Universal Screening for Pediatric Eye Disease
Darius M. Moshfeghi, MD
Twenty percent of newborns have fundus hemorrhages. These hemorrhages are more common in infants delivered vaginally than those delivered by C-section (odds ratio = 10.45)
Dr. Moshfeghi presented the initial results from his Newborn Eye Screen Testing (NEST) study and described universal screening as an emerging tool for pediatric eye disease. The study leveraged the infrastructure built for the Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP), a large telemedicine network
The Workup of the Retinal Vein Occlusion Patient
J. Michael Jumper, MD
The workup of a patient with retinal vein occlusion should focus on atherosclerotic risk factors including hypertension, hyperlipidemia, and diabetes
Retinal vein occlusion (RVO) can occur at any age, although advanced age is a risk factor. RVO is a multifactorial disease that shares risk factors with atherosclerosis. Thrombophilia testing is rarely necessary, although it may be useful for patients with a personal or family history of abnormal thrombosis
Clotting disorders that act on both the venous and arterial system, namely hyperhomocysteinemia and the antiphospholipid antibody syndromes, have the greatest association with RVO
A Retrospective Cohort Study in Patients with Tractional Diseases of the Vitreomacular Interface
Peter W. Stalmans, MD, PhD
Dr. Stalmans presented data from his observational study of 556 patients with vitreomacular interface (VMI) disorders with a follow-up of ~2 years. He reported that tractional disease of VMI is bilateral in 39% of patients. Spontaneous release of vitreomacular traction (VMT) is relatively rare (25% within a year)
Vitrectomy was eventually required in ~26% of eyes with VMT and ~5% of eyes with asymptomatic vitreomacular adhesion (VMA). Patients with VMT progressed from macular hole with VMT to a macular hole without VMT 15% of the time
None of these holes closed spontaneously in contrast to the 40% closure rate seen in the ocriplasmin trials. Visual acuity outcomes in the VMT group were best when spontaneous release occurred, compared to those eyes with no release or surgically induced release
TER and CRYSTAL Studies
Jordi M. Monés, MD
BRIGHTER and CRYSTAL continue the investigation of ranibizumab as a treatment for branch retinal vein occlusion (BRVO) and central retinal vein occlusion (CRVO). The 2 trials were designed to evaluate flexible, stabilization criteria-driven PRN dosing of ranibizumab 0.5 mg in a broad population of patients
Dr. Monés reported that such a dosing regimen was effective in improving visual acuity in an expanded population. Specifically, the BRIGHTER trial revealed that ranibizumab with or without laser was superior to laser alone over 6 months
VIBRANT Trial
Robert E. Leonard II, MD
Patients with macular edema secondary to BRVO were twice as likely to gain ≥ 15 letters in BCVA if they received 6 monthly aflibercept injections (2 mg) compared to laser therapy for macular edema secondary to BRVO (53% vs 37%
Complete data were obtained on 150 of the 183 patients enrolled in this phase 3, multicenter, randomized study. Aflibercept was significantly better than laser when comparing vision improvement and reduction in retinal thickness as measured by OCT
Development of Atrophy in Neovascular AMD Treated with Anti-VEGF Therapy: Results of the HARBOR Study
SriniVas R. Sadda, MD
The HARBOR trial was designed to determine if anti-VEGF therapy can influence the development of atrophy in neovascular AMD. While the study was not able to completely address the question, the results do suggest that the risk of developing macular atrophy does not outweigh the benefits of ranibizumab therapy for wet AMD. Specifically, visual acuity gains do occur in the presence of atrophy, at least through 24 months of ranibizumab therapy
Because atrophy developing in cases of treated wet AMD may differ from classically defined geographic atrophy, the HARBOR study uses the term "macular atrophy" to describe this phenomenon
? Sustained-Release Drug Delivery: Where Do We Stand
Glenn J. Jaffe, MD
Local sustained drug delivery can be tailored specifically to the disease and appears to be a reasonable approach for the treatment of neovascular AMD. Sustained delivery can occur using multiple systems, different platforms, and various drugs
Sustained-delivery platforms for neovascular AMD include encapsulated cell technology (ECT), nanostructured Tethadur (pSivida Corp, Watertown, MA), refillable reservoir/port delivery systems (PDS), and implantable, refillable, programmable pump delivery systems
ECT, refillable reservoirs, and programmable pump delivery systems have all successfully gone through proof-of-concept clinical trials
Update on Gene Therapy for AMD
Jeffrey S. Heier, MD
Regular therapy delivers the best visual outcomes for patients with wet AMD; thus, gene therapy has been identified as having the potential to benefit these patients. And the human retina is ideally suited for gene-based therapies
Dr. Heier described 2 gene therapy approaches for treating AMD: intravitreal injection of a fusion protein containing sFlt binding domain and subretinal injection of naturally occurring sFlt. The intravitreal method is undergoing study in a phase 1 clinical trial at recognized centers of excellence, and the subretinal approach is being studied in a phase 2 trial. The data indicate that both therapies are well-tolerated and biologically active
An Easy Way to Save Money
George A. Williams, MD
By using the 0.3 mg dose of Lucentis (ranibizumab, Genentech, Inc, South San Francisco, CA) for conditions for which the 0.5 mg dose of Lucentis is indicated, significant savings could be achieved
Dr. Williams reported that with the rapid increase of intravitreal injections in the United States (an estimated 4,500,000 injections in 2014), the cost of FDA-approved anti-VEGF agents has risen to ~$3 billion, a significant proportion of the entire Medicare Part D budget ($19.5 billion)
There is currently an effort by payers (including Noridian Healthcare Solutions, LLC, and Novitas Solutions, Inc) to expand the indicated use of the 0.3 mg dose of Lucentis. There is enough drug in the 0.3 mg Lucentis vial to give a full 0.5 mg dose. It is important to note that billing for the 0.5 mg dose and using the 0.3 mg dose is considered fraud and should be avoided
The Future of Retina: A SWOT Analysis
David W. Parke II, MD
Retina is a subspecialty founded on medical knowledge as well as unique and complex surgical skills. Dr. Parke's SWOT (strengths, weaknesses, opportunities, and threats) analysis included a description of the retina specialty as resting at the top of the medical pyramid. While the position is inherently strong, it also has vulnerabilities
Examples
Strengths: Many of the core diseases managed by retina specialists have blindness as a frequent natural outcome. This makes it easy for the public and policy makers to prioritize the care provided by retina specialists
Weaknesses: The retina specialty relies on a concentration of billing and procedure codes; this leaves retina specialists vulnerable should treatments of diseases such as age-related macular degeneration or diabetic retinopathy become markedly simplified
Opportunities: New outcomes data from scientific innovation and the Academy's IRIS (Intelligent Research in Sight) clinical data registry will enable retina to develop hard numbers for aggregate and individual practice value
Threats: New science can pose a threat to those unable to anticipate the need for change and to remain flexible. Practices need to be able to adapt to major shifts, such as if AMD treatment required only 1 treatment a year, or if macular surgery became largely a thing of the past
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