JAN 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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February 2011 January 2013 Retinal pharmacotherapy for the anterior segment surgeon EW FEATURE 35 rePlay online content "In my practice, I am more likely to use macular laser to treat truly focal areas of exudation, i.e., circinate lipid rings within 500 µm of the macular center, and in patients with better vision where DME is related to leaking microaneurysms not in the macular center," he said. "For most other cases of DME treatment, I prefer to start treatment with intravitreal anti-VEGF agents. I will certainly consider adding macular laser in cases where the response to anti-VEGF is suboptimal." An important question to consider would be the current role of laser, Dr. Mahmoud said. He said that most current anti-VEGF trials included patients with subfoveal DME of a specific thickness. Those trials emphasize the better outcome with injections alone. However, for patients with macular edema that does not involve the center but is clinically significant with microaneurysms seen as the source of leakage outside the fovea, laser photocoagulation would be the treatment of choice because it typically resolves the edema, he said. Dr. Stone also uses laser in those cases where the focal edema is outside the macula but threatening it. Additional factors for laser are good vision and asymptomatic cases, he said. He said such cases often do not need the repetitive nature of the intravitreal injection treatment regime. "And with their good vision, I have the time for the laser to work. I've found it [to be] very successful," he said. Future of treatment The future of treatment for proliferative retinopathy and DME will most likely include a combination of the current treatments with new delivery methods or products, Dr. Pieramici said. He emphasized that physicians need to remember that diabetic retinopathy patients have a systemic disease that also needs to be controlled and should be monitored by a team of physicians. It is important that the team communicates on the status of the patient. "We can have a big effect on the disease and the progression of the disease by controlling the systemic health, so it's important to counsel our patients to be following up with their medical doctor and encouraging them to do better with their systemic control because that will help," he said. Advances in lasers could also enhance their use, with such technology as IRIDEX's (Mountain View, Calif.) TxCell Scanning Laser Delivery System, which uses a multi-spot scanning that appears more efficient than the traditional single-spot mode, in the approval pipeline. Dr. Mahmoud said the future of diabetic retinopathy treatment could be a combined approach that employs injections, steroids, laser, and small gauge vitrectomy on a case-by-case basis. "I don't think we can take the information from clinical trials and all the evidence-based medicine that we have and apply it to every patient in our clinic," he said. "It has to be a custom approach. What's the status of diabetes, are they insulin dependent or non-insulin dependent? Do they have concomitant high blood pressure? Do they have high cholesterol? Do they have neuropathy, kidney disease, have had strokes or heart problems? What's their age? What's the hemoglobin A1c? Every one of us is genetically different, and it may be that our response to injections will differ." In the future, a slow-release method of administering anti-VEGF drugs could enhance patient quality of life by reducing office visits, Dr. Solomon said. She called the potential of such drug delivery methods a "great leap forward" that could help enhance the treatment of DME. Dr. Stone said the future would most likely also yield results of antiVEGF agents for proliferative retinopathy. "It's encouraging that we can offer our patients a wider array of treatment options going forward for this potentially blinding disease," he said. "While most of the therapy has centered on DME, there's certainly a role for antiVEGF agents in proliferative disease as well. It will be interesting to see the results of the ongoing studies on this condition." EW Editors' note: Dr. Pieramici has financial interests with Genentech, ThromboGenics (Brussels), Allergan (Irvine, Calif.), and Regeneron. The other physicians have no financial interests related to this article. Contact information Baker: 270-442-1671, eyedude3@paducaheyes.com Mahmoud: 888-275-3853, tamer.mahmoud@duke.edu Pieramici: 805-963-1648, dpieramici@yahoo.com Solomon: 410-955-3518, ssolomon1@jhmi.edu Stone: 800-627-2020, drstone@retinaky.com TORIC/LRI MARKERS S9-2033 Pre-Operative Alignment Marker For marking patient on gurney or at slit lamp prior to procedure • Three fine marking points at 3, 6 and 9 for accurate reference • Properly angled handle allows an unimposing approach to patient S9-2060 Mendez Style Degree Gauge Intra-operative ring for aligning to steep axis and defining LRI points • Large 11.7mm internal diameter provides for maximum visualization • Beveled surface reduces reflections form microscope lighting • Crisp laser etched markings every 5˚ for greater marking accuracy S9-2065 Axis Marker Works inside the Degree Gauge to mark prime meridian (steep axis) for LRIs and Toric alignment. • Fits inside Degree Gauge perfectly • Crisp edges create a fine demarcation • Length of marks accommodates both limbal and corneal marking S9-2050 LRI Marker Provides crisp marks at commonly used LRI Positions • Fits inside Degree Gauge perfectly • Creates symmetrical, opposing marks for 30˚, 45˚ and 60˚ incisions • Fine arc connects degree endpoints for easy, acurate incisions 2500 Sandersville Rd., Lexington, KY 40511 USA Phone: 800-354-7848, 859-259-4924 Fax: 859-259-4926 E-Mail: stephensinst@aol.com www.stephensinst.com

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