Does Surgery Have A Future in Retina Care?
Advancements in medical treatments mean less time in the OR for retina specialists.
STEVE LENIER, CONTRIBUTING EDITOR
It’s no secret that the treatment of retinal disease is changing. With the pharmacological advances that have been made, retina specialists face the choice of continuing to use the standard surgical techniques they have relied on for years, or the newer, less invasive medical treatments that are evolving at a rapid pace.
Not all retina specialists agree on how completely their peers should embrace this change in the treatment paradigm. What are the reasons to adopt the newer methods, and the reasons not to?
MEDICAL TREATMENT NOW STANDARD FOR AMD
In the treatment of AMD, clearly the first-line treatment of choice has moved away from surgical options to anti-VEGF agents. Ron Adelman, MD, MPH, MBA, at Yale University, gives some perspective on how this has changed.
“For AMD, we used to do a number of surgeries, including vitrectomy and removal of subretinal choroidal neovascular membrane,” he says. “Some people used to do other surgeries, such as macular translocation. Those are rarely being done now. There was a time that we did four of those macular degeneration surgeries in one day. Now, I haven’t done any in the last two years because the anti-VEGF treatment is so effective.”
Philip Rosenfeld, MD, PhD, at Bascom Palmer Eye Institute in Miami, FL, has seen a similar trend in his clinic. “If a patient comes in with wet AMD, with salvageable vision, they get an injection,” he says. “I can’t recall treating a macular degeneration patient with laser or PDT in the past five years.”
The consensus is similar among other thought leaders. Sharon Fekrat, MD, FACS, at Duke Eye Center in Durham, NC, says injection with an anti-VEGF agent is the only treatment needed for wet AMD. At Wills Eye Institute in Philadelphia, PA, Julia Haller, MD, likewise takes an anti-VEGF-only approach for AMD. If a patient is nonresponsive, she’ll move onto a different anti-VEGF agent. Adds Steve Charles, MD, of Memphis, TN, “Vitrectomy was never effective for AMD and laser has been obsolete since intravitreal anti-VEGF agents became available.”
However, some retina specialists still find a place for PDT, and even thermal laser, in select AMD patients. “Occasionally, PDT is a component of treatment for subtypes of macular degeneration, and occasionally we’ll still do a laser for an area of choroidal neovascularization outside of the fovea itself,” says William Mieler, MD, of the University of Illinois–Chicago. “We’ll do conventional laser vs PDT, and there still is an occasional surgical case as well where someone comes in with a massive subretinal hemorrhage that warrants surgery, but those are becoming less and less common.” Otherwise, Dr. Mieler treats most of his AMD patients pharmacologically.
Dr. Haller points out she would consider PDT in a polypoidal case, a treatment Dr. Rosenfeld concurs could be beneficial in such cases “if the lesion is away from the foveal center and is truly unresponsive to anti-VEGF therapy.” He also notes conditions that masquerade as AMD, such as chronic recurrent central serous retinopathy and vitelliform lesions, could lead doctors to think they have AMD patients who are non-responsive to pharmacologic treatment.
TREATMENT OF RETINAL DETACHMENT
Retinal detachment, to a large degree, still requires a surgical treatment. “The tendency has been more and more to go toward vitrectomy,” Dr. Mieler says. “In the past we would use scleral buckles — and we will still do buckles, primarily in patients who are phakic. Or we’ll do a combination of a buckle with vitrectomy if someone has rather extensive pathology in his or her inferior periphery.” The exception is in pseudophakic patients who have had previous cataract surgery and a lens implant which tends to make them amyotrophic. “We generally avoid buckles, because that has a good chance of throwing off their refraction,” Dr. Mieler says.
Dr. Charles counters that scleral buckles are obsolete. “Retinal detachment is best repaired by using vitrectomy, tamponade and laser,” he says.
Surgery for repair of retinal detachment is becoming less invasive, notes Dr. Adelman. “We still do a fair number of surgeries for retinal detachment, but some of the retinal detachments that were fixed with surgery in the past now can be done in the office with less invasive procedures such as pneumatic retinopexy,” he says. He estimates 20% to 30% of retinal detachments he treats are done this way.
But pneumatic retinopexy is being done less, according to Dr. Mieler. “I think a lot of us that have done pneumatic retinopexy in the past are doing it less frequently,” he says. “The intent was if we could do something in the clinic and avoid an operation in the OR, that’s great; but the success rate is not as good as a vitrectomy and/or scleral buckle, so a lot of us aren’t doing it as frequently.”
ADDITION OF OCRIPLASMIN
Ocriplasmin, (Jetrea, ThromboGenics, Iselin, NJ) recently received FDA approval for treating symptomatic vitreomacular adhesion (VMA). While it isn’t a treatment for retinal detachment, it might aid in helping to close macular holes and in the release of traction in VMA in some eyes that develop macular holes (Figure).
Ocriplasmin could lead to fewer surgeries for symptomatic VMA and macular holes in her practice, Dr. Fekrat says — just as the surgical volume was already dropping off when she began using anti-VEGF agents for AMD.
“It’s going to take some time to determine our treatment plans,” Dr. Mieler says. “The studies that were done with ocriplasmin certainly showed that patients who had relatively small macular holes or well-defined VMAs responded favorably. Forty to 45% of cases had resolution of the abnormality with a single injection.”
Dr. Charles is less optimistic about the future of ocriplasmin. “Only 12% of patients get a posterior vitreous detachment (PVD) with ocriplasmin, a very low success rate,” he says. “Surgery has a 90% success rate or better for all conditions proposed for treatment with ocriplasmin.” His conclusion: “The drug has no application in retinal detachment and is rarely indicated for vitreomacular traction cases.”
A select group of patients may be ideal for treatment with ocriplasmin, says Dr. Rosenfeld. He defines them as patients “with vitreomacular adhesions that focally elevate the posterior pole, resulting in the type of configuration more likely to progress to macular hole or already causing an early-stage hole.” Those patients can be easily identified, he says, “by the way the anatomy appears on SD-OCT. It’s very characteristic.”
Figure. OCT displaying vitreomacular adhesion.
COURTESY MICHAEL P. KELLY, FOPS, DUKE UNIVERSITY EYE CENTER.
Counters Dr. Charles, “It is very difficult to reliably determine if there is vitreous adherent to the margins of macular hole using OCT, the so-called stage 2 macular hole, said to be an indication for ocriplasmin. If there is no vitreous adherence, which is usually the case, the agent is not indicated.”
He further points out two potential downsides to using ocriplasmin. “A few patients in the clinical trial had immediate, profound, unexplained visual loss from which they recovered — a very disturbing event,” he says. The cost, expected to be around $4,000 in the United States, also is prohibitive — “over twice the cost of Lucentis (ranibizumab, Genentech, South San Francisco, CA) or Eylea (aflibercept, Regeneron, Tarrytown, NY), and about the cost of surgery in an ASC,” Dr. Charles says.
A MATTER OF CONVENIENCE AND LESS INVASIVENESS
What are the reasons for retina specialists moving in the direction of injection of pharmaceutical medications rather than a surgical procedure?
“There’s a move toward more in-office management of patients and surgicenter management of patients and away from the hospital, particularly the hospital operating room,” Dr. Rosenfeld says. Dr. Mieler agrees. “It will keep a number of cases out of the operating room and we will have a simpler, less invasive means of fixing the patient’s problem,” he says.
“The greatest advantage is convenience for the patient and the retina specialist,” Dr. Rosenfeld says. “We hope that this is being done for the benefit of the patient. But there are also huge benefits for the clinician, because it’s much more efficient to stay in the office, manage the problem in the office, or manage the problem in a surgicenter rather than wait in line for a hospital operating room.”
What’s in it for the patient? “Whenever you can avoid surgery you’re always better off — as long as the outcomes are as good or better,” Dr. Rosenfeld says.
Dr. Adelman will change to a new treatment if it is less invasive and equally efficacious as the existing treatment, he says. “The two things I look for are, if there is an agent that does the same job but in a less invasive way, or if the invasiveness is similar but the treatment is more effective,” he says.
“I would like things to be as safe and as uncomplicated and as successful as possible,”
Adds Dr. Haller: “So whichever is all those things is what I’m in favor of. Certainly in general, pharmacologic treatments are less invasive and thus safer than a surgical procedure. And because of that you can often offer them as an alternative at an earlier stage of disease, which has a lot of appeal because you might be able to save more vision.”
Dr. Fekrat’s criteria for changing are “efficacy, safety, and cost, in that order,” she says. “An injection is generally safer for the patient — less risky because the patient is not getting exposed to either general anesthesia or intravenous sedation; and it’s quicker.”
TEACHING ‘OUTGOING’ METHODS
As treatments evolve and older procedures are used less frequently, is there any need to continue teaching the old way to incoming students and residents?
The need for surgery will never go away, Dr. Rosenfeld points out. “The problem moving forward for future generations is maintaining a certain level of expertise while the volume of a procedure may diminish,” he says. “Just look where we are in the use of PDT. I’m sure there are residents and fellows who have never seen PDT or a scleral buckle performed. While a certain amount of historical knowledge and expertise may be lost when new treatments are introduced, we always hope the benefits outweigh the loss of a particular skill.”
Adds Dr. Haller: “The more things that you have in your armamentarium, the more techniques you’ve mastered, the better off you are. You never know when a situation is going to come up where you may have to reach into your bag of tricks and pull out something unusual, so I think the surgeons who have the most experience, the most training, and the most varied and diverse backgrounds and experience are always going to be the better surgeons.”
Surgical techniques must remain part of the teaching curriculum, Dr. Mieler says, “because there are always going to be indications for surgery.” Dr. Adelman agrees. “When a game changer comes along, it applies to most of the patients but not to everybody,” he says. “There is a minority of patients who will not respond to the new treatment. So it is still a good idea to know about the older techniques because they still occasionally will be in use.”
However if a newer, better approach replaces an older one, the need to continue teaching the old methods decreases, Dr. Fekrat says.
Adds Dr. Charles: “There are rare indications for buckling so it should still be taught to retinal fellows, but not to students or residents.”
ALWAYS A ROLE FOR SURGERY
Despite the advances in medical therapy and the discoveries certain to occur in the future, the need for surgery will continue. “I think as we get more and more treatment options, it’s going to take us even further down the road of pharmacologic intervention more than surgery, but there’s always going to be a role for surgery, it will never go away,” Dr. Mieler says. “There will always be patients who just aren’t amenable to pharmacologic therapy.”
Likewise, Dr. Fekrat sees a continuing role for the vitreoretinal surgeon. “There will always be the patient that comes in with more advanced disease, so we’ll never get rid of surgery,” she says. “But the ratio of how we spend our time has shifted, and more of our time is spent in the clinic than in the OR now, whereas over a decade ago, it was more equal.”
Looking to the future, Dr. Rosenfeld says stem cell research will be the next paradigm shift in retina therapy. “We may come full circle and go back to the operating room at that point,” he says. RP