Eyeworld

EW RETINA 74 by Lauren Lipuma EyeWorld Contributing Writer biologic sense. It would be like PRN diabetes mellitus management—rec- ommending holding insulin injec- tions until one has a hyperglycemic episode would be a disaster." An important detail to remem- ber is that although fluid is a marker for disease activity, with diabetes and AMD, it's not a direct marker for visual acuity, Dr. Brown said, because some of those retinas are too far gone. If a patient does have a functioning, viable retina, however, the absence of fluid is the way to maintain vision gains, he said. "On a population basis, fluid is bad for the retina," he said. "You shouldn't tolerate any persistent or recurrent fluid if you want the best visual acuity outcome." How to inject It's not only knowing when to inject but how that matters, according to Steve Charles, MD, Charles Retina Institute, Germantown, Tennessee, and clinical professor of ophthal- mology, University of Tennessee, Knoxville. Dr. Charles discussed how to properly perform injections and described simple precautions sur- geons can use to reduce the risk of infection. There is no consensus in the retinal community about wheth- er these precautions are necessary, Dr. Charles said, but in his experi- ence, they are essential to offering patients the highest level of safety. "Everybody is concerned about costs; masks are not free, sterile bladed speculums are not free, and sterile gloves are not free," he said. "But on the other hand, endoph- thalmitis isn't free either." Dr. Charles recommends exam- ining every patient at the slit lamp before injecting to check for blepha- ritis, conjunctivitis, and other signs of infection. "Sticking needles in people's eyes without knowing the anterior segment situation is not a good idea," he said. Second, always have the patient, technician, and physician wear masks to prevent oral and nasal bac- teria from contaminating the nee- dle; simply not talking and holding your breath are unrealistic options, Dr. Charles said. Use 5% Betadine (povidone- iodine, Purdue Products, Stamford, Connecticut) antiseptic for all patients, Dr. Charles continued. he said. Cataract surgery may be associated with worsening DME in some cases nowadays, but DME and wet AMD are not contraindications for surgery, he said. Do not remove a cataract until the macula is either dry or has stabilized, and use OCT to deter- mine if the macula is stable and dry, Dr. Boyer said. Consider anti-VEGF therapy or steroid injections 1 to 2 weeks prior to surgery, and use steroidal and non-steroidal anti-in- flammatory agents before and after surgery, he said. When to inject David Brown, MD, clinical profes- sor of ophthalmology, Cullen Eye Institute, Houston, discussed how surgeons should use OCT to guide AMD treatment and described the various dosing regimens for anti- VEGF therapy. Perform OCT on every potential retina patient, Dr. Brown said, and look at every single scan, wheth- er there are 6 or 50. "You can see disease on scans that automated seg- mentation programs miss," he said. The goal for anti-VEGF therapy, Dr. Brown said, is to give the patient monthly shots until the retina is totally dry and then to keep it dry. "About 70% of patients need shots forever; the question is finding that interval where they stay dry," he said. With OCT-guided therapy, all you're looking for on the scan is fluid, and it doesn't matter if you get rid of the fluid with a cheap drug or an expensive one, he continued. Typically, patients will require at least 2–3 shots before their retinas are dry, and some require indefinite monthly therapy, Dr. Brown said. Once they are dry, there are several treatment regimens physicians can follow: continuous-fixed or month- ly/bi-monthly shots; variable-con- tinuous or a "treat and extend" approach; and variable-discontin- uous or PRN treatment, where the physician gives shots as needed. According to Dr. Brown, the majority of retina specialists use a treat and extend approach. He recommends balancing a contin- uous-fixed regimen with treat and extend and does not recommend using a PRN approach. "I call PRN 'Progressive Retinal Neglect,'" he said. "Requiring fluid recurrence for each anti-VEGF injection makes no manage cataract patients who have wet AMD or diabetic retinopathy. Cataract surgery is one of the most successful surgical procedures performed today, but in the past, treating cataract patients with neovascular AMD has had limited success, Dr. Boyer said. The advent of anti-VEGF therapy, however, has changed all that; anti-VEGF agents have stabilized and in some cases improved visual acuity in patients with AMD, he said. Cataract surgery most likely does not cause dry AMD to progress to wet AMD, Dr. Boyer said, but patients with dry AMD need careful preop evaluations. On the other hand, diabetics who undergo cataract surgery risk doubling the rate at which their vision deteriorates because of dam- age to the capillaries that nourish the retina, Dr. Boyer said. The good news, however, is that phacoemulsi- fication leads to less disease progres- sion than older surgical methods, Retina specialists shared best practices for treating patients who need these injections A growing number of an- terior segment surgeons are giving intravitreal injections, but many may not have a complete understanding of proper injection procedures, according to several reti- na specialists. At a symposium at the 2016 ASCRS•ASOA Symposium & Congress in New Orleans, specialists shared their best practices for treat- ing patients who require injections with attending cataract surgeons. Before going into the specifics of intravitreal injections, David Boyer, MD, clinical professor of ophthal- mology, University of Southern California Keck School of Medicine, Los Angeles, discussed how best to Giving intravitreal injections: When, why, and how July 2016 Dr. Charles presents at the "Intravitreal Injections: The How, What, When and Why" session at the 2016 ASCRS•ASOA Symposium & Congress. Source: ASCRS ASCRS•ASOA spotlight

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