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EW RETINA 64 October 2015 by Maxine Lipner EyeWorld Senior Contributing Writer they had infected materials," Dr. Charles said. For those interested in expand- ing into this area, it goes beyond the question of whether it's OK to inject an anti-VEGF and becomes an issue of knowing which drugs to use and understanding the problems associated with Avastin because of compounding pharmacy issues, he said. In addition, retina specialists commonly administer bilateral anti-VEGF injections on the same day. "It's very inconvenient for the patients [if we inject on two differ- ent days]," Dr. Charles said. While there are some arch- conservatives who won't inject anti-VEGF bilaterally, most retina specialists will do so, Dr. Charles noted. "With Lucentis and Eylea we don't have a problem because it's packaged by a completely sterile technique with incredible quality control, and [there hasn't been] a single incidence of infection com- ing from the companies," he said. "With Avastin it's coming from the compounding pharmacy." When he injects Avastin bilaterally he always uses a different batch for each eye. Those injecting anti-VEGFs should be committed to doing so regularly, he advised. Lucentis lasts 4 to 5 weeks, Eylea 5 to 6, and Avastin about the same, Dr. Charles said. While patients need month- ly injections, the average number nationwide for those on a "month- ly" program is well less than 12. For those with wet AMD, skipping a month of treatment may result in a bleed or a new membrane growing underneath the fovea. "You can move from treatable to untreatable visual loss in a couple of months," he said. "There is no viable tech- nology today to go 2 or 3 months between injections, so it's a big deal to stay on schedule." Using a sterile technique is also imperative. This means not scrimping on things such as sterile speculums, Dr. Charles said. He also thinks practitioners should follow the recommendation of Harry Flynn, MD, Bascom Palmer Eye Institute, Miami, who advises that the technician, the doctor, and the patient all wear a mask during choice is Avastin. "That is the least effective drug for diabetic retinop- athy," he said. "It finished last in a head-to-head trial with Lucentis." Likewise, when it came to AMD in the Comparison of AMD Treatments Trials, which also compared Lucentis to Avastin, Lucentis was a bit better. "OCT findings of subretinal flu- id as well as visual outcomes showed that Lucentis won by a little bit," Dr. Charles said. On the podium this tends to be presented as the two being substantially equivalent, but Medicare pays just $40 or $50 for Avastin, whereas Lucentis is $1,950. Likewise, Eylea, not included in the study, is also much more expensive at $1,850. Protocol T showed that Eylea was best, Lucentis second, and Avastin last, Dr. Charles said. "There was a fair distance between Lucentis and Avastin in terms of outcomes," he said. Yet the substantial cost dif- ference may sway some who don't want an inventory of an $1,850 or $1,950 drug, he said. In addition, since Avastin use in the eye is off-label, it must be made by a compounding pharmacy. "There are a number of eyes that have been blinded by now-defunct compounding pharmacies because and many other forms of leakage in the posterior pole, all of which may coexist in patients with cataracts," he said. Anti-VEGF arsenal Currently, there are 3 anti-VEGF agents in use: Lucentis (ranibizum- ab, Genentech, South San Francis- co), Eylea (aflibercept, Regeneron, Tarrytown, N.Y.), and Avastin (bev- acizumab, Genentech). Dr. Boyer relies on each of these for different reasons. "There has been only one head-to-head study where all 3 drugs were utilized, and that's the Protocol T from the Diabetic Reti- nopathy Clinical Research Network," he said. Results were connected to the patient's vision. "If vision was 20/40 or better, all drugs seemed to act similarly; if vision was 20/50 or worse, aflibercept had a bigger advantage in improving vision," Dr. Boyer said, adding that this seems to cause a better drying effect. Howev- er, it was the group of patients who were severely edematous and who had very poor vision in the study who responded better with afliber- cept. Dr. Charles pointed out that many in the cataract community erroneously believe that the drug of Update for the cataract surgeon O ne of the biggest events in ophthalmology in 100 years was when Napoleone Ferrara purified cloned VEGF and made antibodies against it, according to Steve Charles, MD, clinical profes- sor of ophthalmology, University of Tennessee, and founder of Charles Retina Institute, Germantown, Tenn. While all that was hoped for was that this would slow the rate of vision loss, it exceeded expectations. "Not only did they stop it dead in its tracks in 75% of patients, but 40% of people saw visual improvement," Dr. Charles said. Here's the latest on what these drugs have to offer. There are several reasons why patients slated to undergo cata- ract surgery may be on anti-VEGF therapy, said David S. Boyer, MD, clinical professor of ophthalmology, Keck School of Medicine, University of Southern California, and part- ner at Retina Vitreous Associates, Torrance, Calif. "Anti-VEGF therapy has been shown to improve age-re- lated macular degeneration, diabetic retinopathy, retinal vein occlusions, Anti-VEGFs in the spotlight Eye of a patient with stable proliferative diabetic retinopathy that has received multiple intravitreal bevacizumab injections Source: David S. Boyer, MD Pharmaceutical focus 11/11/2010 4/28/2011 6/30/2011

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