Survey shows more surgeons using ICG, intravitreal steroid injections

A preferences and trends survey by the American Society of Retina Specialists showed increases in these areas from last year.

Intraoperative use of indocyanine green and use of intravitreal steroid injections for treatment of macular edema are emerging trends in retinal procedures, according to the Preferences and Trends Survey by the American Society of Retina Specialists.

Newer surgical techniques such as retinal translocation and optic neurotomy are still not widely used, the survey found.

The survey had a 30% return rate, with 466 retina specialists responding, said John S. Pollack, MD, editor of the Preferences and Trends (PAT) Survey. Kirk H. Packo, MD, is coeditor of the survey. They presented the findings at the annual meeting of the American Society of Retina Specialists in New York.

“The results reflect new trends regarding how retina specialists are managing their patients,” Dr. Pollack said.

Most of the respondents practice in the Northeast (23%), Southeast (21%) and Midwest and Mountain (29%) states. The majority (44%) are in private practice for retinal conditions only and have been in practice between 8 and 15 years (35%).

Increased use of ICG

Use of indocyanine green (ICG) for staining the internal limiting membrane (ILM) continues to increase, the survey found. This year, 78% of respondents reported using ICG, and 68% reported being moderately or very satisfied with its use. In 2002, 59% of respondents reported finding ICG moderately or very useful, and in 2001, 36%, Dr. Pollack said.

Several reports have suggested the potential for toxicity from intraocular ICG use, Dr. Pollack said, but the increased popularity of the dye suggests that minimal complications have been encountered. The results may indicate that a significant percentage of respondents believe the benefits of ICG outweigh the risks, he said. Use of ICG may reduce the risk of phototoxicity in epiretinal membrane and ILM removal by shortening the duration of the surgery. The risk of using ICG also depends on the individual, he said.

“The survey results may reflect the possibility that most surgeons using this technique have not seen any apparent cases of toxicity using their personal technique, which varies from person to person with regards to concentration used, total amount injected, time duration that ICG is left in contact with the macula and whether ICG is injected in an air- or fluid-filled eye,” he said.

Intravitreal steroids

Intravitreal injection of steroids for treatment of macular edema also showed a high frequency of utilization in the survey, Dr. Pollack said.

“The PAT Survey results suggest that intravitreal steroid injection is quickly becoming the preferred treatment for clinically significant diabetic macula edema that does not respond to conventional laser treatment, with 69% of respondents favoring this technique,” he said.

Intravitreal steroid injections were the preferred choice for treatment of refractory cystoid macular edema associated with branch retinal vein occlusion (BRVO); 54% of respondents reported using this option. Twenty-one percent preferred laser treatment, and 12% pars plana vitrectomy and sheathotomy surgery, he said.

Intravitreal steroids were also the preferred method of treatment for cystoid macular edema associated with central retinal vein occlusion (CRVO). Forty-three percent reported using this option; 23% would choose observation, and 20% would select optic neurotomy, he said.

Reports on intravitreal steroid injections for these indications were first presented in 2001, and the technique seems to have gained in popularity because of its perceived ability to improve vision quickly and relatively safely, Dr. Pollack said.

“This is unlike our current treatments for macular edema, which usually do not result in significant visual improvement,” he said.

Although the safety profile of the technique has not been verified in large trials, it seems to be acceptable based on current experience, Dr. Pollack said. Several ongoing prospective trials, such as the Intravitreal Steroid Injection Study trials, are expected to give more detailed safety information, he said.

Retinal translocation

The PAT survey showed that several procedures are performed infrequently for a variety of reasons. Retinal translocation for treatment of wet age-related macular degeneration (AMD) remains largely unused. Seventy-seven percent of respondents said they have never performed limited retinal translocation; 95% have never performed 360° retinal translocation, and 75% said they would not recommend any type of retinal translocation.

“I think retinal translocation has not caught on because it is perceived by many that the potential risks of this surgery outweigh the potential benefits,” Dr. Pollack said. “Issues of concern include proliferative vitreo-retinopathy, retinal detachment, the need for additional muscle surgery in binocular patients and the added risk of losing peripheral vision that most AMD patients depend on for [mobility] once central vision is lost. In addition, between photodynamic therapy and the many experimental studies that are enrolling patients with wet AMD, there are now many less invasive potential treatment options for these patients.”

Optic neurotomy

Fifty-six percent of surgeons said they have never performed optic neurotomy for CRVO. Sixty-one percent have done a sheathotomy for BRVO.

Dr. Pollack believes surgeons are not using optic neurotomy in the initial management of CRVO either because they are not convinced that it is useful or because many manage patients using a stepwise approach. This would involve beginning with the least invasive treatment, typically intravitreal steroid injection, and then moving on to optic neurotomy if the patient does not respond.

For treatment of BRVO, conventional laser treatment is preferred over both intravitreal steroid injection and sheathotomy for first-line treatment and remains the gold standard, he said. However, if laser treatment fails, than intravitreal steroid injection is the most popular next step. “Since it is far simpler and potentially safer to perform an office-based intravitreal steroid injection than to perform sheathotomy surgery in the operating room, I think that most of us are beginning choose the former,” he said.

25-gauge vitrectomy system

Experience with 25-gauge sutureless vitrectomy systems also remains low, according to the survey.

Seventy percent of the 307 respondents to this question said they had never tried a 25-gauge sutureless system. Those who have tried these systems were divided over their effectiveness: 44% said the experience was below their expectations, while 40% said it met theirs. Only 16% said it exceeded their expectations.

Dr. Pollack said he believes the lack of experience is because the devices are new and contain design limitations.

“Although these devices are still relatively early in their development, I believe they will gain in popularity if future modifications to the instruments … allow them to be used for a wider variety of cases. If this can be accomplished, cost-effectiveness of these systems will improve,” he said.

Fifty-eight percent of respondents said the 25-gauge vitrectomy system is appropriate in less than 25% of their cases. Thirty-three percent said it is appropriate for 26% to 50% of their cases.

Use of Indocyanine green stain for ERM or ILM peeling

(Source: PAT Survey)

Preferred treatment for clinically significant diabetic macular edema in patients who did not respond to laser treatment

(Source: PAT Survey)

Preferred treatment for refractory cystoid macular edema associated with branch retinal vein occlusion

(Source: PAT Survey)

Preferred treatment for cystoid macular edema associated with central retinal vein occlussion

(Source: PAT Survey)

For Your Information:

• John S. Pollack, MD, can be reached at Illinois Retina Associates, SC, 300 Barney Drive, Suite D, Joliet, IL 60435; (815) 744-7515; fax: (815) 744-7661; e-mail: pollackjs@aol.com.

• The survey results are available for viewing by American Society of Retina Specialists members on the ASRS Web site: www.vitreoussociety.org. An ASRS-issued user ID and password are required for access to the survey. If you are a member of ASRS and cannot locate this information, contact Cordie Miller at cordie@vitreoussociety.org or (530) 566-9181.