IMT Study Shows Vision Gains
Device Could Help End-stage AMD Patients.
Ophthalmic Technologies, Inc., a developer of advanced visual prosthetic devices
for the treatment of AMD, announced positive results from the phase 2/3 clinical
trial of the investigational Implantable Miniature Telescope (IMT). The data were
published in a recent issue of Ophthalmology.
IMT is currently in the regulatory review process, having received a setback in
July when the FDA Ophthalmic Devices Advisory Panel voted 10 to 3 to reject the
device because of safety concerns. The IMT is implanted in a complex anterior segment
procedure that requires the participation of an anterior segment surgeon, retina
specialist, and low-vision specialist for comprehensive patient management.
The Ophthalmology article,
entitled "Implantable miniature telescope for the treatment of visual acuity loss
resulting from end-stage age-related macular degeneration," details the results
from the IMT002 trial that enrolled 217 patients at 28 U.S. investigational sites.
Patients entering the trial had severe vision loss due to the characteristic central
blind spot caused by end-stage macular degeneration. The publication reports 90%
of patients met or exceeded the protocol-specified primary efficacy endpoint of
visual improvement, defined as a 2-line gain in either distance or near vision on
the study eye chart. The protocol stated the endpoint would be achieved if at least
50% of patients met this target.
is truly a breakthrough because it is the first clinical trial to show the potential
for improved vision and quality of life specifically in patients with bilateral,
irreversible AMD," said Henry L. Hudson, MD, lead author of the IMT002 study publication
and retina specialist at Retina Centers, PC, in Tucson, Ariz. "From an efficacy
standpoint, we hoped that half of this study population with untreatable forms of
AMD could achieve at least a 2-line visual acuity gain. The results surpassed our
expectations because 90% achieved the efficacy endpoint, and, furthermore, over
two-thirds of patients improved by at least 3 lines and one-quarter improved by
at least 5 lines in distance vision."
Secondary efficacy outcome measures
suggest improvement in patients' vision-related quality of life and activities of
daily living. On the National Eye Institute 25-item Visual Function Questionnaire,
patients improved significantly from baseline in 7 of 8 relevant vision-specific
and psychosocial subscales, including General Vision, Social Functioning, and Dependency.
However, corneal endothelial cell density, a safety endpoint, was reduced 20% from
preoperative at 3 months and 25% at 1 year, compared with the 17% protocol-specified
"In an end-stage AMD population,
the indicated improvements in this study are substantial compared to risks of surgery,"
commented R. Doyle Stulting, MD, PhD, professor of ophthalmology at Emory University
in Atlanta and study coauthor.
"Despite the endothelial cell loss
from surgery, we believe that corneal health was maintained," said Stephen S. Lane,
MD, the trial's medical monitor and adjunct professor of ophthalmology, University
of Minnesota. "There was a significant correlation between postoperative cell loss
and the level of corneal edema on the first postoperative day. Therefore, it appears
that the majority of cell loss was due to the impact of the surgical procedure.
Stabilization of cell density 3 to
12 months after surgery was consistent with
what we'd expect after large-incision intraocular surgery.
"While the techniques required
to implant the device are well within the skill set of anterior segment surgeons,
a surgeon training program will be utilized to address the risk of acute endothelial
cell density loss during implant," Dr. Lane concluded.
On page S-7 of the November/
December issue of Retinal Physician, part
of a continuing medical education section titled "Management of vitreous hemorrhage
in the high-risk, nonsurgical patient," a quote by Michael A. Singer, MD, was accompanied
by a photograph of Kent W. Small, MD. We regret this error and apologize for any
Seeks to Exit Eye Care
Sales Continue in Steep Decline.
When OSI Pharmaceuticals announced its intention to acquire Eyetech in a $650 million
deal in the summer of 2005, the reaction of the stock market was immediate and sharply
negative. Within a matter of weeks, OSI shares fell almost 50% before recovering
While OSI saw significant potential
in Eyetech's Macugen therapy for wet AMD, the market was clearly dubious about the
drug's long-term prospects. What concerned investors was the looming presence of
Lucentis, a Genentech treatment for wet AMD, then in phase 3 clinical trials, that
had proven far more efficacious than Macugen in studies. While Macugen was a safe
drug able to slow, or sometimes even halt, the progression of the disease, Lucentis
demonstrated that it could actually improve vision.
As it became clear that Lucentis
was likely to be approved and be a formidable competitor, OSI CEO Colin Goddard,
PhD, put forward several strategies designed to spur Macugen sales. He advocated
the drug as part of a "1-2 punch" in treating AMD, with Macugen serving as a maintenance
therapy after initial treatment with the Genentech drug. He also emphasized Macugen's
excellent safety profile and its effectiveness when used in the early stages of
Some studies have confirmed that
these approaches have validity. However, OSI's advocacy of these strategies proved
to be unable to overcome the efficacy obstacle.
Lucentis was approved by the FDA
in June 2006 and generated an impressive $153 million in sales in its first 3 months
of US availability. Meanwhile, Macugen US sales slumped to just $9 million for the
same 3-month period after having recorded sales of $50.5 million in the first quarter
of 2006 and $36.7 million in the second quarter.
These plummeting numbers were too
compelling for OSI management to ignore.
In November, OSI announced that
it planned to exit its eye disease business and would seek to maximize value for
Macugen and its research assets through either licensing, partnering, or an outright
sale of the business.
"We continue to believe that Macugen's
product profile, our induction/maintenance strategy, and promising data in the diabetic
retinopathy area will ultimately result in a meaningful place for Macugen in treating
retinal eye disease. However, it is evident that a key strategic goal behind our
acquisition of Eyetech that of generating positive cash-flow from the eye
business in the 2006-2008 period will not be realized," stated Dr. Goddard.
"This, and our reluctance to invest near-term in the eye disease business given
our priorities in the oncology and diabetes areas, has led us to conclude that we
can better realize value from these assets through strategic partnering strategies.
In the near-term we, and our marketing partner, Pfizer, intend to continue to support
the brand commercially."
OSI said it will continue its important
phase 4 LEVEL study designed to test Macugen's effectiveness as a maintenance therapy.
The company also plans to continue studies using Macugen to treat diabetic macular
edema, diabetic retinopathy, and central retinal vein occlusion. The company believes
that impressive results from any or all of these studies could help maximize the
value of Macugen in a sale, partnership, or license agreement.
Dr. Goddard asserted that there
was already strong interest in the Macugen franchise and that a favorable deal could
be concluded in the next 6 to 9 months.
Cellgate begins drug study. Cellgate Inc., a company developing anti-proliferative
drugs to combat eye disease, has dosed the first patient in a phase 1
dose-escalation study of CGC-11047 in patients with wet AMD. CGC-11047
is a polyamine analogue that targets hyper-proliferating blood vessel
The open label phase 1 trial is designed to determine the safety and
tolerability of CGC-11047. A total of 15 patients will be treated in
cohorts of escalating doses. Patients will be treated subconjunctivally,
avoiding the need to inject into the eye. Patients will be monitored for
adverse events and for preliminary evidence of suppression and
regression of choroidal neovascularization following administration.
Merck to purchase Sirna. Pharmaceutical giant Merck has agreed to
acquire Sirna Therapeutics, Inc., a developer of a new class of
medicines based on RNA interference (RNAi) technology. One of the key
target areas of Sirna research is ophthalmic diseases.
selectively catalyze the destruction of the RNA transcribed from an
individual gene. This enables a novel approach to discovering drugs with
the potential to produce highly specific, potent, and long-lasting
Sirna's lead clinical
development candidate, Sirna-027, is a chemically optimized, short interfering
RNA (siRNA) currently moving into phase 2 development for the treatment of wet
AMD as part of a broad collaboration with Allergan, Inc., in the area of
Combination AMD trial. Novartis Pharmaceuticals said it will conduct a
randomized, controlled, multi-center, clinical trial in the United States and
Canada to explore combination therapy in the treatment of patients with the wet
form of AMD. The DENALI trial will compare the efficacy, safety, and impact on
retreatment rates of Visudyne used with Lucentis vs Lucentis monotherapy in
patients with subfoveal choroidal neovascularization secondary to wet AMD.
Novartis has a partnership stake in Visudyne and is also the international
marketer of Lucentis.
The 2-year, 300-patient
study will evaluate whether patients treated with combination therapy need fewer
treatments than those receiving Lucentis monotherapy.
Eye drops for AMD. Athenagen, Inc., a privately held biopharmaceutical company
based in South San Francisco, Calif, said it has begun testing ATG003, its
topical therapy for wet AMD, in a phase 1 clinical trial.
ATG003 is a proprietary
topical formulation of mecamylamine that has shown efficacy in animal models.
Athenagen believes it is a possible alternative to current therapies for AMD
that require frequent needle injections directly in the eye. This study
represents the first human study of an eye drop antiangiogenic therapy for AMD,
with a phase 2 efficacy study expected to follow early next year.
Athenagen says ATG003 is a
novel antiangiogenic agent that inhibits endothelial nicotinic acetylcholine (nACh)
receptors and has been shown to decrease new blood vessel growth as well as
vascular permeability, 2 well-known hallmarks of neovascular AMD. Athenagen's
study is a randomized, placebo-controlled, ascending dose clinical trial
designed to evaluate ocular tolerability and safety for up to 14 days
Diabetic Retinopathy in Developing Countries
Retina Clinic in Zimbabwe.
MAKI & KIMBALL WOODWARD, MD, PHD, FACS
is a country of amazing natural beauty, from the Masasa-covered mountains to the
red earth of the Zambezi valley. Unfortunately, an increasing number of its citizens
cannot see this beauty, nor in many cases can they work, care for themselves, or
lead productive lives due to visual complications from diabetes.
A general paucity of medical
care and the lack of trained specialists, especially in rural areas, contribute
to delays in diagnosing diabetes and poor blood glucose control once the disease
is diagnosed. In addition, a myriad of social issues that affect the delivery of
medical care, including the provision of proper ophthalmic care to individuals with
diabetes, have led to an increase in the prevalence of proliferative diabetic retinopathy
(PDR) in Zimbabwe. This article chronicles the difficulties in treating diabetic
retinopathy in developing countries, specifically in Harare, Zimbabwe, where Kimball
(Kim) Woodward, MD, has held an annual retina clinic for the past 9 years in association
with Surgical Eye Expeditions (SEE) International and Eyes for Africa.
DIABETES: A GLOBAL EPIDEMIC
The World Health Organization (WHO)
estimates that by 2030 the global burden of diabetes will double; one of the regions
with the greatest expected increase in prevalence is sub-Saharan Africa.1
A dramatic example of this is found in Zimbabwe, where diabetes has been on the
rise since the country declared its independence in 1980.
diabetes had been a disease more common in the wealthier Caucasian and South Asian
populations, but many successful young Africans now enjoy western diets. This change
in lifestyle has contributed to a predicted 160% increase in the prevalence of type
2 diabetes mellitus over the next 25 years.
A second factor in the spreading
diabetes epidemic within Zimbabwe are current drug shortages in the country, which
hinder appropriate care, thus increasing diabetic comorbidities. For example, a
lack of antihypertensives limit pharmacologic interventions to control blood pressure.
Studies have shown early treatment of hypertension to be as important as controlling
glycemic index in minimizing the progression of diabetes.2 In the 1980s,
improved accessibility to primary health care and adequate medications protected
many Zimbabweans from diabetic complications. However, due to deterioration in the
economic and social fabric of Zimbabwe, these same patients, as well as those newly
diagnosed with diabetes, no longer have access to resources necessary to control
their disease. Consequently, Zimbabwe has experienced drastic increases in diabetic
complications, such as cardiovascular disease, nephropathy, and retinopathy.
A CASE IN THE CLINIC
A worn, tired, brightly garbed
woman named Tsitsi approached the retina clinic at the Greenwood Park Eye Center
in Harare. Tsitsi had heard of the clinic that provided free care. She walked for
over half a day to have her 13-year-old son see the doctor. Mother and son waited
patiently until the doctor was able to see them. Tsitsi's son had been blind in
1 eye from birth, and it was quickly apparent that we could offer no help to her
son, who had permanent damage, likely from congenitally acquired toxoplasmosis.
It was also clear from Tsitsi's mannerisms and the way she squinted at the admission
forms, that her vision was not quite intact.
blood pressure was taken in the office and found to be 140/90. A finger-stick
glucose was 238. She told the doctors that she had pills for her "blood" but had
not taken them in years and had not seen a doctor in equally as long. She lived
hours outside of Harare, the closest city, and lacked money for medications. Indirect
examination of Tsitsi's eyes showed evidence of diffuse neovascularization and hemorrhaging
consistent with proliferative retinopathy. She was unaware of her medical condition,
nor did she know that it was contributing to her deteriorating vision.
That afternoon, Tsitsi underwent
vitrectomy and photocoagulation. At follow-up the next day, the patient thanked
the doctors profusely. While disappointed that the doctors could not save her son's
vision, she was grateful for the gift they had given her. Maintaining her vision
would allow her to continue working and support her family.
She told the team that paying for
her operation would have forced her to make significant sacrifices. She would not
be able to pay the school fees for her son and other children. She was worried that
tears would hurt her recently repaired eye, but those worries could not keep her
eyes from welling up as she communicated her heartfelt gratitude to the doctors
at the Greenwood Park Eye Center.
LITTLE ACCESS TO MEDICAL CARE
The obstacles Tsitsi faced to attain
care are not rare; rather they are the norm in Zimbabwe. The majority of patients
live in rural areas and survive through subsistence farming or hold poorly paying
jobs as laborers. They lack transport to urban-based medical facilities and pharmacies,
do not have the financial means to pay for care, and are often unaware of the complications
of their diagnosis. Access to affordable care and transport to medical facilities
are 2 of the most pressing and potentially remediable barriers to preventing diabetic
Of the 22 certified ophthalmologists
in Zimbabwe, 13 are in Harare, the capital city, and serve the 1.2 million residents
there. Zimbabwe has a total population of 12 million, 60% of whom are rural citizens.
There are 3 ophthalmologists in the country who perform vitrectomies and 5 laser
centers in the large cities of Harare and Bulawayo. The effects of concentrating
ophthalmologists and modern equipment in only a few urban areas are compounded by
a severe fuel shortage in Zimbabwe that has hindered transportation in all areas
of the country. It is common for people to wait in line for days to get fuel, often
leaving cars in line overnight.
These limitations challenge the
ability of patients with diabetes in Zimbabwe to follow recommendations for annual
dilated eye exams. Routine exams are critical for timely diagnosis and treatment
of proliferative diabetic retinopathy with panretinal laser treatments. There is
a limited window of opportunity to treat PDR. Panretinal photocoagulation (PRP)
must be offered to patients on a regular basis in order to slow continued retinal
damage from PDR and prevent more serious complications such as vitreous hemorrhage,
retinal detachment, and blindness.
Unfortunately, obtaining regular
retinal exams can prove highly difficult for patients in Zimbabwe, especially those
in rural areas. Financial difficulties, a poor patient-to-provider ratio, and the
scarcity of highly skilled specialists are barriers to medical care. Overall, these
hurdles have led to a marked decrease in non-emergency medical visits and have prevented
even those patients with the time and financial means from receiving adequate care.
Further complicating the delivery
of adequate care to diabetics are barriers that hamper clinic operations. To
perform PRP, for example, clinics must obtain an endolaser and train local ophthalmologists.
Unfortunately, the cost involved in the purchase and maintenance of an endolaser
is far from insignificant, especially for clinics already struggling to provide
care under the constraints of too few skilled physicians, drug shortages, and other
financial burdens. Patients with evolving PDR also need to be properly diagnosed
by regular fundoscopic exam. In developed nations, use of a flourescein angiogram
would be advised to measure the extent of neovascularization after retinopathy is
detected, but this test is rarely performed in Zimbabwe, even in the best clinics.
The Greenwood Park Eye Center, the leading eyecare center in Zimbabwe, performs
approximately 1 angiogram every 1 to 2 weeks.
Because changing the social structure
to improve medical care in Zimbabwe would require local political action, a more
practical method to improve care is to augment the training and skills of local
ophthalmologists. This process is enhanced through the donation of supplies and
equipment that improve the daily functionality of eye clinics. For the past 17 years,
Dr. Woodward has been doing this by teaming with SEE International, a Goleta, Calif-based
nonprofit organization dedicated to providing medical, surgical, and educational
services to the disadvantaged blind worldwide, and Eyes for Africa, a Zimbabwean
organization devoted to serving the vision needs of the rural poor. Dr. Woodward
visits Harare for 1 week each year to train local ophthalmologists in diagnosis,
treatment, and surgical skills. He operates side-by-side with local ophthalmologists
and brings vital donated supplies. The efforts of Dr. Woodward, SEE International,
and Eyes for Africa provide sustainable improvements to the care of patients who
Prior to treatment at a retina
clinic sponsored by SEE and Eyes for Africa, 2 local Zimbabwean ophthalmologists,
Drs. Guramuntunhu and Sibanda, assess patients with severe or complicated retinal
cases. Patients with treatable conditions are seen during the clinic week. A typical
day in the clinic consists of a morning educational lecture by Dr. Woodward for
local doctors, followed by patient consultations between the doctors. Those patients
who are referred for surgery undergo afternoon operations, often on the same or
the next day.
The lectures focus on the detection
and treatment of diabetic retinopathy and include slides and surgical videos. Age-related
macular degeneration, vitrioschisis, and anterior hyaloidal proliferation are among
other topics discussed. These topics are then applied in the consultations and the
surgeries. Dr. Woodward guides the local physicians through the cases so that they
are equipped with the skills necessary to handle similar cases in the future. Many
medical missions rely on the skills of foreign surgeons. These missions can often
address a large number of cases in a short period of time. However, with the departure
of these foreign doctors, so too goes the skill. Thus, education of local physicians
is important to improve overall quality of retinal care in Harare in a long-term,
A new addition to retinal surgery
in Harare this year is the use of triamcinolone acetonide during vitrectomy surgery.
Dr. Guramuntunhu has been pleased with the results and reported increased confidence
while extracting posterior membranes. The anti-inflammatory effects of triamcinolone
are expected to be as beneficial to surgeons in Zimbabwe as they have been in the
United States.3,4 Given the extent of the ophthalmic burden of diabetic
disease in Zimbabwe, improvements in treatment will no doubt have far reaching effects.
KEY TO SUCCESS: TRAINING LOCAL DOCTORS
The take-home message from the
clinic in Zimbabwe is clear: there is an urgent need to provide access to ophthalmic
care for patient with type 2 diabetes mellitus. PDR does not resolve without interventional
measures; however, with laser treatment the risk of vision loss decreases to less
than 5%. Thus, when patients are not seen regularly by a primary-care physician,
much less by an ophthalmologist, untreated ophthalmic complications secondary to
diabetes are common. By increasing the early detection of PDR, patients can be treated
aggressively to preserve their vision and quality of life. This is an effort that
cannot be accomplished 1 week each year by 1 doctor; it needs the dedication
and understanding of local ophthalmologists who treat the people of Zimbabwe year-round.
With this greater goal in mind, Dr. Woodward has been offering his skills
and services to the patients and doctors in Harare, Zimbabwe, for the last decade
and can be undoubtedly credited with improving the quality of care for retinal patients
Maki is a third-year student at Harvard Medical School in Boston and can be reached
at firstname.lastname@example.org. Kimball Woodward, MD, PhD, FACS, is owner of Orangetown
Ophthalmology, LLC in West Nyack, NY. Neither author has any financial interest
in the information contained within the article.
1. The World Health Organization.
Diabetic Care page. Available at http://www.who.int/diabetes/facts/en/diabcare0504.pdf.
Accessed October 12, 2006.
2. Scheen AJ. Prevention of
type 2 diabetes mellitus through inhibition of the Renin-Angiotensin system. Drugs.
3. Jonas JB. Intravitreal
triamcinolone acetonide: a change in paradigm. Ophthalmic Res. 2006; 38:218-245.
4. Bandello F, Polito A, Pognuz
DR, Monaco P, Dimastrogiovanni A, Paissios J. Triamcinolone as adjunctive treatment
to laser panretinal photocoagulation for proliferative diabetic retinopathy. Arch
Retinal Physician, Issue: January 2007