A 68-year-old Indian woman presents with gradual loss of central vision over the past 6 months. She reports seeing wavy lines (metamorphopsia) when looking at straight edges and has difficulty reading. Visual acuity is 6/24 in both eyes. Fundoscopy reveals choroidal neovascularization (CNV) with subretinal hemorrhage and lipid exudates in the macula of the right eye. The left eye shows drusen and retinal pigment epithelial changes. What is the most appropriate next step in management?

Explanation

## Clinical Diagnosis **Key Point:** This patient has **wet (exudative) age-related macular degeneration (AMD)** with active choroidal neovascularization, evidenced by CNV, subretinal hemorrhage, lipid exudates, and metamorphopsia. ## Management of Wet AMD **High-Yield:** Wet AMD is a sight-threatening emergency requiring immediate anti-VEGF therapy. The standard of care is intravitreal anti-VEGF agents (bevacizumab, ranibizumab, or aflibercept) administered as monthly injections, with response assessed by optical coherence tomography (OCT). ### Why Bevacizumab is Correct 1. **Mechanism:** Bevacizumab is a monoclonal antibody against vascular endothelial growth factor (VEGF), which drives CNV formation and leakage in wet AMD. 2. **Efficacy:** Anti-VEGF therapy halts CNV progression, reduces macular edema, and stabilizes or improves vision in 90% of patients when initiated early. 3. **Timing:** Early intervention (within weeks of CNV detection) is critical to prevent irreversible photoreceptor loss and preserve central vision. **Clinical Pearl:** The presence of subretinal hemorrhage and exudates indicates active, progressive disease requiring urgent intervention—not observation. ## Why Other Options Are Suboptimal | Option | Why Incorrect | |--------|---------------| | **Oral zinc + antioxidants** | Appropriate for dry AMD or early-stage disease; ineffective for active CNV. These are preventive agents, not treatment for wet AMD. | | **Laser photocoagulation** | Historically used but now superseded by anti-VEGF therapy. Laser causes collateral photoreceptor damage and is reserved only for extrafoveal CNV (rare). | | **Observation** | Contraindicated in wet AMD. Active CNV will progress, causing rapid vision loss and irreversible macular scarring within weeks to months. | **Mnemonic:** **VEGF-driven wet AMD = Anti-VEGF therapy.** Bevacizumab, ranibizumab, aflibercept are first-line; laser and observation are obsolete for active CNV. [cite:Parson's Diseases of the Eye 22e Ch 9]