EyeWorld Asia-Pacific June 2011 Issue

June 2011 42 EW CORNEA Alternatives to trabeculectomy may be better suited to some patients and particular treatment goals A nti-VEGF injections have become the go-to standard for treating patients with wet AMD and other vascular diseases of the eye, including vein occlusions. The treatment is also the top choice of physicians combatting macular edema associated with diabetic retinopathy. However, the exponential expansion of patients, especially with wet AMD, and the injections given to treat them have started to cause some hardship—both for patients who need the monthly injections and for practitioners who are seeing their appointment books overflow with them. More than 200,000 cases of wet AMD are diagnosed each year. There are 2 million patients with the disease now, and that number is expected to climb to 3 million by 2020, according to retinal specialist Pravin U. Dugel, MD, Phoenix, Ariz., USA. “This is a group of patients that, just a few years ago, we really could do absolutely nothing for,” Dr. Dugel said. “They would come into our office, we would make a diagnosis, and there really wasn’t a lot we could do except provide supportive care. Now we are giving these patients injections on a monthly basis.” Currently, the most popular anti-VEGF injections available— Lucentis (ranibizumab, Genentech, South San Francisco, Calif., USA) and Avastin (bevacizumab, Genentech)—are used to stabilize vision or reduce vision loss in macular edema The latest with intravitreal injections by Jena M. Passut EyeWorld Staff Writer A patient is injected with Avastin Source: María H. Berrocal, MD patients, mostly those with exudative AMD. “The main disadvantage or limitation of the anti-VEGF treatment is that it’s not a cure,” Dr. Dugel said. “There have been wonderful, magnificently designed and executed studies done, and the studies show, even after monthly injections, the size of the neovascular membrane does not go away; in fact, it doesn’t even shrink. These injections, as good as they are, stop the blood vessel from leaking, but they do not get rid of the problem, thus having to inject patients on a monthly basis, probably ad infinitum. “Right now, we’re in a situation where it’s difficult for the patients, it’s difficult for physicians, and it’s difficult for the healthcare system.” Even so, Dr. Dugel and colleague retinal specialist María H. Berrocal, MD, professor of ophthalmology, University of Puerto Rico, San Juan, Puerto Rico, recognize and appreciate the transformation anti- VEGF injections have brought about in treatment paradigms. Avastin, which costs a fraction of what Lucentis does to administer, has been “revolutionary”, Dr. Berrocal said. “People don’t like to talk about cost, but it doesn’t really help to have a fantastic treatment that very few can afford,” she said. “We want a good treatment that can be accessible to as many people as possible. Now we have a great treatment that practically everyone can afford. That has been dramatic because it has been used extensively all over the world.” Administering the shot A typical anti-VEGF patient is prepped for the procedure in a sterile fashion, oftentimes with Betadine (povidone-iodine, Purdue Pharma, Stamford, Conn., USA). A speculum is inserted and the administering physician measures 4 mm behind the surgical limbus and injects 0.125 milligrams through the conjunctiva. Dr. Dugel prefers the standard 30-gauge needle, while Dr. Berrocal opts for the smaller 32-gauge. After the injection, the patient usually is placed on antibiotic drops. Generally, the injections are given on a monthly basis, although some practitioners try a method called “treatment extend”, which involves treating the patient three or four times on a monthly basis, observing how the treatments behave, and then extending the treatment period to every 6 weeks. Other indications for anti-VEGF injections In addition to wet AMD, the same course of anti-VEGF injections can be used to treat vein occlusions and diabetic macular edema. In Dr. Berrocal’s poorer patient population, diabetes is highly prevalent, causing her to use the treatment protocol quite often on her patients. “We have very bad diabetics, so we do see cases of neovascular glaucoma, too, where the patients come in with a painful eye and neovascularization in the iris and associated glaucoma,” she said, adding that the anti-VEGF treatments work “excellently” on those patients. “It causes regression of all the vessels, so you can actually apply photocoagulation later on and then do a bleb with minimal bleeding,” Dr. Berrocal said. Another indication is to use the VEGF inhibitor to pretreat diabetic surgery patients who have extensive neovascularization on the retina. “Those cases were very challenging in the past because when we tried to operate on them, they would bleed a lot, and controlling the bleeding during the surgery was very difficult,” Dr. Berrocal said. “When pretreating them with a VEGF inhibitor, all the vessels regress so we can perform all of our surgical maneuvers in a very safe and efficient way with minimal complications.” Central retinal vein occlusion, retinal branch vein occlusion, and regular diabetic macular edema patients can be treated for several