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36 | EYEWORLD DAILY NEWS | MAY 5, 2019 ASCRS SYMPOSIA by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer with ranibizumab. Emerging new classes of drugs for retinal eye disease are underway using different mechanisms of action from anti-VEGFs. According to Timothy Olsen, MD, Rochester, Minnesota, intravitreal injections carry risks and should be done by eye doctors only. The incidence of endophthalmitis at the Mayo Clinic was reduced from 1/2,000 cases to 1/12,000 by following a strict, systematic anti-VEGF appli- cation procedure, involving topical betadine 5% and betadine lid prep, mandatory masks, sterile instru- ment tray, gloves, bladed lid specu- lum, registered nurse involvement, office-based to ASC, and numer- ous eye, site mark, patient ID, and medication checks. Editors' note: The physicians have no relevant financial interests. were significantly different among drugs by 100-fold and the intraoc- ular half-life was estimated to be longest with bevacizumab. De- spite improved pharmacokinetic properties with newer anti-VEGF agents, the duration of drug effect has only made incremental gains. Each injection treatment regimen has its advantages and disadvan- tages but treat and extend is the most commonly used today (com- pared to monthly and PRN). Speaking on drugs in devel- opment, William Mieler, MD, Chicago, noted that faricimab demonstrated improved efficacy and durability in DME according to the BOULEVARD study. It achieved significant visual acuity gains over ranibizumab in anti- VEGF treatment-naïve patients and demonstrated prolonged disease stabilization, anatom- ic improvements, like greater reductions in CST and mean macular cube volume compared entertain another diagnosis, pay attention to choroidal thickness, look for drusen, and interpret the OCT map. If, however, wet AMD is diagnosed, the first line of treatment is definitely anti-VEGF agents, according to Ron Adel- man, MD, New Haven, Connecti- cut, of which there are currently three that perform equally well: bevacizumab, ranibizumab, and aflibercept. Future anti-VEGF options may include broluci- zumab, abicipar, and conbercept. He reminded attendees that the incidence of diabetes is steadily rising, likely to affect one-third of children born since 2003. Despite drugs that reduce neovasculariza- tion in patients with wet AMD, the data show little improvement in visual acuity 20 years after diagnosis. Pravin Dugel, MD, Phoenix, maintained that new drug devel- opment was vital for improving vision in patients suffering from wet AMD. We are at a precipice of changing how we handle wet AMD and about to embark on a new direction for neovascular macular degeneration thanks to new anti-VEGF drugs in de- velopment, he said. In 2016, an estimated 5.9 million intravitreal injections were given in the U.S. alone. Drug efficacy and duration of action depend on the drug's tissue penetration, binding affinity to the target ligand/receptor, and intraocular half-life, according to Christina Weng, MD, Hous- ton. Pharmacokinetics clinically translate into drug dosing and frequency, but unfortunately despite a number of experimental studies, the pharmacokinetics of intravitreal drugs is still not fully understood. She explained that the intraocular interactions and clearance of drugs is highly com- plex. VEGF-A binding affinities I n a symposium on Satur- day, panel moderator Steve Charles, MD, Germantown, Tennessee, welcomed seven retina experts to discuss the gamut of what we know about intravitreal injections, starting from OCT interpretation to injection technique. According to Colin McCannel, MD, Los Angeles, the retinal layers are per- fectly represented on OCT, which can therefore be a good predictor of visual acuity outcomes in both DME and RVO. The disruption of retinal inner layers (DRILs) is one such predictor, specifically disruptions of any of the bound- aries between the ganglion cell inner plexiform layer and inner nuclear layer or the inner nuclear layer and the outer plexiform layer. The more DRILs in the central 1 mm subfield, the worse the visual acuity outcomes. Other predictors include ellipsoid layer disruptions. He noted that treatment criteria for DME was centrally involved DME, not "clinically significant macular edema." David Boyer, MD, Los Angeles, highlighted the fact that not all swollen maculas reflect wet AMD. Masquerade syndromes such as basal laminar drusen, acquired vitelliform lesions, acute exudative polymorphous vitel- liform maculopathy syndrome, pseudo optic pit syndrome, and central serous all have signs and symptoms in common with wet AMD and need to be differentiat- ed. Patients showing no response after 2 weeks or three anti-VEGF therapy injections are not anti- VEGF sensitive and do not have AMD. He advised physicians to Bringing surgeons up to speed with intravitreal injections Dr. Adelman said diabetes is likely to affect one-third of children born since 2003.

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