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Experts weigh-in on reducing treatment burden in medical retina
Reducing the Treatment Burden in Medical Retina by Brooke Herron
Home monitoring for age related macular degeneration (AMD), drug delivery systems and new medical agents were among the highlights discussed during the Latest Developments in Medical Retina session on the first day of the 37 th World Ophthalmology Congress (WOC2020 Virtual®).
Home monitoring for AMD patients
The pandemic has taught us many things — and among them, it’s brought the importance of home monitoring to the forefront. So, how does home monitoring compare with in-office optical coherence tomography (OCT)?
During her presentation, Prof. Anat Loewenstein from the Tel Aviv Medical Center in Israel, reported results from a study that evaluated self-operability by elderly AMD patients with VA ≥20/400: 90% of patients successfully self-operated at home and captured graded images of their macula using ForeseeHome® (Notal Vision, Tel Aviv, Israel) device. She said the patient assessment was positive and further, the fluid detection sensitivity was 91.5% and the specificity was 97%.
“We think that home-based monitoring can improve personalization in treatment regimens to provide a PRN or treat-andextend approach,” she added.
On slow release devices
Also on the forefront of AMD treatment are the differing approaches to sustained drug delivery. These include slow release drug reservoirs/pumps, modifying drugs for extended release, and gene therapy, said Dr. Dante Pieramici from California Retina Consultants, prior to discussing some of these in depth. the Ozurdex dexamethasone implant as well as Iluvien (fluocinolone acetonide),” he said. Dr. Pieramici next presented an implant from Neurotech that uses encapsulated cell technology and has reported positive results. “A phase 3 trial is currently underway and is due to report data sometime in 2021,” he shared.
Other devices of note included the Ophthalmic MicroPump System™ developed by Replenish, Inc. (California, USA) and the Port Delivery System with ranibizumab (PDS), a novel permanent refillable eye implant developed by Genentech (California, USA).
Longer lasting retinal disease drugs
“We need to have drugs that stay inside the eye for a longer time, said Prof. Francesco Bandello from VitaSalute San Raffaele University in Milan, Italy. “Reducing the treatment burden is a concern for patients and doctors alike, and longer duration drugs could alleviate the problem of under-treatment without compromising on efficacy,” he explained.
One promising agent for neovascular age related macular degeneration (nAMD) is brolucizumab. However, due to 14 cases of retinal vasculitis recently reported by the American Society of Retina Specialists (ASRS), he said further studies are needed to assess its inflammatory profile, confirm efficacy findings and evaluate its use in an expanded disease spectrum.
Furthermore, Prof. Bandello discussed the fluocinolone acetonide implant. “Real life studies reveal that a single implant of fluocinolone acetonide is able to improve VA and reduce central foveal thickness,” he shared. drugs called DARPins, is also currently under evaluation for treating nAMD, reported Prof. Bandello. Studies are also in development to assess abicipar pegol for treating DME.
On early vs. late starts
In a free paper presentation at WOC2020 Virtual®, Prof. Dr. Sebastian Wolf, Professor of Ophthalmology, Director and Chairman University Eye Hospital Bern (Bern, Switzerland), and colleagues, presented results from the ARIES study, which assessed whether intravitreal aflibercept injections administered in an early treat-andextend (T&E) regimen were non-inferior to a late-start T&E regimen in 271 nAMD patients.
The authors noted that “around half of the letter-score difference between the groups was already evident at week 16.” And at week 104, the mean change in BCVA from week 16 was –2.1 and –0.4 ETDRS letters; from baseline it was +4.3 and +7.9 ETDRS letters, in the early and late groups, respectively. The mean number of injections was 12 in the early group, versus 13 in the late group, and the investigators concluded that the observed mean reduction in the number of injections with early-start T&E following initial dosing was clinically relevant. Meanwhile, the mean change in CRT from baseline to week 104 was −162µm and −159µm in the early and late groups, respectively.
“These results demonstrate a relative consistency of functional and anatomic outcomes with both early- and late-start IVT-AFL T&E regimens for the treatment of nAMD,” concluded the authors.
Prof. Anat Loewenstein
(Tel Aviv Medical Center, Israel @WOC2020 Virtual®
The Latest on Diagnosing and Managing Ocular Surface and Orbital Tumors by Hazlin Hassan
Computer-aided 3D customized facial implants, radiation and a multidisciplinary approach to treating conjunctival melanoma – these are just some of the latest updates in the clinical diagnosis and management of ocular surface and orbital tumors discussed by renowned specialists on the first day of the 37 th World Ophthalmology Congress (WOC2020 Virtual®).
New ways of treating conjunctival melanoma
A rare condition, the survival rate for conjunctival melanoma is high when managed well, Professor Max Conway from University of Sydney, Australia, told delegates at the WOC2020 Virtual®. Misdiagnosis and mismanagement, however, is associated with morbidity and mortality. In order to improve outcomes and patient care, the goal is to reduce disparities in outcomes, improve clinical decision making, ensure access to molecular testing and targeted therapies where appropriate, ensure appropriate followup and collect data for research. A multidisciplinary approach allowed for shorter time frames from diagnosis to treatment and more accurate diagnoses. It also provided a greater likelihood of receiving care in accordance with clinical practice guidelines, including psychosocial support, enabled increased access to information and entry to clinical trials, leading to better survival rates for patients. “We are trying to encourage all ophthalmologists who treat ocular melanoma, especially general ophthalmologists to adopt an early team management model,” he said. That means to utilize the resources of the multidisciplinary team (MDT) from the earliest stage to help plan and share in the management of their ocular melanoma patients. “Patients should also be fully involved and informed of treatment options including risk versus benefits in understandable form,” he said.
The MDT approach does not come without its challenges and dilemmas. It is traditionally not the way ophthalmologists have worked, and may be excessive for good prognosis tumors at an early stage. It requires facilities which some centers may not have, and may present logistical issues for specialist team members to be in the same place at the same time.
Using brachytherapy to zap extraocular melanoma
Conjunctival melanoma, mostly confined to the Caucasian population, is managed successfully with conservative treatment, said Dr. Richard Jennelle of the University of Southern California, USA.
“Complete surgical resection is currently favored. Surgical resection with or without adjuvant treatment is the current standard of care,” Dr. Jennelle added.
Most tumors present as epibulbar tumors, and have a propensity for systemic metastasis.
Non-epibulbar tumors on the other hand are often associated with worse prognosis.
Many different institutions have individual approaches to adjuvant therapy, from topical chemotherapy to cryotherapy and brachytherapy, a type of radiation therapy. “Adjuvant brachytherapy is safe and potentially effective in the management of this disease,” concluded Dr. Jennelle. There is also evidence to suggest that primary brachytherapy may be effective in a manner similar to the management of choroidal melanoma.
The face of the future
A variety of injuries may result in the disruption of the anatomically complex region of the face surrounding the orbit. If inadequately treated, permanent disfigurement, visual dysfunction and unpleasant aesthetics may impair a patient for life. Reconstruction of craniofacial defects has made great leaps and bounds since custom-made implants have been developed over the last few years. Reconstruction of the orbit previously used titanium mesh, but now surgeons can use 3D-printed polyetheretherketon (PEEK) patient specific implants, reported Dr. Stijn Genders of the The Leiden University Medical Center, The Netherlands. “This material is very easy to adjust during surgery, and it will always be a good fit,” he shared.
