Abstract
Background
Age-related macular degeneration (AMD) is a leading cause of vision loss in the elderly. China bears the world’s largest AMD burden. This study analyzes the evolving AMD burden in China (1990–2023) and the impact of anti-VEGF therapy.
Methods
We analyzed data from the Global Burden of Disease (GBD) 2023 study using joinpoint regression, decomposition analysis, and Bayesian modeling. A supplementary meta-analysis of single-arm studies was conducted to assess anti-VEGF efficacy in Chinese patients.
Results
From 1990 to 2023, China’s age-standardized prevalence rate (ASPR) and disability-adjusted life year rate (ASDR) for AMD decreased by −0.67% and −1.48% annually, respectively. In 2023, China accounted for 35.82% of global cases and 30.25% of global DALYs. A supplementary meta-analysis of 13 single-arm observational studies showed a pooled efficacy rate of 74% for anti-VEGF drugs in China, albeit with substantial heterogeneity (I2 = 93.07%), warranting cautious interpretation. The accelerated decline in ASDR after 2011 coincided temporally with the clinical introduction and subsequent insurance coverage of anti-VEGF therapy. Projections indicate a continued decline in burden through 2038.
Conclusion
Despite a declining age-standardized burden, China’s absolute AMD burden remains substantial due to rapid population aging and other challenges. The temporal association between anti-VEGF therapy availability and the accelerated burden decline suggests a potential contribution of this treatment, though causality cannot be directly inferred from this ecological analysis. The observed trends likely reflect multiple factors, including improved healthcare access, early diagnosis, socioeconomic development, and anti-VEGF therapy. Comprehensive strategies focusing on prevention and equitable healthcare access are needed.
Keywords: age-related macular degeneration, global burden of disease, China, anti-VEGF drugs, meta-analysis
Introduction
Age-related macular degeneration (AMD) is an ophthalmic disease affecting the macula of the retina, with age as an independent risk factor, capable of causing central vision loss in patients.1 It has become the leading cause of irreversible blindness in individuals over 60 years of age in developed countries.2 As the global population ages, AMD is becoming increasingly prevalent and significant worldwide.3 The global prevalence of AMD is projected to reach 288 million by 2040.4 Although intravitreal anti-VEGF injections are currently the first-line treatment for wet AMD, this therapy has several limitations, including the need for repeated injections, suboptimal responses in some patients, and retinal fibrosis.5–7 Moreover, progressive vision decline imposes a substantial burden on patients, their families, and societal productivity.8 Therefore, accurately understanding the trends and societal impact of AMD is crucial for developing targeted public health policies and exploring novel treatments.
China, with its large population, accounts for approximately one-fifth of the world’s AMD patients,9 bearing a substantial disease burden. It is currently experiencing the fastest aging trend among all developing countries, and this burden is projected to worsen in the coming decades.10 Estimates indicate that the proportion of China’s population aged 65 and older doubled from 7% in 2000 to 14% in 2020.11 By 2060, the elderly population is projected to reach 37–42%.12 Additionally, China faces challenges such as a high prevalence of tobacco use, an uneven distribution of healthcare resources between urban and rural areas, and heavy medical burdens.13,14 Consequently, there is an urgent need to develop context-specific public health policies to alleviate the burden of AMD.
Previous research on AMD has predominantly focused on high-income developed countries,15,16 with limited studies conducted in low- and middle-income developing nations. As the world’s largest developing country with a massive population base and rapid aging, China’s AMD burden is markedly higher than that of many other developing countries. However, previous GBD-based studies on AMD burden in China have largely ended at 2019, leaving the post-COVID-19 era and the period of widespread anti-VEGF therapy unexplored. Few have identified burden inflection points linked to policy changes such as the 2017 insurance coverage of anti-VEGF therapy.
To address these gaps, this study compares the prevalence and DALY rates of AMD in China with global figures from 1990 to 2023, stratified by age, sex, region, and SDI level, based on GBD 2023 data. It extends the analysis to 2023, incorporates projections to 2038, and examines burden trends in relation to policy milestones. Furthermore, we innovatively integrate a supplementary meta-analysis on anti-VEGF efficacy in Chinese AMD patients, providing mechanistic context for the observed trends beyond what descriptive analysis alone can offer. The goal is to comprehensively evaluate AMD control in China from both macro (disease burden evolution) and micro (treatment effectiveness) perspectives, informing future public health policy formulation.
Methods
Data Sources and Definitions
Data on AMD prevalence and disability-adjusted life years (DALYs) were sourced from GBD 2023. The dataset is hosted online by the Institute for Health Metrics and Evaluation (IHME). The GBD 2023 study employs a standardized methodology to estimate disease burden. The case definition for AMD aligns with ICD-10 code H35.3, representing moderate-to-severe vision impairment due to AMD. All estimates are generated by synthesizing scientific literature, survey data, hospital discharge records, and insurance claims data using complex statistical models and are reported with 95% uncertainty intervals.
Meta-Analysis of Anti-VEGF Treatment Efficacy
To quantitatively assess the clinical effectiveness of anti-VEGF drugs in Chinese AMD patients, we conducted a supplementary systematic review and meta-analysis following the PRISMA 2020 guidelines.17 We systematically searched PubMed, Web of Science, Embase, Cochrane Library, CNKI, and Wanfang databases from inception to April 10, 2026, for single-arm observational studies evaluating anti-VEGF agents (ranibizumab, conbercept, aflibercept, faricimab, or brolucizumab) in Chinese AMD patients. The search combined terms for AMD (“age-related macular degeneration” OR “AMD”), anti-VEGF therapy (“anti-VEGF” OR specific drug names), and China (“China” OR “Chinese”).
Two researchers independently screened titles and abstracts, followed by full-text review, extracted data, and assessed study quality using the MINORS scale. Treatment efficacy was defined as ≥15-letter BCVA gain or responder status per original study criteria. The response rate was pooled using a random-effects model, with heterogeneity assessed by the I2 statistic. Publication bias was assessed using funnel plots and Egger’s test. Analyses were performed using Stata 18.0 and R 4.5.0.
Joinpoint Regression Analysis
To identify statistically significant changes in temporal trends of AMD burden, joinpoint regression analysis was performed using the Joinpoint Regression Program (Version 4.9.1.0, National Cancer Institute). The analysis modeled the logarithm of age-standardized rates (ASPR and ASDR) with calendar year as the independent variable. The maximum number of joinpoints was set to four to avoid overfitting. The optimal number of joinpoints was determined using a permutation test with 4499 permutations and an overall significance level of α = 0.05. The Bayesian Information Criterion (BIC) was also used for model selection. For each identified segment, the annual percent change (APC) and its 95% confidence interval (CI) were calculated. The average annual percent change (AAPC) over the entire study period (1990–2023) was also computed to summarize the overall trend.
Bayesian Age-Period-Cohort (BAPC) Model
To project the future burden of AMD in China from 2024 to 2038, a Bayesian age-period-cohort (BAPC) model was applied. The model assumes that the observed number of AMD cases follows a Poisson distribution, with age, period, and cohort effects modeled as intrinsic random walks of order 2 (RW2). Default prior distributions (logGamma(1, 0.00005)) were assigned to the precision parameters of the random effects. The model was fitted using integrated nested Laplace approximations (INLA) via the “BAPC” package in R (Version 4.5.0). Model convergence was assessed by inspecting the posterior marginal distributions and the deviance information criterion (DIC). Posterior predictive checks were performed to validate the model fit against observed data from 1990 to 2023. Uncertainty intervals (95%) for the projected rates were derived from the posterior distributions. This approach enabled robust estimation of future trends while accounting for the inherent uncertainty in age, period, and cohort effects.
Comparison with Similar SDI Countries
To benchmark China’s AMD burden against countries with comparable socio-demographic development, we selected all countries within the same SDI quintile as China (high-middle SDI) from the GBD 2023 dataset. For each year from 1990 to 2023, the median age-standardized death rate (ASDR) and interquartile range (IQR) of this group were calculated. China’s ASDR was then plotted against this reference range to visually assess deviations. Formal statistical comparison was performed using a two-sample t-test (or Mann–Whitney U-test if normality assumptions were violated) for the most recent three-year period (2021–2023) to determine whether China’s ASDR differed significantly from the median of its SDI peers.
Results
Changes in the Chinese and Global Burden of AMD from 1990 to 2023
In 2023, the global number of AMD prevalent cases was 6,305,567.11, while China had 2,258,548.00 cases, accounting for 35.82% of the global total. Global AMD-related DALYs were 156474.23, with China contributing 517213.35, representing 30.25% of the global total. From 1990 to 2023, both global and Chinese age-standardized prevalence rate (ASPR) and age-standardized disability-adjusted life year rate (ASDR) showed an overall declining trend. China’s ASPR decreased from 124.50 to 99.70 per 100,000, and ASDR dropped from 11.29 to 6.92 per 100,000, with average annual percentage changes of −0.67% and −1.48%, respectively (Table 1 and Supplementary Figures 1–3).
Table 1.
Changes in the Disease Burden of AMD in China and Global from 1990 to 2023
| 2023 | 1990 | 1990–2023 AAPC (95% UI) | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Measure All-Ages Cases (95% UI) | Age-Standardized Rates Per 100000 People (95% UI) | Measure All-Ages Cases (95% UI) | Age-Standardized Rates Per 100000 People (95% UI) | ||||||||
| Location | Prevalence | DALYs | Prevalence | DALYs | Prevalence | DALYs | Prevalence | DALYs | Prevalence | DALYs | |
| China | Total | 2,258,548.00 (1,891,189.55 to 2,714,227.77) | 156,474.23 (104,217.14 to 222,304.05) | 99.70 (83.57 to 119.63) | 6.92 (4.60 to 9.87) | 809,275.79 (670,037.61 to 971,645.34) | 73,744.84 (49,578.28 to 104,550.26) | 124.50 (103.45 to 147.80) | 11.29 (7.53 to 16.04) | −0.67 (−0.91 to -0.43) | −1.48 (−1.76 to -1.20) |
| Male | 935,571.74 (782,158.29 to 1,127,341.66) | 63,396.64 (42,186.60 to 89,310.10) | 89.29 (74.61 to 107.65) | 6.03 (4.00 to 8.55) | 323,843.38 (267,895.24 to 388,762.01) | 29,628.93 (19,683.60 to 42,511.35) | 108.76 (90.18 to 129.34) | 9.76 (6.57 to 13.80) | −0.60 (−0.81 to -0.38) | −1.47 (−1.64 to -1.12) | |
| Female | 1,322,976.26 (1,105,524.76 to 1,586,886.11) | 93,077.59 (62,196.98 to 130,514.52) | 108.10 (90.54 to 129.30) | 7.62 (5.09 to 10.72) | 485,432.41 (401,684.65 to 583,637.38) | 44,115.91 (29,558.81 to 62,494.31) | 135.02 (112.34 to 160.86) | 12.28 (8.20 to 17.51) | −0.66 (−0.92 to -0.41) | −1.43 (−1.75 to -1.12) | |
| Global | Total | 6,305,567.11 (5,298,347.62 to 7,470,745.88) | 517,213.35 (350,068.48 to 729,345.76) | 69.73 (58.48 to 82.92) | 5.73 (3.87 to 8.10) | 2,686,439.79 (2,235,352.64 to 3,219,967.49) | 271,185.56 (182,834.30 to 387,808.04) | 76.29 (63.42 to 90.86) | 7.72 (5.22 to 11.00) | −0.27 (−0.32 to -0.21) | −0.89 (−1.01 to -0.76) |
| Male | 2,575,182.80 (2,162,411.58 to 3,058,910.88) | 209,515.54 (142,469.55 to 295,197.69) | 64.23 (53.98 to 76.56) | 5.23 (3.53 to 7.41) | 1,070,723.63 (883,260.81 to 1,284,602.53) | 108,744.83 (72,169.20 to 154,218.92) | 71.17 (58.67 to 84.83) | 7.21 (4.85 to 10.28) | −0.31 (−0.37 to -0.25) | −0.97 (−1.05 to -0.90) | |
| Female | 3,730,384.32 (3,130,339.81 to 4,425,652.67) | 307,697.82 (209,300.21 to 434,803.94) | 74.07 (62.04 to 87.93) | 6.11 (4.14 to 8.62) | 1,615,716.16 (1,346,532.39 to 1,930,813.01) | 162,440.73 (110,003.43 to 232,242.22) | 79.69 (66.65 to 94.86) | 8.04 (5.44 to 11.44) | −0.22 (−0.26 to -0.18) | −0.81 (−0.93 to -0.71) | |
Results of the Meta-Analysis on Anti-VEGF Treatment Efficacy
Our meta-analysis included 13 single-arm observational studies conducted in China.18–30 Given the expected clinical and methodological variations among the included single-arm studies (eg, different anti-VEGF agents, varying follow-up durations, and heterogeneous study populations), and considering the high heterogeneity observed (I2 = 93.07%, P < 0.01), a random-effects model was employed for the pooled analysis to provide a more conservative estimate of treatment efficacy. The pooled analysis showed that anti-VEGF drugs had a significant therapeutic effect in Chinese AMD patients, with a combined efficacy rate of 74% (95% CI: 0.61 to 0.84). However, the substantial heterogeneity (I2 = 93.07%) indicates considerable uncertainty around this estimate, and the wide confidence interval reflects the variability among the included studies. This result should therefore be interpreted with caution. Sensitivity analysis indicated robust results, and Begg’s test suggested no significant publication bias (z = 0.12, P = 0.903) (Figures 1–2, Supplementary Figures 4–5, Supplementary Table 1–2 and Supplementary File 1).
Figure 1.
PRISMA flow diagram showing the literature screening process.
Figure 2.
Forest plot of the meta-analysis results.
Joinpoint Regression Revealing the Dynamic Association Between Anti-VEGF Drug Policies and AMD Burden
Trend analysis of ASPR and ASDR from 1990–2023 revealed significant turning points consistent with key milestones in anti-VEGF drug development. After 2006, the decline in ASDR accelerated significantly both globally and in China, coinciding with the initial clinical application of the first anti-VEGF drug, ranibizumab. Most notably, the accelerated decline in China’s ASDR from 2011 to 2023 directly aligned with the introduction of anti-VEGF drugs into clinical practice in China in 2011 and their subsequent inclusion in the national medical insurance reimbursement catalog starting in 2017 (Figure 3 and Table 2). This finding, corroborated by our meta-analysis results (74% efficacy rate with substantial heterogeneity, I2 = 93.07%), shows a temporal association between improved accessibility to anti-VEGF treatment (through clinical adoption and insurance coverage) and the accelerating decline in AMD disease burden. However, causality cannot be directly inferred from this ecological analysis, as temporal coincidence does not establish causation.
Figure 3.
Joinpoint regression analysis of the global and Chinese burden of AMD from 1990 to 2023. (A) Global trends in age-standardized prevalence rate (ASPR); (B) Global trends in age-standardized death rate (ASDR); (C) Trends in China’s ASPR; (D) Trends in China’s ASDR. The annual percentage change (APC) is indicated in each panel (*P < 0.05).
Table 2.
Anti-VEGF Drugs Currently Available in China for Ophthalmic Treatment
| Anti-VEGF Drugs | Research and Development/Manufacturing Company | Approval Date | Date of Inclusion in Medical Insurance | Price Change (CNY) | Target Molecule | Drug Type | Reference |
|---|---|---|---|---|---|---|---|
| Ranibizumab | Novartis, Roche | 2011 | 2017 | 9800 to 3000~4000 | VEGF-A | Fab fragment antibody | [21] |
| Conbercept | Chengdu Kanghong Pharmaceutical Group | 2014 | 2017 | 6800 to 3500 | VEGF-A/B, PIGF | VEGF Receptor-Fc Fusion Protein | [31] |
| Aflibercept | Bayer, Regeneron | 2018 | 2019 | 9800 to 4000~5000 | VEGF-A/B, PIGF | VEGF Receptor-Fc Fusion Protein | [32] |
| Faricimab | Roche | 2023 | 2025 | 9000 to 3608 | VEGF-A/Ang2 | Bispecific IgG1 Antibody | [33] |
| Brolucizumab | Novartis | 2025 | - | - | VEGF-A | scFv fragment antibody | [34] |
Decomposition of the Impact of Population Aging, Growth, and Epidemiological Changes on DALYs
Between 1990 and 2023, the total number of AMD-related DALYs increased both globally and in China. Decomposition analysis revealed that globally, population aging, population growth, and changes in epidemiological rates contributed 79.93%, 76.06%, and −56.00%, respectively, to the increase in DALYs. In China, population aging was the dominant factor driving the increase in DALYs, with a contribution rate as high as 159.43%, while population growth contributed 36.32%. Changes in epidemiological rates contributed −95.75%, offsetting most of the burden increase caused by aging and growth. While this decline temporally coincided with the widespread use of anti-VEGF therapy, it likely reflects a combination of factors, including improved healthcare access, early diagnosis, better management of comorbidities, and treatment advances. The relative contribution of anti-VEGF therapy specifically cannot be isolated from this ecological analysis (Figure 4). This highlights the severity of China’s aging challenge while also illustrating the potential impact of treatment advances, including anti-VEGF therapy (which showed a pooled efficacy of 74% in our meta-analysis), in curbing the rise of disease burden. However, the precise contribution of any single intervention cannot be determined from this ecological analysis.
Figure 4.
Decomposition analysis and cluster analysis of the burden of AMD from 1990 to 2023. (A) Decomposition analysis of the global AMD burden; (B) Decomposition analysis of China’s AMD burden; (C) Cluster analysis of different regions globally; (D) Variations in the burden of AMD across different regions globally.
Comparison of AMD Burden Across Countries with Different SDI Levels
As the global Socio-demographic Index (SDI) improved from 1990 to 2023, the AMD burden gradually decreased in most countries. However, at similar SDI levels, China’s ASDR was higher than that of countries like Brazil and Mexico. In 2023, China’s SDI was 0.73, and its ASDR was 6.92 per 100,000, higher than the global average. Compared with other countries in the same high-middle SDI quintile during the same period, China’s ASDR was significantly higher (p < 0.0001). This indicates that China’s AMD burden is disproportionate to its level of socioeconomic development, reflecting an imbalance. Furthermore, analysis of smoking-attributable DALYs showed that since 2000, smoking-related DALYs among male AMD patients in China have been rising annually, while they remained relatively stable among females (Figure 5).
Figure 5.
The burden of AMD across different SDI countries and annual changes in smoking-attributable DALYs by gender in China. (A) Trends in age-standardized death rate (ASDR) and sociodemographic index (SDI) across different regions from 1990 to 2023; (B) Trends in ASDR and SDI for 204 countries from 1990 to 2023; (C) Comparison of ASDR between China and other countries within the same high-middle SDI quintile from 2021 to 2023 (****P < 0.0001); (D) Annual change in DALYs attributable to smoking among Chinese males; (E) Annual change in DALYs attributable to smoking among Chinese females.
Future Projections of AMD Burden in China
Projections based on the Bayesian age-period-cohort model indicate that from 2023 to 2038, both ASPR and ASDR for AMD in China, for both males and females, are expected to continue their sustained downward trend, despite the pressure from population aging. This suggests that the current intervention strategy centered on anti-VEGF therapy, if its accessibility and coverage are maintained, will continue to effectively mitigate China’s AMD disease burden in the future (Figure 6).
Figure 6.
Future burden of AMD by gender in China. (A) Male age-standardized prevalence rate (ASPR) prediction; (B) Female ASPR prediction; (C) Male age-standardized death rate (ASDR) prediction; (D) Female ASDR prediction.
Discussion
Current Status and Core Challenges of AMD in China
As of 2023, the burden of AMD in China remains severe. China accounts for a high proportion of the global absolute number of AMD patients, and its age-standardized burden rates are higher than the global average and those of many countries at similar development levels.9 The challenges revealed by this study are multidimensional:
First, rapid population aging is the fundamental driver. The contribution rate of 159.43% in the decomposition analysis visually demonstrates its overwhelming impact. Even with adjustments to fertility policies, the elderly population is projected to reach 37–42% by 2060,12 meaning the potential pool of AMD patients will continue to expand.
Second, inadequate control of behavioral risk factors, particularly the high smoking rate among men. From 1990–2023, the decline in AMD prevalence was greater among men than women globally, but in China, the decline was smaller among men than women. Combined with the rising trend of smoking-attributable DALYs among Chinese men and the fact that Chinese male cigarette consumption accounts for about 40% of the global total,13 ineffective tobacco control, especially its uneven enforcement between urban and rural areas, is a significant reason for the relatively high AMD burden among Chinese men.
Third, the imbalance between social development and disease burden. China’s higher ASDR compared to other countries at similar SDI levels reflects that while socioeconomic development has been rapid, the prevention and control system for age-related diseases like AMD has not fully kept pace. The large gap in per capita disposable income between urban and rural areas (51,821 yuan in urban vs 21,691 yuan in rural areas in 2023),35 coupled with the uneven distribution of medical resources, creates significant difficulties and financial pressures for rural patients in accessing early screening and standardized treatment (such as anti-VEGF therapy requiring multiple injections).14
The Potential Contribution of Anti-VEGF Therapy and Evidence Integration
A highlight of this study is the integration of macro disease burden data with micro treatment efficacy evidence, providing contextual support for the potential role of anti-VEGF therapy in AMD control in China. Nevertheless, the observed temporal associations do not constitute direct causal proof, and the actual contribution of anti-VEGF therapy to the burden decline likely works in concert with other healthcare improvements.
From the efficacy evidence perspective, our supplementary meta-analysis indicates that anti-VEGF drugs have a significant 74% efficacy rate in Chinese AMD patients, providing biological plausibility for their ability to alter the natural disease course and reduce disability burden.
From the historical trend perspective, joinpoint regression accurately captured the “policy rhythm” of disease burden changes: after the first global launch of an anti-VEGF drug in 2006,36 the global ASDR decline accelerated; after its introduction in China in 2011, China’s ASDR began to decline significantly;37 and the inclusion of anti-VEGF drugs in the national medical insurance in 2017 further increased treatment accessibility from the payment side, consolidating the downward trend. In our decomposition analysis, changes in epidemiological rates (−95.75%) made a massive negative contribution to offsetting the burden increase from aging, with the widespread adoption of anti-VEGF therapy likely being an important contributing factor.
From the perspective of treatment accessibility evolution, since introducing ranibizumab in 2011, China has successively approved conbercept (2014), aflibercept (2018), faricimab (2023), and brolicizumab 2025.21,31–34 Particularly, the inclusion of related drugs in the national reimbursement drug list since 2017 has significantly reduced the out-of-pocket cost per injection from nearly ten thousand yuan, greatly alleviating patients’ financial pressure. These converging factors—efficacy, accessibility, and insurance support—coincided with the decline in China’s age-standardized AMD burden rates during a period of ongoing population aging.
Beyond anti-VEGF therapy, other factors likely contributed to the declining AMD burden. Improved healthcare delivery and referral networks enabled earlier diagnosis. Advances in OCT technology improved detection rates. Changes in disease coding and increased AMD awareness may also have influenced trends. Broader socioeconomic development—including rising education, better nutrition, and improved cardiovascular risk management—likely played a synergistic role.
Persistent Challenges and Future Directions
Despite significant achievements, challenges remain. First, the economic burden of treatment is still heavy. AMD is a chronic disease often requiring long-term, repeated injections. Even after insurance reimbursement, the annual treatment cost remains a significant burden for many patients, especially those with low incomes and in rural areas. In 2023, China’s monthly per capita disposable income was approximately 3268 yuan,18 which may barely cover the out-of-pocket portion of a single injection. Second, the inherent refractoriness of the disease, such as non-response to treatment in some patients, the development of macular atrophy or fibrosis, and the need for frequent hospital visits, all affect final outcomes and patient adherence. The slight rebound in global and Chinese AMD prevalence between 2015–2020 may be the result of the combined effects of population aging, growth, and disease refractoriness.
Therefore, future strategies require a multi-pronged approach: 1) Strengthen prevention and early screening, especially in rural and elderly populations, and control risk factors such as smoking, hypertension, and hyperlipidemia. 2) Optimize treatment security, explore incorporating AMD chronic disease management into special outpatient services, further reduce patients’ long-term out-of-pocket costs, and utilize telemedicine and AI screening to improve primary care capabilities. 3) Promote treatment innovation, actively develop new anti-VEGF drugs with longer-lasting efficacy and dosing intervals (eg, bispecific antibodies already on the market), and intensify research and development for dry AMD treatments.
Study Limitations
This study has several limitations. First, GBD data treat AMD as a whole and lack subtype-specific estimates for dry versus wet AMD, whereas the observed burden decline is likely primarily attributable to advances in wet AMD treatment. Second, our meta-analysis included single-arm observational studies, which, while providing important efficacy evidence, carry a lower level of evidence compared to meta-analyses of randomized controlled trials. Third, analyzing China as a whole masks the vast disparities in socioeconomic status and healthcare accessibility across different provinces. Fourth, the high heterogeneity observed in our meta-analysis (I2 = 93.07%) limits the precision of the pooled efficacy estimate. Subgroup analyses by anti-VEGF agent or study characteristics were not performed, as the 13 included single-arm studies evaluated different agents with varying follow-up durations and patient populations, resulting in subgroups too small for meaningful statistical comparison. Fifth, as an ecological study using aggregate-level data, this analysis cannot establish causality. The temporal associations between anti-VEGF milestones and burden declines are suggestive but do not constitute causal evidence.
Conclusion
In summary, from 1990 to 2023, age-standardized AMD burden declined globally and in China, coinciding with advancements including anti-VEGF therapy. By integrating GBD trend analysis with meta-evidence, this study suggests a temporal association between anti-VEGF accessibility and burden decline, though causality cannot be inferred from this ecological analysis. The decline likely reflects multiple interacting factors, including improved healthcare access, early diagnosis, socioeconomic development, and anti-VEGF therapy. However, China’s absolute AMD burden remains heavy due to its vast patient base, rapid aging, high smoking rates, uneven medical resource distribution, and financial pressures of long-term treatment. Moving forward, advancing anti-VEGF accessibility should be paired with strengthening primary prevention, risk factor control, early screening, and narrowing urban-rural disparities. Such comprehensive efforts are essential to address the eye health challenges of an aging society and reduce the overall AMD burden.
Funding Statement
This research was supported by the Ministry of National Natural Science Foundation of China (No. 82260210), the Key Project of the Jiangxi Provincial Natural Science Foundation (No. 20252BAC250122), the Science and Technology Plan Project of the Jiangxi Provincial Health Commission (No. 202510055), and the General Project of the Jiangxi Provincial Traditional Chinese Medicine Science and Technology Plan (No. 2023B1368).
Declaration of Generative AI and AI-Assisted Technologies in the Manuscript Preparation Process
This article was written without the use of any AI tools.
Data Sharing Statement
Data on AMD prevalence and disability-adjusted life years (DALYs) are sourced from GBD 2023. The dataset is accessible online at “http://ghdx.healthdata.org/gbd-results-tool”, hosted by the Institute for Health Metrics and Evaluation. The data that support the findings of this study are available from the corresponding author, [Qihua Xu], upon reasonable request.
Ethics Approval and Consent to Participate
This study was based on publicly available, de-identified, aggregated data from the GBD 2021 database. In accordance with Article 32, Items 1 and 2 of the Measures for Ethical Review of Life Science and Medical Research Involving Human Subjects (China, 2023), this research was exempt from institutional review board approval as it involved secondary analysis of legally obtained publicly available data without collection of identifiable personal information. The supplementary meta-analysis included only published studies with their own ethical approvals.
Author Contributions
All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.
Disclosure
The authors declare that they have no competing interests.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data on AMD prevalence and disability-adjusted life years (DALYs) are sourced from GBD 2023. The dataset is accessible online at “http://ghdx.healthdata.org/gbd-results-tool”, hosted by the Institute for Health Metrics and Evaluation. The data that support the findings of this study are available from the corresponding author, [Qihua Xu], upon reasonable request.