Optometric Management

FEB 2017

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30 F E B R U A R Y 2 0 1 7 • O P T O M E T R I C M A N A G E M E N T . C O M CLINICAL RE TINA R OUGHLY A decade ago, patients diag- nosed with AMD, dia- betic macular edema, branch retinal vein oc- clusion, central retinal vein occlusion and, most recently, proliferative diabetic retinopathy, were almost certain to experience permanent bilateral severe vi- sion loss. (Although traditional laser treatment is beneficial, it has a small impact on the course of the disease, as well as unwanted side effects, including permanent reti- nal scarring and decreased pe- ripheral, color and night vision.) e groundbreaking advent of anti-vascular endothelial growth factor (anti-VEGF) injections has changed this, significantly improving visual prognosis and outcome and, thus, preventing blindness and improving pa- tients' quality of life. In this article, I discuss VEGF and the available an- ti-VEGF agents, so you can educate your patients before you refer them for such injections. (Also, consider those treat- ments in the pipeline, see "Anti- VEGF erapies on the Hori- zon," p. 32) VEGF AND ANTI-VEGF DRUGS VEGF is a protein that plays a key role in the pathogenesis of many blinding retinal conditions, such as those mentioned above. Specifically, it leads to vascular leakage, edema and neovascular growth, all of which can signifi- cantly reduce vision. e patho- logical process results from in- creased levels of VEGF proteins due to retinal hypoxia or isch- emia. VEGF-A, the most potent mediator, results in the formation of new blood vessel growth or angiogenesis and vascular leak- age. Targeting the VEGF-A path- way is the cornerstone of anti- VEGF therapies. e intravitreal administra- tion of anti-VEGF agents restores and improves visual function. ree anti-VEGF drugs are avail- able: (1) ranibizumab (Lucentis, Genentech), (2) bevacizumab (Avastin, Genentech) and (3) aflibercept (Eylea, Regeneron). [Recently, Ophthotec announced that Pegpleranib (Fovista), which was designed to target platelet- derived growth factor, did not meet its primary endpoint of mean change in visual acuity in two pivotal Phase III studies.] Bevacizumab is an off-label treatment that costs roughly $50 per treatment. e National In- stitutes of Health's Comparison of AMD Treatment Trials study reveals it is equivalent to ranibi- zumab in treating AMD, though causes a higher percentage of serious adverse events, such as heart attacks or strokes vs. its FDA-approved sibling. ere is also a risk of vision-threatening infectious endophthalmitis with THE PROTEIN PREVENTERS A LOOK AT ANTI-VEGF DRUGS AND WHAT'S ON THE HORIZON A) This is an OCT of a patient who has diabetic macular edema. VA was 20/100. B) OCT showing improvement in edema after multiple injections of an anti-VEGF drug. Vision improved to 20/60. SHERROL A. REYNOLDS, O.D., F.A.A.O. Images: Cour tesy of Mohammad Rafieetar y, O.D., F.A.A.O A B

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