Newsletter Autumn 2012

Dear patients and friends,

I have just returned form the Retina Society meeting in Washington DC. A most interesting meeting, where a large group of retina specialists meet up and present recent data and research. Of course this is not the largest meeting in Ophthalmology, the largest is the American Academy of Ophthalmology (AAO), which is a comprehensive meeting that includes not only retina, but every subspecialty for the treatment of eye diseases. For now let me give you a brief summary of what was of interest at the Retina Society, before I jet off to Chicago early November for the AAO. By the way, I have not had any specific requests for a particular topic, so have assumed you are happy for me to pick and choose. If not, please let me know!

I hope you enjoy the newsletters and I look forwards to hearing from you.

Hadi Zambarakji MB ChB, FRCOphth, D.M
info@retinacare.org.uk
Spire Roding Hospital, Roding Lane South, Ilford. IG4 5PZ.

The results of the safety and efficacy of Ranibizumab (also called Lucentis) in the RISE and RIDE trials for diabetic macular oedema confirmed what we expected to hear, that is a significant benefit for vision and anatomic end-points up to 3 years after treatment. However, treatment arms involved monthly injections, a very difficult task to endure as a patient. Delayed treatment however did not result in the same visual acuity benefits. Other research on the development of macular oedema after cataract surgery in diabetic patients was presented. Macular oedema is a cause of reduced vision following cataract surgery, which is more frequently observed in diabetic patients. The incidence of diabetic macular oedema in the study presented by Dr. S. Kim showed an incidence of 7-15%. This clearly highlights the need to develop effective treatments for macular oedema in order to prevent visual loss after uncomplicated phaco cataract surgery.

I often would consider administering an anti-VEGF such as Bevacizumab or Ranibizumab in a diabetic patient after vitrectomy surgery for proliferative diabetic retinopathy if there is a post-operative vitreous haemorrhage. A study by Dr. M. MacCumber showed the benefit of such an approach in a small series of patients, indicating that post-operative vitreous haemorrhage can be managed by intravitreal Avastin rather than repeat vitrectomy surgery.

The poor outcomes in 12 patients secondary to a severe intraocular infection with a Streptococcus following intravitreal injections with Bevacizumab (Avastin) from one compounding pharmacy in Florida were presented. This is a very virulent organism, outcomes were very poor and treatment of very limited efficacy. This highlights the importance of every step in the process from making up the intravitreal injections in pharmacy to the administration of the drug using aspetic techniques.

There were several presentations of novel imaging techniques for the retina and the choroid (the back of the eye), with some of the newer methods potentially being used in the operating room at the time of surgery, so that retinal surgery such as the peeling of membranes off the retina can be assessed per-operatively using imaging rather than clinically alone. This is analogous to the use of OCT (an imaging modality I use in clinic very regularly) during surgery as part of the operating microscope.

The impact on quality of life of floaters were also presented using visual function questionnaires and the benefits of removing floaters were confirmed in patients whose symptoms were severe enough to warrant surgery. Surgery was performed either with conventional small gauge vitrectomy (key hole surgery), or a even less invasive vitrector called the Intrector (single port instead of 3 as used in conventional surgery).

Of course, there is no retina meeting that would not discuss vitreomacular traction (also called VMT), a condition where the vitreous inside the eye causes traction on the retina and results in distortion of the retina and reduced vision. Sometimes, this traction results in a macular hole, and the vision deteriorates even further. The FDA in the United States has approved last month the use of Ocriplasmin, which is administered by intravitreal injection and causes the resolution of VMT, thus improving the vision. In case of macular hole, the release of traction can also result in closure of the hole. The MIVI Trust studies showed that VMT resolution in 30% of injected eyes, but 10% of placebo treated eyes also developed resolution of VMT. Macular hole patients also showed closure of the hole in 40% of cases with an associated visual benefit. Ocriplasmin is therefore an exciting new drug as part of our armamentarium in the management of patients with VMT and macular hole. Ocriplasmin has not been approved in Europe yet, but this is likely to follow soon.

Macular degeneration and current anti-VEGF agents Avastin and Lucentis were also discussed at length. Some data looking at the possible benefit of switching form one anti-VGF to another there is little benefit in this strategy, but this study was retrospective and this data remains preliminary. The results of Aflibercept (VEGF trap) vs. Lucentis (currently standard therapy and NICE approved for wet macular degeneration in the UK) were presented. These confirmed that Aflibercept (also called Eylea) administered

2 monthly at a dose of 2 mg is equally effective to monthly Lucentis 0.5 mg.  Elyea has a good safety profile. We are currently awaiting the approval of Eylea in Europe and in due course NICE approval. So is Eylea going to replace Avastin or Lucentis? Watch this space, as we start to gain clinical experience with the new drug. The main benefit to patient is of course the reduce number of injections, a major factor that needs to be taken into consideration! Finally, radiation therapy is possibly back, with recent data suggesting some benefit to stereotactic radiation in combination with Lucentis for wet macular degeneration, so watch this space as studies are still under way.

Please let me know if you would like to bring up any topics of interest. I realize that my newsletters are heavily retina biased, but it is clearly time to include more common anterior segment topics and this will feature in my next newsletter early in the New Year.

Finally, I would like to wish you all and your families and loved ones a very happy, healthy and successful New Year.

Hadi Zambarakji

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