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107 October 2016 EW SECONDARY FEATURE in RVO patients with edema refrac- tory to anti-VEGF monotherapy. Dr. Boyer explained, "Patients tend to have the majority of their clinical response after the first injection in terms of CT and visual acuity. Following patients closely early on in the course of the treatment can be telling with regard to the overall drug response." EW Reference Diabetic Retinopathy Clinical Research Net- work. Aflibercept, bevacizumab, or ranibizum- ab for diabetic macular edema. N Engl J Med. 2015;372:1193–1203. Editors' note: Dr. Boyer has financial interests with Regeneron and Genen- tech. Dr. Clark has financial interests with Regeneron, Genentech, Bayer, and Allergan (Dublin). Dr. Ferreira has no financial interests related to his comments. Contact information Boyer: VITDOC@aol.com Clark: lclark@palmettoretina.com Ferreira: ferreiramd@hotmail.com DME and RVO Reducing the treatment burden in retinal vascular disease is paramount for patient comfort, said David Boyer, MD, Retina-Vitreous Asso- ciates Medical Group, Los Angeles. Steroids are an important adjunct to anti-VEGF medications in the treatment of retinal vascular dis- eases that in addition to helping in disease management can also ease the therapeutic load, Dr. Boyer said. "Unfortunately, there have been no head-to-head trials comparing intra- vitreal steroids in DME or RVO, but there is evidence that triamcinolone and long-acting steroid implants of dexamethasone and fluocino- lone acetonide can be beneficial if applied in some cases of retinal vas- cular diseases." Dr. Boyer said that steroids offer an option in patients who require monthly anti-VEGF injections or do not respond well to anti-VEGF treatment, and are on label for retinal vascular disease, to aid in disease management. The side effect profile of cataract formation, and intraocular pressure elevations do limit the use of steroids in retinal vascular conditions. DME responds well to intra- vitreal steroids that can be added to a patient's anti-VEGF treatment regimen depending on the response to therapy, patient vision, or OCT observations. "Since many patients with retinal vascular diseases have an inflammatory component to their disease, steroids play an im- portant role," Dr. Boyer said. He explained that patients with DME will often experience an improvement in the diabetic retinopathy severity score within the first year of therapy, after multiple injections, and will not need to continue receiving frequent injec- tions. "Overall, the injection rate decreases in the second and third treatment years. Consequently, the treatments and injection intervals have to be tailored for every individ- ual patient. I rarely treat monthly but usually use a modified treat and extend eventually getting to PRN treatment," Dr. Boyer said. Another approach to DME man- agement was shown by new data from Protocol T, which addresses DME specifically and is very in- structive in terms of patient man- agement. The 1-year results showed superior efficacy of aflibercept 2 mg over bevacizumab 1.25 mg and ran- ibizumab 0.5 mg in eyes with BCVA of 20/50 or worse or with OCT CFT >400 microns. Aflibercept achieved clinical superiority by a seven-let- ter difference to bevacizumab. The study featured monthly evaluation and anti-VEGF monotherapy for pa- tients who showed no improvement after two consecutive injections. Injections were continued unless visual acuity was 20/20 or better and OCT CST "normal" during the first 6 months, followed by continued in- jections from months 6 through 12. However, if there was no im- provement or a worsening after 2 consecutive injections, injections were deferred and a focal/grid laser could be added if edema threatened the center of the macula. "The results suggest that pa- tients with more severe disease may respond better to aflibercept than to other anti-VEGF medications in clin- ical practice. However, in patients who present with 20/50 or better vision, all three drugs represent good choices. The data from Proto- col T is good at shaping the initial drug treatment choice in DME," Dr. Boyer said. Treating macular edema in RVO is more complicated due to the lack of head-to-head data to help choose the right drug. The key to making the right treatment choice relies on understanding how patients in clinical trials responded to anti-VEGF therapy. Furthermore, intravitreal steroids may be valuable OCT demonstrating wet AMD with subfoveal fluid after treatment failure with bevacizumab OCT demonstrating complete resolution of subfoveal fluid after one treatment with aflibercept Source: Claudio Ferreira, MD

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