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PAT survey highlights shifting trends in practice preferences
The results showed a tendency toward vitrectomy without scleral buckling for retinal detachment and laser treatment of DME not involving the foveal center.
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Some U.S. retina specialists would choose aflibercept to manage specific cases of subfoveal choroidal neovascular membrane, according to a survey.
About 10.9% of U.S. and Canadian respondents said they would use Eyelea (aflibercept, Regeneron) as first-line treatment for 1 disc area of subfoveal neovascular membrane, J. Michael Jumper, MD, said at the American Society of Retina Specialists meeting in Las Vegas.
Jumper reported results of the 2012 ASRS Preferences and Trends (PAT) Survey of retina specialists.
In a subsequent interview with OSN Retina, Jumper said that 630 ASRS members responded to the survey, a 65% increase over any previous year for the survey. The volume of responses enabled international comparisons.
“This was the first year that we were able to compare U.S. and Canadian data with everyone else because we had enough numbers,” Jumper said.
In addition, many of the trends identified in the survey concurred with results of clinical research studies, Jumper said.
Infection prophylaxis
According to Jumper, 24.5% of U.S. and Canadian respondents and 12.4% of international respondents reported that within the last 2 years they had changed compounding pharmacies that provide intravitreal bevacizumab.
“I have a feeling that there will be a lot more after this New England pharmacy debacle that’s going on,” he said, referring to a fungal meningitis outbreak traced to the New England Compounding Center’s facility in Framingham, Mass.
The survey results revealed significant geographic variation in terms of whether respondents refrain from speaking during intravitreal injections and ask their patients to follow suit in order to prevent infection; 62.5% of U.S. and Canadian clinicians stated that they follow this practice, compared with 18.8% of international respondents.
Retinal detachment with tear shown by fluorescein angiography and indocyanine green angiography. The PAT survey found that 52.1% of U.S. and Canadian respondents recommended vitrectomy alone without scleral buckling to treat retinal detachment in specific cases.
Image: Heidelberg Engineering
Protocols in many countries more frequently call for both parties to wear masks during intravitreal injections, Jumper said. Results showed that 3.2% of U.S. and Canadian respondents and 17.4% of international respondents said they wear a mask and ask their patients to wear a mask.
Ranibizumab vs. bevacizumab
Clinicians’ opinions on the relative efficacy of Lucentis (ranibizumab, Genentech) and Avastin (bevacizumab, Genentech) for branch retinal vein occlusion (BRVO) differed, Jumper said.
“I think that there appears to be recognition that Lucentis and Avastin may not be the same when treating retinal vein occlusions,” Jumper said. “There may be a difference in the effectiveness of these two drugs. That’s something that was reflected in the answers. Most people think they’re equally effective, but there is a belief among some that Lucentis can be more effective for treating retinal vein occlusions.”
For example, 62.4% of U.S. and Canadian clinicians said the two drugs are equally effective. However, 27.6% said ranibizumab was more effective than bevacizumab for BRVO, and 2.6% rated bevacizumab more effective.
Concerning the relative efficacy of ranibizumab vs. bevacizumab for central retinal vein occlusion (CRVO), 60.8% of U.S. and Canadian respondents said that the two drugs were equally effective.
Results showed that 28.8% of U.S. and Canadian respondents said that ranibizumab was more effective for CRVO, and 2.6% said that bevacizumab was more effective.
In addition, 21.4% of U.S. and Canadian clinicians said they have changed how they treat wet age-related macular degeneration as a result of 2-year CATT data; internationally, 11% of respondents said they made a change based on CATT data.
“It has had an impact, especially in the United States and Canada,” Jumper said.
For AMD patients who already receive ranibizumab or bevacizumab, 44% of U.S. and Canadian respondents recommended switching to aflibercept in cases of persistent subretinal fluid despite multiple injections, persistent primary retinal pigment epithelial detachment despite multiple injections, or recalcitrant cysts despite multiple injections, Jumper said.
BRVO, CRVO and retinal detachment
Jumper said that 59.4% of U.S. and Canadian respondents would recommend intravitreal bevacizumab for treatment of a 55-year-old patient with perfused BRVO, symptomatic cystoid macular edema and 20/30 vision.
“It’s clear that everyone is treating a patient even with good vision and a branch retinal vein occlusion,” Jumper said. “In the past, that would be somebody that you would consider observing longer.”
Results showed that 62.3% of U.S. and Canadian clinicians recommended macular grid laser treatment for BRVO only after the retina has been stabilized with ranibizumab or bevacizumab.
“It seems that most people are stabilizing the retina first but hopefully using laser to decrease the need for repeat injections with anti-VEGF therapy,” Jumper said. “People also find that doing laser treatment in an eye that has less or no edema is safer and less of an issue.”
Shifting preferences in the treatment of retinal detachment were particularly striking, he said.
“There has been a huge change over the years in how we repair retinal detachments,” Jumper said.
For example, 52.1% of U.S. and Canadian respondents recommended vitrectomy alone without scleral buckling to treat a superior retinal detachment in a 65-year-old pseudophakic –3 D myope with a single flap tear half a clock hour in size.
“There was a time when a buckle would have been used very frequently in this type of case,” Jumper said. “Now, vitrectomy without buckling is the most commonly performed procedure. There have been many editorials and comments made on this trend away from scleral buckling and how good that is or not.”
Surgical treatment, diabetes
In a surgical survey scenario, more surgeons indicated that they choose to peel internal limiting membrane for routine epiretinal membrane surgery.
“This [percentage] has gone up over the years such that in 2012, about 45% of respondents overall said that they would do that 76% to 100% of the time,” Jumper said.
In diabetes management, 75.9% of U.S. and Canadian respondents recommended macular laser treatment for diabetic macular edema that does not involve the foveal center.
For vitreous hemorrhage associated with proliferative diabetic retinopathy, 57.8% of U.S. and Canadian respondents recommended observation and 29.1% recommended immediate anti-VEGF injection.
“[It] must be based on clinical experience because there’s not a lot of research data that support doing that,” Jumper said. – by Matt Hasson and Patricia Nale