EyeWorld Asia-Pacific December 2015 Issue

62 EWAP PHARMACEUTICALS December 2015 whereas Lucentis is US$1,950. Likewise, Eylea, not included in the study, is also much more expensive at US$1,850. Protocol T showed that Eylea was best, Lucentis second, and Avastin last, Dr. Charles said. “There was a fair distance between Lucentis and Avastin in terms of outcomes,” he said. Yet the substantial cost difference may sway some who don’t want an inventory of an [US]$1,850 or [US]$1,950 drug, he said. In addition, since Avastin use in the eye is off-label, it must be made by a compounding pharmacy. “There are a number of eyes that have been blinded by now-defunct compounding pharmacies because they had infected materials,” Dr. Charles said. For those interested in expanding into this area, it goes beyond the question of whether it’s OK to inject an anti-VEGF and becomes an issue of knowing which drugs to use and understanding the problems associated with Avastin because of compounding pharmacy issues, he said. In addition, retina specialists commonly administer bilateral anti-VEGF injections on the same day. “It’s very inconvenient for the patients [if we inject on two different days],” Dr. Charles said. While there are some archconservatives who won’t inject anti-VEGF bilaterally, most retina specialists will do so, Dr. Charles noted. “With Lucentis and Eylea we don’t have a problem because it’s packaged by a completely sterile technique with incredible quality control, and [there hasn’t been] a single incidence of infection coming from the companies,” he said. “With Avastin it’s coming from the compounding pharmacy.” When he injects Avastin bilaterally he always uses a different batch for each eye. Those injecting anti-VEGF should be committed to doing so regularly, he advised. Lucentis lasts 4 to 5 weeks, Eylea 5 to 6, and Avastin about the same, Dr. Charles said. While patients need monthly injections, the average number nationwide for those on a “monthly” program is well less than 12. For those with wet AMD, skipping a month of treatment may result in a bleed or in a new membrane growing underneath the fovea. “You can move from treatable to untreatable visual loss in a couple of months,” he said. “There is no viable technology today to go 2 or 3 months between injections, so it’s a big deal to stay on schedule.” Using a sterile technique is also imperative. This means not scrimping on things such as sterile speculums, Dr. Charles said. He also thinks practitioners should follow the recommendation of Harry Flynn, MD, Bascom Palmer Eye Institute, Miami, who advises that the technician, the doctor, and the patient all wear a mask during the injection process. “I think it’s essential because when you draw up the drug in a syringe and adjust it, you hold it right up by your face,” he said. “Then you’re breathing on the needle.” Managing these patients also means looking at the OCT yourself. “You need to use spectral domain OCT, not time-domain OCT,” Dr. Charles said, adding that it’s also important to use black and white, not the color images and to be sure to look at each of the slices yourself and not leave this to the technician. It ultimately comes down to a question of excellence and doing the best by the patient, he said. “I beat up on my vitreoretinal colleagues who dabble in phaco,” he said, adding that the same holds true for those cataract surgeons who may not know all they need to about anti-VEGF injections. Coordinating with cataract When it comes to coordinating the use of anti-VEGFs with cataract surgery, there is a fair amount of flexibility. If a patient is on a 5-week schedule for one of the anti-VEGFs for wet AMD or vein occlusion and has cataract surgery scheduled on Tuesday, it is perfectly fine for him or her to be injected on Monday, Dr. Charles said. However, if the patient underwent cataract surgery on Monday and is due for an injection on Tuesday, it may be best to delay a week or so to ensure that the cataract wounds are more watertight. Dr. Boyer agreed that these can be done in close conjunction. He sometimes advises cataract surgeons to put a suture in to temporarily reinforce the wound so that there is no leak with any increased pressure. “I encourage them to put one suture in, which can be removed later once the wound is healed,” Dr. Boyer said. For the future, he hopes to have longer-acting anti-VEGF drugs. “For almost every condition that is treatable—macular degeneration, diabetes, and vascular occlusions—I think it’s important to identify the patients early and get them in the hands of the retina specialists,” he said. “These are vision-altering drugs that can really help our patients.” EWAP Editors’ note: Dr. Boyer has financial interests with Regeneron, Genentech, and Novartis (Basel, Switzerland). Dr. Charles has no financial interests related to this article. Contact information Boyer: vitdoc@aol.com Charles: scharles@att.net benefits in guiding treatment,” she said. The new test that she is most enthusiastic about is the LipiView II. “The ability to image and see Meibomian gland disease at the root is very exciting. This should get more patients [to understand] the seriousness and chronic nature of their dry eye disease,” she said. ASCRS members were also asked the following question: Overall, when do you believe advanced tear film diagnostics (such as osmolarity and interferometry) should be incorporated into your practice flow? Almost 40% of U.S. respondents don’t see any value in incorporating advanced tear film diagnostics into their practice flow, 5.8% higher than non-U.S. respondents (33.6%). The difference in responses between U.S. and non- U.S. doctors was not statistically significant (Figure 2). According to Dr. Farid, advanced tear film diagnostics should be incorporated into practice at the initial visit, which is when she typically uses them. “There is no reason to wait to appropriately diagnose these patients and categorize their dry eye severity. The rest of the treatment protocol should then be derived from the results of these tests,” she said. EWAP Editors’ note: Dr. Farid has financial interests with TearScience. Contact information Farid: mfarid@uci.edu Tests to diagnose - from page 56 Anti-VEGFs - from page 61