-related macular degeneration

Age-related macular degeneration (AMD) is the leading cause of blindness among the ageing population. The introduction of molecular inhibitors of vascular endothelial growth factor (VEGF), such as pegaptanib, ranibizumab, and bevacizumab, as treatments for exudative AMD has provided new hope for affected patients and has transformed the practices of retina specialists. Phase III clinical trials have demonstrated the efficacy and safety of monthly ranibizumab for the preservation as well as improvement of visual acuity in patients with exudative AMD. Ongoing trials are evaluating the effectiveness of different dosing regimens, monitoring strategies, and combination therapies to determine the optimal niche for this new class of drugs in AMD management. Based on emerging evidence, most clinicians are now adopting a variable VEGF inhibitor dosing strategy guided by serial diagnostic reevaluation by optical coherence tomography. Some are also finding benefit through the addition of photodynamic therapy and steroids to the treatment regimen. The results of current and upcoming trials systematically addressing these issues are expected to establish new guidelines for the management of AMD. Indeed, a new paradigm may emerge wherein numerous modular therapeutic modalities are administered in customized combinations based on specific clinical and diagnostic findings.