EyeWorld Asia-Pacific September 2012 Issue

42 EWAP RETINA September 2012 advised if they have thin retinas that visual outcomes may not be exemplary. Dr. Bellucci advises performing OCT “when the measured visual acuity does not match with the aspect of the retina and with the density of the cataract.” Epiretinal membranes, for instance, are more frequent after other pathologies such as retinal photocoagulation, retinal detachment, or uveitis; for surgeons unfamiliar with OCT, these membranes “look like a black line at the retinal surface, cancelling the foveal depression,” he said (see Figure 1). Post-op, Dr. Mehta said studies showing macular thickening and PVD occur as early as 1 week post- cataract, and he’d advise obtaining a postsurgical OCT image at that time. “If the case is complex, and there is a significant chance for corneal decompensation in the immediate post-op period, then intraoperative spectral-domain OCT may be of benefit before such corneal clouding occurs,” he added. Dr. Mehta also recommends using either a spectral-domain or Fourier-domain OCT in lieu of time-domain OCT, as the former two provide “increased speed and resolution that are essential in determining accurate changes in thickness and anatomy,” he said. C-scan images can identify “even the most subtle macular puckering,” Dr. Mehta said, “as well as [provide] the ability to evaluate the macula for subtle atrophy of the choroid and RPE, as seen in macular degeneration.” Using - from page 41 Expanding - from page 40 practitioners in the U.S. will begin to use Eylea in an off-label fashion for a variety of ocular conditions just as they have with other anti- VEGF agents. Ironically, however, in areas of the world where patients are cash strapped, she doesn’t see Eylea as making in-roads. “Where economics is the driving factor, bevacizumab has the market cornered,” she said. This stems from its early origins. “Because it was developed for cancer, the price was set for a unit of drug,” she said. So, for example, if the drug was priced at US$2,000 for a quart and all that ophthalmologists need is a teaspoon, the cost may be a mere US$5, something with which there is no competing. “Even if that has to be given every single month, if what’s driving decisions is economics, that is still going to be log-units less expensive,” Dr. Bressler said. In contrast, Terence Hurley, spokesperson for Genentech, added, “Even though the monthly wholesale cost of Lucentis in the U.S. for wet AMD is [US]$1,950, the average cost for 1 year of Lucentis treatment in the U.S. depends on the number of injections a patient receives and typically ranges from [US]$9,750-15,600 (for wet AMD, we currently estimate that in the first year of treatment, the average patient receives ~8 injections and then approximately 5 injections in the second year).” Anti-VEGF offers options Overall, Dr. Agarwal is impressed by all of the anti-VEGF agents and what they can offer a wide swath of his retinal patients. “From an ophthalmic point of view all of these drugs are fantastic,” he said. “They are definitely helping the patients; there is no doubt about it because we have this documented everywhere in the world.” He urged practitioners everywhere to begin using these. “The doctor has to move into it because when it affects and helps the patients, it is also going to favor the doctor because he is going to get better results,” Dr. Agarwal said. “Anti-VEGF products are a real boon for patients.” Dr. Bressler agrees. Going forward she thinks that the most powerful strategy will be to make these agents more user friendly. “I think that these are wonderful drugs and that what we can accomplish now is enormously different from where we were 10 years ago,” she said. “The best means of building upon that is going to be with a longer-acting agent or better ways of delivering it rather than something that is going to be more powerful in terms of vision change or a quicker response.” EWAP Editors’ note: This article discusses off-label uses of anti-VEGF drugs. For those with neovascular age-related macular degeneration in the U.S., use of anti-VEGF drugs such as Lucentis and Avastin to stabilize blood vessels and stop the proliferation of new ones is common practice. Likewise for a host of other retinal diseases these anti- VEGF agents are gaining traction, both here and around the globe, according to Dr. Bressler. Mr. Hurley clarified, “Avastin is not manufactured or approved for use in the eye, and thus we do not promote or support its use in the eye. It was developed and is approved for the treatment of patients with certain forms of cancer. Safety findings from large observational studies suggest the risk of systemic serious adverse events may be higher when injecting Avastin into a person’s eye compared to Lucentis, which is approved and manufactured for use in the eye. Therefore, uncertainty remains about the safety of Avastin in the eye.” He added, “We believe Lucentis is the most appropriate treatment for wet AMD, and physicians should have the ability to prescribe the medicine they think is right for their patients.” Anti-VEGF agents are well-suited to treat many different retinal conditions. “One, they stop blood vessels from growing,” Dr. Bressler said.”Two, they seem to stop them from leaking, and both are desirable attributes.” Drs. Agarwal and Bressler have no financial interests related to this article. Mr. Hurley has financial interests with Genentech. Contact information Agarwal: +91-44-2811-6233, dragarwal@vsnl.com Bressler: 410-955-5080, sbressler@jhmi.edu Hurley: 650-225-1000 As soon as corneal transparency has been re- established, cataract surgeons should take an OCT image if visual acuity “is far below the expected,” he said. Although it doesn’t occur often, upon occasion post-op OCT will discover an impending macular hole (Figure 2). “Sometimes thin epiretinal membranes may be present but not discovered until the media transparency has been restored,” he said. OCT is “no longer an esoteric piece of equipment,” Dr. Safran said, but should be an integral part of any anterior segment surgeon’s pre-op/post-op evaluations. “In my opinion, no retina can be defined as ‘normal’ without an OCT evaluation,” Dr. Bellucci said. EWAP References 1. Chen JC, Lee LR. Clinical spectrum of lamellar macular defects including pseudoholes and pseudocysts defined by optical coherence tomography. Br J Ophthalmol . 2008;92(10):1342-6. 2. Spaide RF. Age-related choroidal atrophy. Am J Ophthalmol . 2009;147(5):801-10. 3. Mirshahi A, Hoehn F, Lorenz K, Hattenbach LO. Incidence of posterior vitreous detachment after cataract surgery. J Cataract Refract Surg . 2009;35(6):987-91. Editors’ note: Dr. Bellucci has financial interests with Bausch + Lomb (Rochester, NY, USA). Dr. Safran has financial interests with Heidelberg (Germany). Drs. Boyer and Mehta have no financial interests related to this article. Contact information Agarwal: +91-44-2811-6233, dragarwal@vsnl.com Bressler: 410-955-5080, sbressler@jhmi.edu Hurley: 650-225-1000