JAN 2013

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

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40 EW FEATURE February 2011 Retinal pharmacotherapy for the anterior segment surgeon January 2013 Treatment continued from page 39 therapy. He said it is useful for extrafoveal polypoidal lesions and CNV. "Laser is definitely going to be useful in patients who have neovascularization that's far from the foveal center, peripapillary lesions, RAP lesions, and even polypoidal lesions that are away from the fovea," he said. He said it's the second line of treatment for those patients who may require too many injections or have masquerade syndromes because photodynamic therapy would be preferred in these cases. Dr. Kaiser also indicated his preference when choosing to use an ICG or fluorescein angiography or some combination of the two. "In patients who I'm considering photodynamic therapy and, in particular, to rule out masquerade syndromes, an ICG is very important because then we can rule out or rule in polyps or a patient who has atypical central serous chorioretinopathy," he said. "ICG adds a lot more information than fluorescein does when we're trying to determine if we want to use PDT," Dr. Kaiser said. He also added that fluorescein angiography is still necessary to guide AMD treatment. Dr. Gottlieb said he does not use ICG assessment and very rarely uses photodynamic therapy. "I may use photodynamic therapy if there is persistent fluid despite aggressive monotherapy," he said. However, in most cases, he has not seen a significant benefit from this course of action. "While there may be a temporary reduction in exudation, there is rarely improvement of vision, and I remain concerned abut the longterm effect of photodynamic therapy on the retinal pigment epithelium and choroid," Dr. Gottlieb said. The future of AMD treatment In terms of future treatment of AMD, Dr. Gottlieb said he would like to see longer-acting anti-VEGF agents. "There have been encouraging reports of longer-acting agents for exudative disease," he said. However, he also said that atrophic disease is still difficult to treat. "The results of most newer medical therapies have thus far been disappointing," Dr. Gottlieb said. Dr. Russell said he is interested in the evolving strategies for treating AMD. "A low-toxicity, low-impact drug given over a long period of time at an early stage of the disease would have a much higher likelihood of being beneficial than something that had a whopping effect and significant toxicity given at a late stage of the disease," he said. However, he noted that while he believes this is ultimately the best option, it may not be the most plausible thing at this point in time. "I think the idea of being able to change the regulation or change the stoichiometry of the complement reaction in the eye is the most exciting possibility going forward," Dr. Russell said. Meanwhile, Dr. Kaiser is particularly excited about a new combination treatment called Fovista (Ophthotech, Princeton, N.J.), an aptamer directed against plateletderived growth factor subunit B (PDGF-B), which regulates pericytes. In June 2012, the company announced results of a Phase II study, which indicate the potential for the agent to be superior to Lucentis treatment when used in combination with anti-VEGF therapy. As monotherapy, it might not look like Fovista would do much, Dr. Kaiser said, but in combination with anti-VEGF, the Phase II study reported a significant improvement in vision over Lucentis monotherapy. "That's the first time we're seeing an improvement over our current gold standard," Dr. Kaiser said. He said it's an exciting development even though the drug is only in Phase II of study because there haven't been any similar results to date. "I think that it's a very exciting time for us in retina because we have these new treatments for macular degeneration that we didn't have in the past, so we have something to offer patients," Dr. Kaiser said. EW Editors' note: Dr. Kaiser has financial interests with Alcon (Fort Worth, Texas), Genentech, Bayer (Leverkusen, Germany), Norvatis (Basel, Switzerland), Regeneron, and Ophthotech. Drs. Gottlieb and Russell have no financial interests related to this article. Contact information: Gottlieb: jlgottlieb@wisc.edu Kaiser: pkkaiser@aol.com Russell: steve-russell@uiowa.edu

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