Age-Related Macular Degeneration

Clinical Snapshot

Age-related macular degeneration (AMD) is a progressive degenerative disease of the macula — the central retina responsible for the sharp, detailed vision needed for reading, driving, and recognizing faces — and is a leading cause of irreversible vision loss in older adults.^[1] AMD exists in two fundamentally different forms that drive completely different management: dry (nonexudative) AMD, characterized by drusen deposition beneath the retina and, in its advanced form, atrophy of the retinal pigment epithelium and photoreceptors (geographic atrophy); and neovascular (wet or exudative) AMD, in which abnormal choroidal blood vessels grow underneath and sometimes into the retina, leak fluid and blood, and cause rapid, severe central vision loss if untreated. Neovascular AMD always arises on a background of pre-existing dry AMD.^[2] Peripheral vision is generally preserved even in advanced disease, so most patients retain independent mobility but lose the fine visual precision needed for reading and detail work. This chapter covers the AREDS2-formulation supplementation that slows progression in appropriately selected dry AMD, intravitreal anti-VEGF therapy as the standard of care for wet AMD, the emerging complement-inhibitor class for geographic atrophy, and the counselling points — smoking cessation, home self-monitoring, and urgent recognition of new visual distortion — where pharmacists have the most direct impact.

Recognize the Condition

Typical presentation

Dry AMD is usually asymptomatic in its early stages and, when it does progress, produces a slow, gradual blurring or dimming of central vision over months to years. Neovascular AMD is different in character and urgency: it typically presents with new or rapidly worsening metamorphopsia (straight lines appearing wavy, bent, or broken), a new central blur or dark spot (scotoma), or a drop in visual acuity over days to weeks rather than months. This difference in tempo matters clinically — rapid-onset distortion should always raise suspicion for neovascular conversion, not simply be assumed to be "worsening AMD."

AMD stages and forms

Early AMD

Small to medium drusen only, no pigmentary changes. Usually asymptomatic. Not, on its own, an indication for AREDS2-formulation supplementation.

Intermediate AMD

Large drusen, or medium drusen with retinal pigment epithelium changes. May cause mild visual symptoms. The key stage for AREDS2-formulation supplementation.

Late AMD — geographic atrophy (advanced dry)

Well-demarcated areas of retinal pigment epithelium and photoreceptor loss, causing a permanent, gradually enlarging area of vision loss. No pharmacotherapy is currently available in Canada to treat established geographic atrophy directly.

Late AMD — neovascular (wet)

Choroidal neovascular membrane formation with fluid or blood leakage. The most time-sensitive presentation — outcomes depend directly on how quickly anti-VEGF therapy is started.

Several other conditions can cause similar central visual loss and should be kept in mind when a presentation is atypical — pathologic myopia is the most common mimic — but confirming AMD versus an alternative retinal diagnosis is an ophthalmology-imaging task; the pharmacist's role is recognizing when a patient's symptoms warrant referral, not distinguishing between retinal diagnoses.

Risk Factors

Increasing age — the single strongest risk factor; AMD is uncommon before age 55.
Current or past cigarette smoking — the leading modifiable risk factor.
Family history of AMD in a first-degree relative.
Hypertension and cardiovascular disease.
Light iris and skin pigmentation.
Obesity, and a diet low in leafy green vegetables and dietary omega-3 fatty acids.
AMD already present in the fellow eye — the strongest single predictor of future involvement of the other eye.

Red Flags & Refer

Any new or worsening visual distortion in a patient with known or suspected AMD should be treated as a possible neovascular conversion until proven otherwise — anti-VEGF treatment benefit is time-sensitive, and delay measurably worsens visual outcomes.^[2]

New or worsening metamorphopsia (straight lines appearing wavy, broken, or curved) in either eye — refer urgently (days, not weeks) for OCT and ophthalmology assessment rather than waiting for the next routine visit.
New central blur, dark spot, or scotoma noticed on Amsler grid self-testing or otherwise.
Sudden, painless loss of central vision in either eye.
New visual change in the previously unaffected (fellow) eye of a patient with known unilateral wet AMD — the fellow eye carries a meaningfully elevated risk of neovascular conversion and needs the same urgency as a first presentation.
Severe eye pain, redness, worsening vision, or photophobia developing after a recent intravitreal injection — treat as possible endophthalmitis, a medical emergency requiring immediate ophthalmology assessment, not reassurance about expected mild post-injection discomfort.

Assessment & Diagnosis

History

Character and time course of any vision change — gradual dimming suggests dry AMD progression, while new or rapidly worsening distortion suggests neovascular conversion.
Specifically ask about central scotoma and metamorphopsia (straight lines appearing curved or crooked) — patients rarely volunteer these terms unprompted.
AMD in the patient or any first-degree relative.
Smoking history, current and past.

Physical examination

Visual acuity.
Amsler grid testing, one eye at a time.
Dilated fundus examination with slit-lamp biomicroscopy. Note that the retinal exam alone may be inadequate to exclude a treatable neovascular lesion — imaging is required for a definitive assessment.

Investigations

Optical coherence tomography (OCT) — noninvasive, widely available, uses infrared light to generate a cross-sectional image of the macula. Considered the gold standard for anti-VEGF treatment decisions, since it directly visualizes retinal fluid.
OCT angiography (OCT-A) — uses the same machine as OCT to provide additional vascular detail as an adjunct; it does not replace conventional OCT.
Fluorescein angiography — available only at larger centres and interpreted by retinal specialists; involves an IV injection of fluorescein sodium followed by fundus photography. It is chemically unrelated to iodinated contrast and contains no iodine, so it does not cross-react with an iodine or shellfish allergy, though rare allergic reactions to fluorescein itself can occur. Not a routine first-line test — reserved for cases where OCT findings are ambiguous or a less common lesion type needs characterization.

Several other conditions can produce similar central visual loss and enter the differential — pathologic myopia is the most common — but differentiating these from AMD is a retinal-imaging-based diagnosis made by ophthalmology, not a community pharmacy assessment.^[2]

Treatment Targets

Minimize or prevent further vision loss.
In neovascular AMD, preserve — and where possible improve — central visual acuity through prompt, adequately dosed anti-VEGF therapy.
In intermediate AMD that meets AREDS2 eligibility, slow progression to late (advanced) disease with daily supplementation.
Minimize enlargement of geographic atrophy and central scotomas.
Detect neovascular conversion as early as possible through structured self-monitoring, so treatment can start before irreversible damage accumulates.
Maintain functional independence and quality of life, including low-vision rehabilitation once vision loss has occurred.

Choose Initial Treatment

Dry (nonexudative) AMD track

Smoking cessation counselling, a balanced diet, AREDS2-formulation supplementation for patients who meet eligibility, and structured Amsler grid self-monitoring to catch neovascular conversion early. No pharmacotherapy currently available in Canada reverses or halts established geographic atrophy.

Neovascular (wet) AMD track

Urgent intravitreal anti-VEGF therapy, started as soon as the diagnosis is confirmed and continued on a treat-and-extend or fixed-interval schedule guided by OCT. Photodynamic therapy is reserved for select lesion subtypes not well suited to anti-VEGF alone.

Direct treatment rule

Who qualifies for AREDS2-formulation supplementation

Start supplementation in patients with intermediate AMD (large drusen, or medium drusen with pigmentary changes) in one or both eyes, or late AMD (geographic atrophy or neovascular) in one eye with intermediate AMD in the fellow eye — this is exactly the population enrolled in the trial that established the formulation.^[3]

Do not routinely recommend supplementation for early AMD alone (small or medium drusen without pigmentary change) or for a patient with no clinical AMD, even with a strong family history — neither group was shown to benefit.^[3]

Always choose a beta-carotene-free (AREDS2) formulation — it is equally effective as the original beta-carotene-containing formulation and avoids the increased lung cancer risk beta-carotene carries in current and former smokers.^[4]

Anti-VEGF agent selection for confirmed neovascular AMD

1st line ranibizumab or aflibercept — both carry a Health Canada indication specifically for wet AMD and are supported by the largest evidence base in the class.

Bevacizumab, used off-label, is also extremely common as a first choice in practice — large randomized trials found equivalent visual outcomes to ranibizumab at far lower cost, even though it does not carry a Health Canada ophthalmic indication.^[5]

Faricimab or brolucizumab are reasonable alternatives when extending the interval between injections is a priority; weigh brolucizumab's higher inflammation risk against that benefit before choosing it over the other options.^[6]^[7]

Photodynamic therapy with verteporfin is no longer first-line for typical neovascular AMD given inferior efficacy compared with anti-VEGF agents — reserve it for select lesion subtypes (for example, polypoidal choroidal vasculopathy) where a retinal specialist specifically directs it.

Non-Pharmacologic Treatment

Assess smoking status at every relevant encounter and offer active cessation support — smoking is the single largest modifiable risk factor for AMD and its progression.
Encourage a balanced diet with regular leafy green vegetables, which naturally provide lutein and zeaxanthin.
Teach Amsler grid self-monitoring to every patient with any stage of AMD or a strong family history: use adequate lighting and the patient's usual reading correction, hold or post the grid about 33 cm away, cover one eye at a time, and stare at the centre dot while checking for missing borders, broken lines, or new blur or waviness. Test weekly, and report any new change immediately rather than waiting for the next scheduled visit.
Refer patients with established vision loss to low-vision rehabilitation services — magnifiers, high-power glasses, reading machines, and low-vision clinics (for example, through the Canadian National Institute for the Blind) can meaningfully restore function for reading and household tasks even when central acuity cannot be recovered.
Reassure patients that mild eye ache and a small spot of subconjunctival hemorrhage after an intravitreal injection are expected and generally resolve within about two weeks; normal showering and bathing afterward is fine.
Device-based therapies such as photobiomodulation are under active investigation for non-neovascular AMD but are not yet standard of care or broadly authorized for this indication in Canada.

Pharmacologic Treatment Options

Drug / intervention	Role	Dose / use	Important adverse effects	Teaching points
AREDS2-formula vitamin-mineral supplement Preferred	Slow progression to late AMD in patients who meet AREDS2 eligibility	Vitamin C 500 mg + vitamin E 400 IU + lutein 10 mg + zeaxanthin 2 mg + zinc oxide 80 mg (or low-dose 25 mg) + cupric oxide 2 mg, PO daily (schedule varies by product — see product label)	GI upset/nausea (zinc-related); rare severe sideroblastic anemia at high cumulative zinc doses	Only proven to benefit intermediate AMD (or late AMD in one eye with intermediate AMD in the fellow eye) — do not recommend for early AMD alone. Take with food. Avoid beta-carotene-containing formulations, especially in current or former smokers.
Ranibizumab Preferred	1st-line intravitreal anti-VEGF for confirmed neovascular AMD	0.5 mg intravitreal injection every 4 weeks initially; treat-and-extend per OCT response thereafter	Eye pain, subconjunctival hemorrhage, rare endophthalmitis or intraocular inflammation	Administered only by an ophthalmologist. Carries the longest-established Health Canada indication specifically for wet AMD.
Aflibercept Preferred	1st-line intravitreal anti-VEGF; a high-dose formulation allows longer treatment intervals	Standard dose: 2 mg every 4 weeks x3, then treat-and-extend up to every 8-12 weeks. High-dose (Eylea HD): 8 mg every 4 weeks x3, then every 8-16 weeks.	Eye pain, subconjunctival hemorrhage, rare endophthalmitis or intraocular inflammation	The high-dose formulation (Eylea HD) is a distinct approved product allowing extended intervals for patients with a stable response.
Bevacizumab (off-label) Alternative	Off-label intravitreal anti-VEGF; equivalent efficacy to ranibizumab at far lower cost	1.25 mg intravitreal injection every 4 weeks initially; treat-and-extend thereafter	Eye pain, subconjunctival hemorrhage, rare endophthalmitis or intraocular inflammation	Not Health-Canada-authorized for intravitreal ophthalmic use — repackaged into single-use ophthalmic syringes by a compounding pharmacy. Very widely used first-line in practice despite the off-label status.
Faricimab Alternative	Dual VEGF-A/angiopoietin-2 inhibitor; extended-interval option	6 mg intravitreal injection every 4 weeks x4, then extend up to every 16 weeks based on anatomic and visual response	Eye pain, subconjunctival hemorrhage, rare endophthalmitis or intraocular inflammation	Consider when reducing injection frequency and treatment burden is a priority and disease activity allows extension.
Brolucizumab Special situation	Extended-interval anti-VEGF alternative	6 mg intravitreal injection every 4 weeks x3, then every 8-12 weeks based on disease activity	Higher rate of intraocular inflammation and retinal vasculitis than other anti-VEGF agents, including rare severe vision loss	Discuss the class-leading inflammation risk before selecting. Instruct patients to report new eye pain, redness, floaters, or vision change urgently at any point in treatment.
Verteporfin (photodynamic therapy) Special situation	PDT for CNV lesion subtypes not well suited to anti-VEGF alone	6 mg/m2 IV infusion over 10 minutes, followed by laser light activation; may repeat at 3-month intervals	Photosensitivity reaction, rare severe or irreversible vision loss, transient back pain during infusion	Patients must strictly avoid sunlight and bright indoor light exposure to skin and eyes for 2 days after infusion. Reserved for select lesion subtypes rather than routine first-line CNV management.

Special Populations

Pregnancy: AMD is overwhelmingly a disease of later adulthood, so pregnancy is rarely a direct consideration, but the principle still applies when it arises. Intravitreal anti-VEGF agents have minimal but nonzero systemic absorption, and VEGF inhibition carries a theoretical risk to fetal vascular development based on data from systemic (oncology-dose) bevacizumab use — treatment decisions in pregnancy should be individualized with the treating ophthalmologist and obstetric provider rather than deferred automatically. For AREDS2-formulation supplementation, the beta-carotene-free formula does not carry the specific pregnancy contraindication tied to beta-carotene, but routine use in pregnancy has not been specifically studied and should be discussed with the prescriber.

Breastfeeding

As with pregnancy, breastfeeding intersects with AMD treatment only rarely given the age demographics involved. Systemic absorption of intravitreal anti-VEGF agents is low but not zero, and dedicated lactation data are lacking — an individualized specialist discussion is appropriate rather than a blanket restriction.

Pediatric population

AMD does not occur in children, and this chapter's supplementation and anti-VEGF guidance does not apply to pediatric patients. (Some of the same anti-VEGF agents, notably ranibizumab, do have a separate pediatric indication for retinopathy of prematurity — an unrelated disease process outside the scope of this chapter.)

Renal impairment

Intravitreal anti-VEGF agents require no dose adjustment for renal impairment given their minimal systemic absorption. For AREDS2-formulation supplementation, high-dose vitamin C requires caution in renal disease given a risk of oxalate stone formation, high-dose vitamin E requires caution in renal disease, and high-dose zinc can cause GI upset and, rarely, a severe sideroblastic anemia — review the specific product's doses against these thresholds in a patient with significant renal impairment.

Older adults

AMD is fundamentally a disease of older adults. Screen for fall risk and home-safety concerns once central vision is affected, and reassess driving safety directly rather than assuming a patient will self-report vision changes that affect it.

Iodine allergy

Intravitreal injections are prepped with a topical antiseptic, most often povidone-iodine; ask about iodine allergy before the procedure. A chlorhexidine-based topical antiseptic is an available alternative in Canada when povidone-iodine is not appropriate.

Anticoagulant or antiplatelet use

Subconjunctival hemorrhage after an intravitreal injection is more common in patients taking ASA or anticoagulants; this is not itself a reason to withhold anticoagulation or delay the injection, and the bleeding is benign and self-limited.

Monitoring & Follow-Up

For neovascular AMD, monitoring is OCT-driven: visual acuity and OCT are checked at essentially every injection visit to confirm the treatment interval remains appropriate, since persistent or recurrent fluid signals the need to shorten the interval or switch agents rather than continue extending it. Watch for declining response to a previously effective agent (tachyphylaxis) — a meaningful proportion of patients require a switch to a different anti-VEGF agent at some point in their course, and response to switching, including switching back to a previously used agent, cannot be predicted in advance.^[5]

For dry AMD, whether or not the patient is on AREDS2-formulation supplementation, reinforce Amsler grid self-monitoring at every pharmacy encounter and ask specifically about new central blur or distortion — this is the single highest-yield community pharmacy question for this condition, since it is what triggers referral for possible neovascular conversion. Confirm adherence to daily supplementation and screen for unnecessary duplicate zinc, copper, vitamin C, or vitamin E supplements taken alongside a combination AREDS2 product.

After any intravitreal injection, patients should be told explicitly to seek immediate care — not to wait for their next scheduled visit — for severe eye pain, marked new vision loss, redness, or photophobia, which suggest endophthalmitis.^[8]

Treatment Failure / Next Step

Confirm adherence first: daily AREDS2-formulation supplementation taken as directed, or anti-VEGF injections completed on schedule without missed or excessively delayed doses.
For dry AMD that continues to progress despite supplementation, confirm this reflects the expected reality that AREDS2-formulation supplementation slows but does not eliminate progression risk, rather than a red flag — but re-screen specifically for new metamorphopsia or scotoma that would instead indicate neovascular conversion requiring urgent referral.
For neovascular AMD with an inadequate anatomic or visual response to the initial anti-VEGF agent despite correct dosing and interval, the standard next step is switching to an alternative anti-VEGF agent — the mechanism of action is similar across agents, an individual patient's response cannot be predicted, and switching (including back to a previously used agent) frequently restores response.
For recurrent intraocular inflammation on brolucizumab, discontinue it and switch to an alternative anti-VEGF agent given its class-differentiated inflammation signal.^[9]
For advanced geographic atrophy with continued enlargement and no approved pharmacotherapy currently available in Canada, focus on low-vision rehabilitation referral and continued monitoring of the fellow eye — preserving remaining function and catching neovascular conversion early remain the achievable goals.

Common Errors to Avoid

Recommending AREDS2-formulation supplementation for early AMD alone, or for a patient with no diagnosed AMD who simply has a family history — neither group was shown to benefit in the trial that established the formulation.^[3]
Choosing or continuing a beta-carotene-containing vitamin formulation, particularly in a current or former smoker — an equally effective beta-carotene-free (AREDS2) option exists and avoids the added lung cancer risk.
Missing duplicate supplementation — a patient taking a combination AREDS2 product alongside a separate standalone zinc, copper, vitamin C, or vitamin E supplement risks excess intake without added benefit.
Reassuring a patient with new metamorphopsia or central blur that it is "just their AMD" without urgent referral — this delay directly worsens visual outcomes, since anti-VEGF benefit is time-sensitive.
Treating a missed or substantially delayed intravitreal injection appointment as low-stakes — delayed treatment risks disease reactivation and permanent vision loss the same way nonadherence does in any other chronic disease.
Confusing expected, benign post-injection findings (mild ache, a small subconjunctival hemorrhage) with true red-flag symptoms (severe pain, marked new vision loss, photophobia) — under-triaging risks missing endophthalmitis, and over-triaging causes unnecessary alarm.
Not asking about smoking status and not offering cessation support at every opportunity, given it is the single largest modifiable risk factor for AMD.

Clinical Decision Algorithm

Initial assessment and staging

Patient with drusen, visual symptoms, or known AMD risk factors

Dilated fundus exam and OCT to stage AMD and confirm dry vs. wet

Early AMD (small/medium drusen only)

No pharmacologic supplementation indicated — reinforce smoking cessation, balanced diet, and routine ophthalmology follow-up

Intermediate AMD, or late AMD in one eye only

Qualifies for AREDS2-formulation supplementation — start daily, reinforce smoking cessation and Amsler grid self-monitoring

Late AMD identified in the eye being assessed

Geographic atrophy: no approved pharmacotherapy in Canada, proceed to supportive care and monitoring. Neovascular: proceed to Algorithm B immediately

Neovascular (wet) AMD — urgent pathway

New or worsening metamorphopsia, central blur, or exam/imaging findings suggesting a choroidal neovascular membrane

Urgent (days, not weeks) ophthalmology referral — do not wait for the next routine visit

Confirm with OCT, with fluorescein angiography reserved for ambiguous cases

Neovascular AMD confirmed

Start intravitreal anti-VEGF therapy (ranibizumab, aflibercept, or off-label bevacizumab) — loading phase, then treat-and-extend guided by OCT

Reassess visual acuity and OCT at every visit; switch to an alternative anti-VEGF agent if response is inadequate

Continue anti-VEGF therapy indefinitely as long as OCT shows active disease

No neovascular activity found

Continue the dry AMD management pathway and reinforce ongoing self-monitoring for future changes

Symptoms after an intravitreal injection

Any new symptom reported after a recent intravitreal anti-VEGF injection

Mild ache or a small subconjunctival hemorrhage

Expected — reassure the patient and monitor; typically resolves within about 2 weeks

Severe pain, marked new vision loss, redness, or photophobia

Treat as endophthalmitis until proven otherwise — immediate emergency ophthalmology assessment

Drug Tables

Adult dosing only — AMD does not occur in the pediatric population, so no pediatric dosing line applies to any drug in this table.

Vitamin-Mineral Supplementation (AREDS2 Formulation)

The individual components below make up the evidence-based AREDS2 formulation; most patients take them as a single combination product rather than as separate supplements.

Drug	Dosage	Adverse effects	Drug interactions	Comments
Vitamin C	Daily dose: 500 mg PO	High-dose supplementation can cause oxalosis and kidney stones in renal disease	None significant at AREDS2 doses
Vitamin E	Daily dose: 400 IU PO	May exacerbate retinitis pigmentosa and certain non-AMD inherited retinal degenerations; caution in renal disease	Theoretical additive bleeding risk with anticoagulants at high dose
Copper (cupric oxide)	Daily dose: 2 mg PO	Generally well tolerated at this dose	None significant	Included specifically to offset the copper deficiency and anemia risk caused by high-dose zinc — always paired with zinc in the formulation.
Zinc oxide	High-dose option: 80 mg PO daily Low-dose option: 25 mg PO daily	GI upset/nausea; rare severe sideroblastic anemia at high cumulative doses	Reduces absorption of tetracycline and fluoroquinolone antibiotics if taken together — separate dosing by at least 2 hours	The low-dose option was found as effective as the original high-dose option with less nausea.
Lutein + zeaxanthin	Daily dose: Lutein 10 mg + zeaxanthin 2 mg PO	Well tolerated	None significant	Replaced beta-carotene in the AREDS2 formulation; naturally occurring carotenoids concentrated in the macula.
Beta-carotene (historical AREDS formulation — not recommended today)	Historical daily dose: 25,000 IU PO	Increased lung cancer risk in current and former smokers regardless of when they last smoked; contraindicated in severe liver disease, renal insufficiency, dialysis, and pregnancy	None significant	Superseded by the lutein/zeaxanthin-based AREDS2 formulation, which is equally effective without this risk — do not select a beta-carotene-containing product today.
Combination AREDS2-formula product (for example PreserVision AREDS 2, Vitalux Advanced, and generic equivalents)	Typical adult dosing: 1 caplet PO twice daily, or per product-specific directions to reach the full daily AREDS2 dose	GI upset/nausea, primarily zinc-related	Separate any concurrent tetracycline or fluoroquinolone dosing by at least 2 hours	Confirm the specific product's per-dose amounts against the full daily AREDS2 targets above, since commercial formulations vary in how the daily dose is divided; take with food to reduce nausea.

Vascular Endothelial Growth Factor (VEGF) Inhibitors

All agents in this class are given as an intravitreal injection by an ophthalmologist following topical anesthesia and antiseptic preparation (usually povidone-iodine; chlorhexidine is an available alternative). Systemic absorption is minimal, so significant systemic drug interactions are not expected.

Drug	Dosage	Adverse effects	Drug interactions	Comments
Ranibizumab	Loading phase: 0.5 mg intravitreal injection every 4 weeks Maintenance: Treat-and-extend per OCT response, or continued monthly dosing if extension is not tolerated	Eye pain, subconjunctival hemorrhage, rare endophthalmitis or intraocular inflammation	None significant — minimal systemic absorption	Carries a Health Canada indication specifically for wet AMD with the longest track record in the class.
Aflibercept (standard dose)	Loading phase: 2 mg intravitreal injection every 4 weeks for 3 doses Maintenance: Treat-and-extend up to every 8-12 weeks per OCT response	Eye pain, subconjunctival hemorrhage, rare endophthalmitis or intraocular inflammation	None significant — minimal systemic absorption	Standard-dose formulation; Health Canada indicated for wet AMD.
Aflibercept, high-dose (Eylea HD)	Loading phase: 8 mg intravitreal injection every 4 weeks for 3 doses Maintenance: Extend up to every 8-16 weeks based on anatomic and visual response	Same class effects as standard-dose aflibercept	None significant — minimal systemic absorption	A distinct, higher-concentration formulation approved in Canada allowing longer treatment intervals for patients with a stable response.^[10]
Bevacizumab (off-label)	Loading phase: 1.25 mg intravitreal injection every 4 weeks Maintenance: Treat-and-extend per OCT response	Same class effects as other anti-VEGF agents	None significant — minimal systemic absorption	Not Health-Canada-authorized for intravitreal ophthalmic use; the vialed oncology product is repackaged into single-use ophthalmic syringes by a compounding pharmacy. Large randomized trials found equivalent visual outcomes to ranibizumab.
Faricimab	Loading phase: 6 mg intravitreal injection every 4 weeks for 4 doses Maintenance: Extend up to every 16 weeks based on anatomic and visual response at weeks 20 and 24	Same class effects as other anti-VEGF agents	None significant — minimal systemic absorption	Dual VEGF-A/angiopoietin-2 inhibition; supports extended intervals for a substantial proportion of patients by around one year of treatment.
Brolucizumab	Loading phase: 6 mg intravitreal injection every 4 weeks for 3 doses Maintenance: Every 8-12 weeks thereafter based on disease activity	Higher rate of intraocular inflammation and retinal vasculitis than other anti-VEGF agents, including rare severe vision loss	None significant — minimal systemic absorption	Reserve for patients where extended dosing is a clear priority and discuss the class-leading inflammation risk before selecting; instruct patients to report new eye pain, redness, floaters, or vision change urgently at any point in treatment.

Photodynamic Therapy

Drug	Dosage	Adverse effects	Drug interactions	Comments
Verteporfin	Adults: 6 mg/m2 IV infusion over 10 minutes, followed by laser light activation to the affected eye; may repeat at 3-month intervals	Photosensitivity reaction (risk of severe skin/eye burns with sun or bright-light exposure), transient back pain during infusion, rare severe or irreversible vision loss	Additive phototoxicity with other photosensitizing drugs	Reserved for select CNV lesion subtypes not well suited to anti-VEGF alone (for example, polypoidal choroidal vasculopathy); patients must strictly avoid sunlight and bright indoor light exposure to skin and eyes for 2 days after infusion.

Emerging Complement Inhibitors for Geographic Atrophy — Not Currently Available in Canada

Both agents target the complement cascade to slow geographic atrophy lesion growth rather than restore vision, and neither is currently authorized for sale in Canada — included here for awareness given active clinical and regulatory interest, not as a prescribable option.

Drug	Dosage	Adverse effects	Drug interactions	Comments
Pegcetacoplan (intravitreal, Syfovre)	Trial regimen: 15 mg intravitreal injection monthly or every other month	Risk of conversion to neovascular AMD, mild eye pain/irritation, rare endophthalmitis or retinal vasculitis	None established	A complement C3 inhibitor shown to slow geographic atrophy lesion growth in phase 3 trials.^[11] The Health Canada submission for this intravitreal formulation was cancelled by the sponsor before a final decision, so it is not currently available in Canada.^[12] This is a different formulation and indication from the existing subcutaneous pegcetacoplan product used for paroxysmal nocturnal hemoglobinuria.
Avacincaptad pegol (Izervay)	Trial regimen: 2 mg intravitreal injection monthly	Risk of conversion to neovascular AMD, mild eye pain/irritation, rare endophthalmitis	None established	A complement C5 inhibitor shown to slow geographic atrophy lesion growth in phase 3 trials.^[13] Health Canada's reimbursement review for this agent remains unresolved with no Notice of Compliance issued, so it is not currently available in Canada.^[14]

References

Age-related macular degeneration — New England Journal of Medicine (Apte RS). N Engl J Med 2021;385(6):539-547
Age-Related Macular Degeneration Preferred Practice Pattern — Ophthalmology, American Academy of Ophthalmology Preferred Practice Pattern Retina/Vitreous Committee (Vemulakonda GA, Bailey ST, Kim SJ, et al.). Ophthalmology 2025;132(4):P1-P74
Lutein + zeaxanthin and omega-3 fatty acids for age-related macular degeneration: the Age-Related Eye Disease Study 2 (AREDS2) randomized clinical trial — JAMA, Age-Related Eye Disease Study 2 Research Group. JAMA 2013;309(19):2005-2015
A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta carotene, and zinc for age-related macular degeneration and vision loss: AREDS report no. 8 — Archives of Ophthalmology, Age-Related Eye Disease Study Research Group. Arch Ophthalmol 2001;119(10):1417-1436
Ranibizumab and bevacizumab for neovascular age-related macular degeneration — New England Journal of Medicine (CATT Research Group; Martin DF, Maguire MG, et al.). N Engl J Med 2011;364(20):1897-1908
Efficacy, durability, and safety of intravitreal faricimab up to every 16 weeks for neovascular age-related macular degeneration (TENAYA and LUCERNE): two randomised, double-masked, phase 3, non-inferiority trials — The Lancet (Heier JS, Khanani AM, Quezada Ruiz C, et al.). Lancet 2022;399(10326):729-740
HAWK and HARRIER: phase 3, multicenter, randomized, double-masked trials of brolucizumab for neovascular age-related macular degeneration — Ophthalmology (Dugel PU, Koh A, Ogura Y, et al.). Ophthalmology 2020;127(1):72-84
Pooled estimates of incidence of endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents with and without topical antibiotic prophylaxis — Retina (Reibaldi M, Pulvirenti A, Avitabile T, et al.). Retina 2018;38(1):1-11
Risk of inflammation, retinal vasculitis, and retinal occlusion-related events with brolucizumab: post hoc review of HAWK and HARRIER — Ophthalmology (Monés J, Srivastava SK, Jaffe GJ, et al.). Ophthalmology 2021;128(7):1050-1059
Regulatory Decision Summary — Eylea HD (aflibercept injection, 8 mg) — Health Canada, Drug and Health Products Portal. Health Canada Regulatory Decision Summary, 2024
Pegcetacoplan for the treatment of geographic atrophy secondary to age-related macular degeneration (OAKS and DERBY): two multicentre, randomised, double-masked, sham-controlled, phase 3 trials — The Lancet (Heier JS, Lad EM, Holz FG, et al.). Lancet 2023;402(10411):1434-1448
Summary of Cancellation — Syfovre (pegcetacoplan intravitreal injection) — Health Canada, Drug and Health Products Portal. Health Canada Summary of Cancellation, 2025
Efficacy and safety of avacincaptad pegol in patients with geographic atrophy (GATHER2): 12-month results from a randomised, double-masked, phase 3 trial — The Lancet (Khanani AM, Patel SS, Staurenghi G, et al.). Lancet 2023;402(10411):1449-1458
Avacincaptad pegol — reimbursement review status — Canada's Drug Agency (CDA-AMC). CDA-AMC reimbursement review

Professional reference only. Apply clinical judgment and verify patient-specific decisions against current authoritative guidance and product information.