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Use of intravitreal injections rising ‘exponentially’
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WAIKOLOA, Hawaii — Intravitreal injections increased exponentially in 2006, becoming the fastest growing procedure in ophthalmology, a speaker said here.
At Retina 2008, held in conjunction with Hawaiian Eye 2008, Kevin J. Corcoran, COE, CPC, FNAO, OSN Practice Management Section Member, presented CMS data from 2006 showing intravitreal injections ranked third among ophthalmic procedures. He said the procedure underwent exponential growth over the course of 5 years, making it the fastest growing procedure in all of Medicare.
“You’re looking at the engine that will eat ophthalmology,” Mr. Corcoran said. “This one is the biggest thing on the planet, and nothing is growing this fast — nothing.”
Cataract surgery with IOL implantation still ranked No. 1, with YAG capsulotomy coming in second, but intravitreal injections grew by 111% in 1 year, outpacing all other procedures, he said. Most of the other procedures that increased were lacrimal procedures, he said. Complex cataract surgery increased 25%.
“Intravitreal injection is now No. 3. It certainly wasn’t No. 3 last year,” Mr. Corcoran said. “This one is on its way to becoming No. 1 in a real big way.”
The CMS data showed that, in 2006, there were more than 500,000 procedures performed in the United States through Medicare. Out of every 100 eye exams performed, there were 2.4 intravitreal injections administered, he said.
Conversely, photodynamic therapy, laser choroid and focal laser decreased by 61%, 30% and 9%, respectively.
“Those are the ones that, formerly, you did for the same reasons, so clearly a huge shift in retina,” Mr. Corcoran said.
These items appeared originally as daily coverage from the meeting on OSNSuperSite.com. Look for more in-depth coverage of these and other topics in upcoming issues of Ocular Surgery News.
Dry AMD treatments needed to supplement anti-VEGFs
Regression back to high-risk dry age related macular degeneration after successful anti-VEGF treatments can still cause vision loss, pushing one speaker to call for continued research into future combination therapy incorporating dry AMD treatments.
“Most failures do not result from continued growth and leakage of the CNV,” OSN Retina/Vitreous Section Editor Carmen A. Puliafito, MD, MBA, said. “Our problem really is that in treating neovascular AMD with anti-VEGF agents, we are dealing with one side of the disease package of this equation and leaving the other side alone because loss of visual acuity results from progression of the dry AMD.”
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Image: Altersitz K, OSN |
Dr. Puliafito said Philip J. Rosenfeld, MD, PhD, analyzed why patients lost vision in the MARINA and ANCHOR trials. Dr. Rosenfeld concluded that patients who have retinal pigment epithelium tears and greater total lesion area resulting in atrophic scars or geographic atrophy are more likely to suffer loss of vision.
“We all have patients who are treated with Avastin (bevacizumab, Genentech) or Lucentis (ranibizumab, Genentech) who have drying of the retina and restoration of normal anatomy that subsequently lose vision,” Dr. Puliafito said.
He suggested that after treatment with these anti-VEGF agents, patients revert back to high-risk dry AMD that is associated with visual loss from drusen or geographic atrophy. What has not been determined is why some dry AMD patients develop wet AMD and some develop geographic atrophy.
“I don’t think this is related to the treatment with the anti-VEGF agents but the ongoing disease progression that anti-leakage agents don’t touch,” Dr. Puliafito said.
In the future, he said research should focus on combining treatment of the underlying dry AMD with anti-VEGF treatment for wet AMD.
Dr. Puliafito acknowledged that combination therapy trials are difficult to design, but that perhaps efficacy and safety of consecutive treatments could be studied.
“We’re dealing with patients and treating so many patients with wet macular degeneration and they want to know, ‘Why aren’t I doing better?’ and we want to know why aren’t they doing better,” he said. “The reason they’re not doing better is they have dry AMD after the successful treatment of wet AMD.”
Experts: Use AREDS on a case-by-case basis
Although the Age-Related Eye Disease Study laid out guidelines for nutritional recommendations, experts said they look at each case individually and sometimes stray from protocol.
In a panel discussion led by Dr. Puliafito, experts in AMD and nutrition, Johanna M. Seddon, MD, ScM, Andrew P. Schachat, MD, and Elias Reichel, MD, discussed their preferences in applying the AREDS formula to AMD patients.
Dr. Puliafito proposed hypothetical situations in which a patient comes for an initial consultation with stage 2 AMD. He asked the experts if they would prescribe the AREDS supplement.
“According to AREDS, no,” Dr. Seddon said. Yet, in practice, “I actually highly recommend the dietary modification.”
Dr. Schachat said he would, in light of growing evidence that vitamins have been shown to slow cataract progression.
If a long-time patient progressed from pretty small drusen to slightly larger drusen but was still within the stage 2 category, Dr. Seddon said she would start the patient on AREDS supplements.
“Of course, in the AREDS study, the problem is the study was not designed to detect the difference in these mild cases,” Dr. Puliafito said. “So there may be an impact; we just weren’t able to detect it.”
On the other end of the spectrum, Dr. Puliafito asked the experts if they continue to treat with AREDS after patients have progressed to advanced AMD.
“Yes, because there is a possibility that atrophy can convert to neovascular disease. I know that’s a small percentage, but it is a possibility,” Dr. Seddon said.
In a comment that roused laughter from the crowd, Dr. Schachat said, “I tell them what they want to hear.” He referred to both the costs to and the convictions of his patients as reasons for either terminating or continuing the supplements. Both Dr. Seddon and Dr. Puliafito agreed.
“It’s true. We’re living in the real world here. Patients have different preferences, and you’re interacting with them,” Dr. Puliafito said.
“If I have a patient who comes in with bottles of lutein and omega-3 fatty acid pills that they’re taking and they’re convinced that they see better if they’re taking them, then I say continue taking them,” Dr. Seddon said.
She also confirmed a suggestion from the audience that Centrum Silver (multivitamin, Whitehall-Robins) is a satisfactory recommendation for early AMD patients or for use with the AREDS supplements.
AMD radiation therapy safe and effective, may reduce injections, study found
Data presented here showed continued safety and efficacy of epiretinal brachytherapy at 2 years. In the discussion that followed, physicians expressed their hope that a combination therapy with this technology could reduce intravitreal injections.
“Why do we need to revisit radiation as a potential treatment for age-related macular degeneration?” Michael S. Ip, MD, asked.
The radiation technology, produced by NeoVista, uses strontium 90 in a minimally invasive core pars plana vitrectomy to target the lesion, he said.
In the study of 18 patients followed for 24 months, Dr. Ip showed that 89% of patients lost fewer than 15 letters, 50% gained more than zero letters and 17% gained 15 or more letters. He showed there was no evidence of radiation toxicity at 2 years.
Dr. Ip also reviewed the 1-year results of a study examining radiation therapy in combination with Avastin (bevacizumab, Genentech); these results were previously reported at the American Academy of Ophthalmology.
“This treatment modality may reduce the number of anti-VEGF treatments that we do, permanently disabling the proliferating [choroidal neovascularization] cells,” Dr. Ip said.
He said 85% of subjects received no additional injections after their initial injections. Visual acuity results showed 96% of patients lost fewer than 15 letters and 78% gained letters.
Dr. Reichel said, “There clearly does seem to be an alteration here where we can reduce the number of treatments.”
Physicians must prepare for possible anaphylaxis during fluorescein angiography
Physicians must prepare for the relatively uncommon complication of anaphylaxis during fluorescein angiography to avoid potentially life-threatening consequences, a presenter said.
“We all know that fluorescein angiography is not without complications,” Sharon Fekrat, MD, FACS, said.
“Anaphylaxis is actually relatively uncommon, but the allergic reactions that do happen can be life-threatening and they do require immediate attention and expertise of a trained physician. You can’t just not have an MD physician in the office at the time of fluorescein angiography and rely on 9-1-1,” she said.
Of 1,400 patients who underwent fluorescein angiography in a Duke University satellite office, only four (0.02%) had anaphylactic reactions, Dr. Fekrat said. But in a show of hands, about half of the physicians in the audience said they had experience with anaphylaxis during a fluorescein angiography exam.
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Image: Altersitz K, OSN |
Dr. Fekrat presented four cases and described the symptoms of each that led her to diagnose anaphylaxis and begin administration of epinephrine. Patients must have involvement in two systems, such as gastrointestinal tract and skin. Symptoms can include vomiting, coughing, nausea, swelling of the mouth or throat, and hives, but Dr. Fekrat emphasized that hives are not always present.
“You have to do a lot of decision-making,” she said. “We do know that anaphylaxis can be very rapid and can be unpredictable.”
When anaphylaxis is diagnosed, epinephrine, the “treatment of choice,” must be administered within 30 minutes for most effective treatment, she explained. If symptoms do not show signs of improvement within 5 to 10 minutes, Dr. Fekrat said the patient can receive another dose of epinephrine.
“Relying on 9-1-1 to go ahead and treat your anaphylaxis is not always wise,” she added, because not all emergency medical technicians are authorized to carry or administer epinephrine and they may not arrive in time.
Because anaphylaxis can be bi-phasic, Dr. Fekrat said patients should always be taken to the emergency room for further observation and treatment, if needed.
All of these factors contribute to Dr. Fekrat’s conclusion that fluorescein angiography should not be performed without a medical doctor in the office, she said.
“Optometrists are attempting to expand the scope of their practice,” Dr. Fekrat said. “And now, in North Carolina, they are able to do fluorescein angiography in their office.”
Retinal opacifications in patients may indicate underlying disease
Detection of a cotton-wool spot in a non-diabetic patient requires a full examination in order to find the underlying cause, a surgeon said.
“We used to just ignore this” because the spots would often disappear over the course of 5 to 7 weeks, Gary C. Brown, MD, MBA, said. Twenty years ago, in an effort to determine the cause, he analyzed non-diabetic patients with cotton-wool spots.
“Lo and behold, 96% had associated systemic disease and bad diseases,” he said. “So if you see even one cotton-wool spot in a non-diabetic, you need an explanation … right there in the chair.”
Hypertension was seen in 20% of those studied, while 20% had undiagnosed diabetes, Dr. Brown said. The rest included a variety of diseases such as AIDS, radiation retinopathy and pancreatitis, he explained.
Areas of superficial retinal opacification are often secondary to the obstruction of terminal retinal arterioles that occur when autoregulation ability is exceeded, causing fibrinoid necrosis, he said. They are seen when diastolic blood pressure is between 105 mm Hg and 110 mm Hg, Dr. Brown said.
“One cotton wool-spot needs a complete workup, same as a stroke patient. You can’t ignore it. If you don’t want to do it, send them to the internist and tell them what to do,” he said. “Nowadays, they need a stress test and there’s a good chance you may save their life.”
Various strategies exist for resolution of thick hemorrhagic exudative AMD
Despite more conservative methods used by his peers, one clinician said he attacks large hemorrhages related to exudative AMD with surgery.
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“If they come in with a thick hemorrhage, I operate or I offer them the surgery,” OSN Retina/Vitreous Section Member Allen C. Ho, MD, said. “If it’s a thin hemorrhage, I’ll still consider injection of an anti-VEGF therapy because oftentimes [patients] can do well.”
Dr. Ho defined a thick hemorrhage as greater than 1 mm in thickness. When these hemorrhages present, he said that he uses a 41 gauge subretinal needle and a 25 gauge cannula to complete a vitrectomy, install submacular tissue plasminogen activator (tPA) at 25 µg/0.1 cc, inject a gas bubble and perform a fluid exchange with pneumatic displacement of the hemorrhage. The patient is then positioned face down, he said.
“I have had some reasonable cases and some home runs that keep you coming back when you do the vitrectomy, do the submacular tPA and put a full gas bubble,” he said.
One pearl Dr. Ho shared was to inject tPA in several locations, particularly along the inferior border.
“You want the tPA to kind of swirl around the whole area of blood to liquefy, but I do it inferiorly so I can begin to open that central space between the juncture of the large hemorrhage and attached retina inferiorly” to promote the displacement, he said.
If a hemorrhage is less than 1 mm in thickness, Dr. Ho said he will not perform this procedure.
“With thin hemorrhages, surgery may not be necessary. In fact, I would say do not do surgery. The risks of surgery are not warranted in these cases,” he said.
Dr. Ho said although some question whether anti-VEGF medications can permeate blood, he prefers to treat thin hemorrhage exudative AMD patients with ranibizumab or bevacizumab.
“I tend to treat because I’m not willing to not treat exudative AMD,” Dr. Ho said.
Spectral-domain OCT holds promise for management of dry AMD
Image: Altersitz K, OSN |
Spectral-domain optical coherence tomography should be investigated and utilized for the management of dry AMD, Dr. Puliafito said.
“After the advances with Lucentis and Avastin, patients, industry and the investment community are looking at new treatments for dry AMD,” he said. “The big problem is how to assess the treatment effect, looking at an intervention that may have to be done over a long period of time and a disease which is slow moving.”
Dr. Puliafito said that Snellen acuity is not an effective primary endpoint in studies and suggested spectral-domain OCT as a tool with the “unique capability of creating documentation” that is detailed beyond fundus photography.
“This is a very heterogeneous picture,” he said, showing a spectral-domain OCT image. “How will all these things change and how will we measure them? It’s a big problem.”
With the latest spectral-domain OCT technology, Dr. Puliafito showed this problem is ameliorated with automated segmentation to match the top of the retina to the bottom of the retina, retinal pigment epithelium images, retinal thickness images, and correlation and compilation of the gathered data.
“These eyes are packed full of abnormalities that you cannot see by simply looking at the fundus or looking at a color fundus photograph,” Dr. Puliafito said. “[Spectral-domain] OCT permits quantitative analysis of dry AMD pathologies and this technology will be useful for assessment of new therapies.”
Endophthalmitis rates low in ongoing intravitreal steroid trials
Endophthalmitis rates after triamcinolone injections in the SCORE and DRCR.net trials are low and comparable to those encountered with anti-VEGF injections, a surgeon reported.
“As of Sept. 30, there have been over 2,600 injections and only one culture-proven endophthalmitis, for a rate of endophthalmitis of 0.04% with one case of presumed sterile endophthalmitis,” Dr. Ip said. “We released these results because we feel there is a public health importance to realize that, with triamcinolone, you don’t necessarily get a higher rate of endophthalmitis than you do with anti-VEGF [injections].”
Dr. Ip reported that there were 898 injections performed in the SCORE (Standard Care vs. Corticosteroid for Retinal Vein Occlusion) Study and 1,716 injections performed in the DRCR.net (Diabetic Retinopathy Clinical Research Network). Of those 2,614 injections, there was one confirmed case of endophthalmitis and one presumed case of sterile endophthalmitis.
In pooled data from seven other studies involving 3,248 patients treated with intravitreal injections of Kenalog (triamcinolone, Bristol-Meyers Squibb), Dr. Ip said there were 10 (0.3%) cases of endophthalmitis.
“The thought of this may be changing in terms of why this occurs. Previously, we’ve always agreed that it might be one of the excipients of the Kenalog formulation,” he said. “But perhaps one of the new thoughts is that this may actually be due to a particle dispersion.”
Unlike these other studies, the SCORE study uses a proprietary formula of triamcinolone prepared by Allergan, Dr. Ip said. He explained that this formula is sterile, free of endotoxins and potentially harmful excipients. It is a hyaluronate suspension not prone to crystal dispersion and comes in a pre-loaded syringe that allows for multiple dosing. Dr. Ip said this formulation is not yet commercially available.
“It looks as if with this study and this formulation, it’s comparable to anti-VEGF endophthalmitis rates,” he said.
The VISION, ANCHOR and MARINA trials had endophthalmitis rates of 0.1%, less than 0.1% and 0.05%, respectively, Dr. Ip said.
“I would say at this point we’re having a love-fest with anti-VEGF therapy. We go to meetings and that’s all we hear,” he said. “I’d like to remind you that just a few short years ago we certainly had a love-fest with intravitreal corticosteroids. You couldn’t go to a meeting without hearing 20 talks on intravitreal corticosteroids.”
Robotic vitreoretinal surgery needs refinement, but shows promise for future
Robotic vitreoretinal surgery, which could be performed on patients in remote locations such as Iraq while the surgeon is in another location, is feasible despite needing significant mechanical improvements, a surgeon said.
Steven D. Schwartz, MD, discussed work done at the University of California, Los Angeles, Center for Advanced Surgical and Interventional Technologies (CASIT) to refine a robotic surgery model for use in intraocular surgery.
“Robotic surgery is actually gaining acceptance in mainstream critical care,” Dr. Schwartz said. “The robot translates complex hand and wrist movements in a coordinated manner while maintaining hand-eye coordination.”
He explained that advantages such as a three-dimensional view, greater magnification, superior instrument maneuverability and reduced tremor are useful in other surgical specialties, in which trans-Atlantic surgeries have already been performed.
“Ironically, ophthalmic surgery and instrumentation formed the foundation for robotic surgical strategies and instrumentation, so the biggest advantages may be irrelevant to vitreoretinal surgery,” Dr. Schwartz said.
Image: Altersitz K, OSN |
At CASIT, Dr. Schwartz and colleagues performed surgery with the da Vinci (Intuitive Surgical) model to assess the feasibility of performing robotic intraocular surgery, as well as the equipment’s dexterity and maneuverability. They performed foreign body removal, capsulorrhexis and 25-gauge pars plana vitrectomy in 10 porcine eyes, he said.
The model has two components, “the master and a slave,” Dr. Schwartz said, explaining that the surgeon manipulates the master console, which controls the multiple-arm surgical unit. The unit is equipped with detachable surgical tools that are already commercially available.
“You really have complete control over the robotic arms,” he said. “There was no measurable delay between the movement of the surgeon’s controls and the movement of the robot.”
Dr. Schwartz said there are still aspects of the model that are less suitable for ophthalmology, such as the high location of the robotic arm pivots. He said they are working to move the pivots closer to, or even within, the eye. In addition, Dr. Schwartz said, they are also working toward designing additional instruments better suited for intraocular surgery.
“The control and manipulation of the surgical instruments was relatively easy and intuitive. Wrist movements were more intuitive than the robotic arm instruments,” he said.
He noted that the intraocular visual system was poor compared with currently available systems that many ophthalmic surgeons use. Also, the location of the endoscope, which was centered on the porcine eyes, further limited the use of the robotic arms.
“We concluded that robotic intraocular surgery is feasible, but probably not with the da Vinci system in its current iteration,” Dr. Schwartz said. “There are engineering challenges, but we think they are surmountable.”
25-gauge vitreoretinal surgery has advantages for pediatric patients
Using smaller instruments during vitreoretinal surgery is advantageous for pediatric patients, Dr. Schwartz said.
Despite limited literature on 25-gauge instruments in the pediatric population, he said that in addition to the advantages shown in adults, such as more rapid healing, improved patient comfort and less surgical trauma, the reduced instrument sizes seem to be conducive to the smaller eyes of children.
“So 25-gauge vitrectomy has distinct advantages, we feel, in the pediatric populations,” he said. “We do not feel there is an increased risk of 25-gauge surgery in kids.”
Dr. Schwartz presented a retrospective study performed at the University of California, Los Angeles, in which he and colleagues performed a 5-year chart review of consecutive patients younger than 18 years. All cases underwent 25-gauge pars plana vitrectomy for various indications.
The study included 56 eyes of 49 children who averaged 4.5 years of age, ranging from 2 months to 17 years. Follow-up ranged from 10 days to 4.2 years; 26 eyes had retinopathy of prematurity (ROP).
The anatomic goal was achieved in 75% of eyes. It was not achieved in 16% of eyes, and 9% did not have sufficient follow-up to determine whether success was achieved, Dr. Schwartz said.
He said the sutureless techniques commonly used with 25-gauge instruments could potentially be a problem for pediatric patients. In particular, premature infants could pose a risk due to the potential for hypotony, bleeding in vasoproliferative diseases and the likelihood of rubbing their eyes postoperatively.
“We were really worried about postop bleeds,” he said. “In ROP, bleeding is really better to avoid. I know it sounds crazy to say it that simply, but it’s bad. If you’re doing any pediatric vitreoretinal surgery, it’s a lot different than managing vitreous hemorrhage in adults.”
Dr. Schwartz said he and his colleagues have modified the 25-gauge vitrectomy procedure to further ensure pediatric safety. They accomplished this by incorporating conjunctival dissection, a 22-gauge needle, 20-gauge sclerotomies without trocars, a 20-gauge shielded bullet, and closure of the sclerotomies and conjunctiva.
“The transconjunctival approach may not be appropriate for younger babies. Careful placement of sclerotomies is important. We like to cover them in certain circumstances,” he said. “We do actually suture up these 25-gauge incisions.”
A note from the editors:
To facilitate bringing news to readers rapidly, for OSN SuperSite articles and meeting wrap-up articles, OSN departs from its editorial policy and typically does not send these items out for source corrections.