Physician Symposium Provides Forum for Specialists
data on pharmacologic and surgical therapies spark conversation on the best
methods of managing retinal pathologies in practice.
BY RACHEL RENSHAW, EXECUTIVE
EDITOR JACQUELINE ZUMMO, MEDICAL EDITOR
David Abramason, MD
Riva Lee Asbell
Abdhish Bhavsar, MD
Jay S. Duker, MD
Harry W. Flynn, MD
Thomas R. Friberg, MD, MS
Christine R. Gonzales, MD
A. Jabs, MD
K. Kaiser, MD
A. Mainster, MD, FRCOphth, PhD
D. Regillo, MD
E. Tornambe, MD
T. Trese, MD
The first annual Retinal Physician
Symposium (RPS) was held May 19-22, 2005 at the Atlantis Resort on Paradise Islands,
Bahamas. More than 80 retinal specialists attended the meeting, which was spread
over 3 days and featured symposia, a welcome cocktail reception and exhibitor's
reception, and a golf tournament.
who attended were given the opportunity to learn from their colleagues and interact
in an intimate, unique open-forum setting, which permitted interaction among the
attendees in a free and approachable fashion. The symposium included lively discussions
among attendees that addressed the controversial aspects of each presentation, including
the on- and off-label use of age-related macular degeneration (AMD) treatments.
Each presenter took questions after their presentations, which gave attendees an
opportunity to challenge and question the information presented, as well as have
any materials clarified that they felt were unclear. Jason Slakter, MD, and Rick
Spaide, MD, led the discussions.
The symposia began with a presentation
on blue-blocking IOLs, in which Martin A. Mainster, MD, FRCOphth, PhD, addressed
the issue of whether the advantages of lenses that block UV light outweigh the increased
visual acuity (VA) that blue light offers aging patients in mesopic and scotopic
conditions. Dr. Mainster concluded in his presentation that because there is no
clinical or experimental proof that normal light exposure causes AMD, it is more
important to give aging patients the maximum amount of blue light for increased
VA rather than provide protection from retinal photoxicity that may be, in effect,
many of the presentation during RPS revolved around anti-vascular endothelial growth
factor (VEGF) therapy. With the approval of pegaptinib sodium (Macugen, Eyetech/Pfizer)
and the impending approval of ranibizumab (Lucentis, Genentech) and anecortave acetate
(Retaane, Alcon Laboratories, Inc.), these data were of great interest to attendees
and spurred a good amount of questions and debate.
Christine R. Gonzales, MD, provided
attendees with an overview of the latest data on pegaptinib sodium injections for
anti-VEGF therapy. In her presentation, Dr. Gonzales discussed the role of VEGF
in pathologic ocular choroidal neovascularization (CNV) and AMD, as well as the
use of pegaptinib sodium to block pathologic VEGF. Dr. Gonzales outlined the design
and results of the VEGF Inhibition Study in Ocular Neovascularization (VISION),
which showed pegaptinib sodium injections to be safe, tolerable, and effective in
preserving vision over a 2-year period regardless of angiographic subtype, lesion
size, or baseline VA.
In her second presentation, Dr.
Gonzales discussed pegaptanib sodium following the Food and Drug Administration
(FDA) approval, including case selection, imaging studies, patient expectations
and informed consent, the importance of early treatment and continued therapy, and
its potential role in combination therapy.
is currently still undergoing FDA phase 3 trials. Philip J. Rosenfeld, MD, PhD,
reviewed the phase 1 and 2 data and discussed the phase 3 studies that are currently
underway. Thus far, the FDA study results have been promising for this new injection
therapy for AMD, which is expected to receive final approval by late 2006 or early
Slakter presented data on anecortave acetate, which addresses AMD via multiple mechanisms
of action. The preliminary results of the phase 2 and 3 study to evaluate the 24-month
dose response with monotherapy for 3 doses (3 mg, 15 mg, and 30 mg) vs. placebo
has found that anecortave acetate reduces vision loss compared with placebo, and
is effective in inhibiting the growth of CNV lesions.
In addition to providing a photodynamic
therapy (PDT) patient management update, Peter K. Kaiser, MD, presented on the development
of small interfering RNAs (siRNAs) as ocular therapeutics. Basically, siRNAs are
short molecules that seek out targets, specifically VEGF in the case of AMD, that
IMPROVEMENTS ON AVAILABLE
Dr. Mainster again took the podium
to discuss how using micropulsing with transpupillary thermotherapy (TTT) can significantly
reduce the amount of chorioretinal damage and how lower lite-dose applications can
be used in PDT. Dr. Mainster explained how repetitive micropulsing delivers the
energy in short bursts, thus minimizing heat build-up and conduction to the neural
retina or collateral sites.
Spaide, MD, presented information
to support why combination therapies may be useful in AMD. He referred to the 2-component
model that is often used in cancer treatment and related its usefulness for approaching
AMD. Dr. Spaide also discussed retinal vascular treatments. He explored the benefits
of this type of treatment, including the decrease in vascular diameter, number,
and permeability; the decrease in tissue hydrostatic pressure; and the possibility
that it can improve circulation.
While laser photocoagulation continues
to be the most widely accepted therapy for classic CNV secondary to AMD, retinal
specialists generally agree that there is no good treatment for subfoveal CNV. However,
as Henry Hudson, MD, outlined in his presentation "High-speed Feeder Vessel Therapy,"
photocoagulation of feeder vessels may stabilize or improve VA for patients with
subfoveal CNV. Dr. Hudson reviewed the studies that have been performed with feeder
vessels and evaluated the techniques that were used.
To finish the morning presentations,
Micheal T. Trese, MD, broached the topic of stem cell therapy for retinal disease.
According to Dr. Trese evidence exists to suggest that stem cells may be able to
be used to treat progressive retinal cell loss in atrophic AMD, retinitis
pattern dystrophy, neovascular AMD, familial exudative vitreoretinopathy, retinopathy
of prematurity (ROP), and Coats' disease. By utilizing the stem cells' potential
ability to incorporate themselves and function, transplants may be able to rebuild
subretinal space after treatment with anti-VEGF therapy.
Dr. Trese also presented the results
of a study on the 10-year incidence of blindness from ROP, which also incorporated
the results of consistent screening and treatment for ROP. According to Dr.
timely screening and laser or surgical intervention can result in a low incidence
of blindness in these patients.
PHARMACOLOGY AND IMAGING
TECHNOLOGIES FOR AMD
Dr. Slakter began Friday afternoon
sessions with a presentation on the pharmacologic approach to preventing CNV, addressing
the importance of prevention, safety and tolerability, the limitations that exist
with current therapy, and the future therapies to treat and prevent vision loss.
Laser therapy, nutrition, and antiangiogenic therapy all currently target the control
of AMD in terms of vision stabilization to limit acuity loss. However, most patients
with CNV have lost a significant amount of VA. Dr. Slakter highlighted the success
of AREDs for preventing CNV, as well as the early success of anecortave acetate
in clinical trials to stabilize and improve VA after CNV.
S. Duker, MD, discussed in detail ultrafast, ultrahigh resolution optical coherence
tomography (OCT), which is an improvement of 3 generations of OCT. The current version
of OCT, the Stratus OCT3 (Carl Zeiss Meditec, Inc), which became commercially available
in 2002, has a resolution of 8 μm–10 μm, but is still unable to
perform true optical biopsy, according to Dr. Duker. Thus, a newer technology has
been developed in high resolution OCT, which allows for resolution of 2 μm–3
μm and fast 3D imaging. This technology uses a mode-locked, titanium sapphire
laser light source that offers higher spectral bandwidths to allow for better imaging
for macular hole, idiopathic telangietasia, AMD, retinitis pigmentosa and macular
dystrophies, and "microscotoma" cases.
Friberg, MD, MS, continued
the discussion on imaging technologies with his presentation "Wide-Angle and
Retinal Imaging and Angiographic Systems." Among several nonmydriatic retinal-imaging
systems that were included, all of the systems fall short in terms of lack of stereo
imaging and low resolution. Dr. Friberg reported on the 200°-plus wide-angle
imaging system (Panoramic 200) from Optos (Marlborough, MA) and the nonmydriatic
angiography component that is currently in development. The device is able to provide
high-resolution images to aid in accurate diagnoses. Wide-angle angiography is produced
by adding a blue-laser (488 nm) to the scanning array, while the existing green
channel detector images the fluorescence, according to Dr. Friberg. The capabilities
of panoramic angiography include the evaluation of areas of peripheral ischemia,
identification of peripheral neovascularization, the ability to follow proliferative
diabetic retinopathy, identification of retinal angiomas, and evaluation of treatment
Friday's sessions concluded with
presentations by George Williams, MD, and Riva Lee Asbell, who own a coding consultation
company which focuses on reimbursement and coding issues. Dr. Williams gave a history
of physician reimbursement, beginning with the inception of Medicare in 1964. According
to Dr. Williams, the primary issue in physicians reimbursement is "the adverse effect
of the sustainable growth rate," and that "the formula for calculating the sustainable
growth rate is based on unrealistic and invalid assumptions, which penalize physicians
for factors that are beyond their control." Also at issue is how surgical and laser
codes are reviewed. The surgeon may, in the end, be penalized for implementing procedures
that shorten surgical time and increase efficiency.
Asbell's presentation followed
with an update of the codes that should be used in vitreoretinal surgical procedures,
including modifier challenges and CPT codes for new technology.
NEW TREATMENTS AND
Photodynamic therapy and intravitreal
triamcinolone were the topics of Dr. Spaide's first presentation on Saturday. Combination
therapy can provide effective results for AMD cases that are nonresponsive to
Combination therapy has also been used successfully in patients with cancer. According
to Dr. Spaide, patients who are treated with combined PDT and triamcinolone have
better results than patients treated with only PDT. The rationale for this combination,
as well as case reports that show efficacy were presented to attendees.
Bhavsar, MD, presented
data on the hyaluronidase (Vitrase, ISTA Pharmaceuticals) for injection for the
treatment of vitreous hemorrhage. The mechanism of action for hyaluronidase is such
that it cleaves glycodisic bonds of hyaluronan, leads to the collapse and liquefaction
of vitreous, thereby facilitating diffusion of molecules, including pro-inflammatory
chemotactic factors and promoting ingress of phagocytic cells and egress of red
blood cells and proteins, said Dr. Bhavsar. phase 3 studies have shown that hyaluronidase
injection can improve VA by at least 3 lines, as early as 1 month after injection
and can reduce the density of the hemorrhage. This office procedure can allow physicians
to treat patients early and
is proven safe, he said.
A new agent that was approved by
the FDA for the treatment of chronic noninfectious uveitis was the topic of the
presentation given by Henry Husdon, MD. The fluocinolone acetonide intravitreal
implant (Retisert, Bausch & Lomb) has demonstrated a statistically significant
increase in visual acuity of 3 lines or more for some patients who have had the
device implanted. Dr. Husdon reported that the implant results in a low rate of
posterior uveitis recurrence and reduces the need for adjunctive therapy.
In his presentation, "Laser Pneumatic
Retinopexy: Myth, Reality, and Current Applications," Dr. Friberg compared the technology
to conventional pneumatic retinopexy and provided a summary of the clinical results
that he has seen with the laser method as well as criteria for use. According to
Dr. Friberg, laser pneumatic retinopexy can reduce healthcare costs, simplify what
were once considered emergency procedures, speed patient recovery, and induce fewer
refractive errors than other methods.
Intravitreal injection technique
and safety have become crucial for retinal specialists who are planning to add these
therapies to their armamentarium. Harry W. Flynn, MD, addressed the evolving guidelines
for administering intravitreal injections, providing a step-by-step approach to
prepping the eye, lids, and lashes, measuring the injection site and IOP, and selecting
injection needles. Dr. Flynn also discussed the complications that are involved
with injection procedures and outlined the existing data and strategies for management.
RETINAL SURGERY: TECHNIQUE
Ocular illumination and retinal
function vs. what is actually seen in an eye postoperatively were 2 separate presentations
given by Paul E. Tornambe, MD. In his first presentation, Dr. Tornambe included
slit-lamp microscope illumination, handheld endo-illumination, nonfocused illumination
probes and fixed illumination. Featured in his presentation was the Torpedo (Alcon)
illumination system with Xenon lighting. In his second presentation, Dr. Tornambe
detailed the many reasons why some patients do not experience improved vision after
retinal surgery. These include noncystoid retinal swelling, postoperative pathology,
persistent clinically invisible serous detachment, among others. Imaging technology
can help the retinal specialist identify and explain these occurrences to their
patients and may help to identify procedures that more quickly restore the fovea.
Regillo, MD, posed the
question of whether scissors are still needed in vitrectomy in his
on Saturday. Outlining the basic surgical approaches and the surgical advances that
include high-speed cutters, 25-g vitrectomy, wide-field imaging, new illumination
devices, and illuminated scissors, Dr. Regillo concluded that although scissors
are less frequently used, they are done so with greater efficiency, effectiveness,
Spaide finished off the day of presentations with a talk on small-incision retinal
procedures. The 23- and 25-g instruments are bound to replace 20-g instrumentation,
according to Dr. Spaide, but even though 25-g instruments offer the smallest incision
and the most flexibility, 23-g technology acts most like the familiar and easy to
use 20-g instruments with the more precise and flexible maneuverability.
AN UPDATE ON RETINOBLASTOMA
Abramason, MD, started Sunday
morning's sessions with 2 separate presenations, the first on retinoblastoma and
the second on melanoma. Dr. Abramason presented statistical information for 2005
including, the 95% patient survival rate and the 75%-100% of curable metastatic
disease. He also presented in great detail the centrifugal pattern of development
and treatment options for the disease. Treatment options include observation,
exenteration, enucleation, external beam, irradiation, brachytherapy, laser/TTT,
Dr. Abramason also presented second
nonocular cancers in retinoblastoma. Included in his presentation were the factors
that increase incidence and the risk of new cancer after radiotherapy. Dr. Abramason
also discussed treatment options for this form of the disease. He also presented
the results of the C.O.M.S. Medium Tumor Trial during his second presentation.
Douglas A. Jabs, MD, also offered
2 presentations. The first discussed cytomegalovirus retinitis. During this presentation
he presented the frequency of the disease in BMT, renal transplants, and AIDS both
pre-highly active antiretroviral therapy (HAART) and with HAART. Dr. Jabs discussed
how HAART affects AIDS and how it can aid in the suppression of HIV replication.
The idea that this therapy also contributes to immune recovery (CD4+T cells) was
presented as well. He concluded his presentation with a discussion on the treatment
goals for CMV retinitis.
His second presentation on systemic
therapy for uveitis discussed the visual loss associated with uveitis. He presented
information on prescription-guided anatomic location, such as anterior uveitis:
topical corticosteroids and other uveitis: regional or oral corticosteroids ±
immunosuppression. He also discussed some of the problems associated with the different
types of treatment currently available. Dr. Jabs concluded his presentation with
a discussion on the side effects that could be possible with each available treatment.
Harry Flynn, MD, discussed the
onset of endophthalmitis after cataract surgery. During his presentation Dr. Flynn
presented the systemic, operative, intraoperative, and peri-operative risk factors
associated with endophthalmitis. He also discussed the possible treatment options
to treat any type of risk that may occur. The treatment options currently available
are vancomycin, vit. tap/injection, and PPV/injection. Dr. Flynn concluded his presentation
with an overview of the Endophthalmitis Vitrectomy Study and Bascom Palmer Eye Institute
CENTRAL RETINAL VEIN
OCCLUSION AND MACULAR EDEMA
George A. Williams, MD, from the
Beaumont Eye Institute in Royal Oak, MI presented the combined radical optic neurotomy
(RON) and intravitreal triamcinolone for central retinal vein occlusion (CRVO).
Central retinal vein occlusion is a common blinding disease with no effective therapy
to treat it. Dr. Williams presented the results of the Central Vein Occlusion Study,
as well as the rationale for using RON in CRVO cases. Dr. Williams also explored
why patients develop macular edema from CRVO.
In another presentation Abdhish
R. Bhavsar, MD, gave an update on retinal venous occlusive disease. De. Bhavasar
called to our attention the fact that retinal vein occlusion is a major public health
problem, with 130000 patients a year being diagnosed with the condition. Dr. Bhavsar
also discussed the common misconception about the condition, and the possible treatment
options available, including acetazolmide, carbon dioxide inhalation, hyperbaric
oxygen, and corticosteroids. The condition can also be treated surgically or with
a laser. In the future, IVTA, steroid implants, and anti-VEGF will be used in the
treatment of this condition.
The session came to a conclusion
with an update on the management of diabetic macular edema (DME) presented by Carl
D. Regillo, MD. Dr. Regillo discussed treatment options, including macular laser
treatment-ETDRS, corticosteroids, vitrectomy, and phamacogic approaches. He also
presented the risk factors associated with DME and the treatment options available
to treat the condition, including laser treatment.
The Retinal Physician Symposium
provided an opportunity to learn and interact in an intimate, unique open-forum
setting. Overall, the symposium was a way for the retinal community to come together
to discuss diseases, technology, and treatment options that affect the posterior
segment of the eye in a fashion in which attendees could be interactive with the
The 2006 RPS will be held May 31-June
3, at the Atlantis Resort on Paradise Islands, Bahamas. We hope to see all of you
at next year's symposium.
Retinal Physician, Issue: July 2005