Article Date: 5/1/2010

Fellows: Why They Chose Retina

SUBSPECIALTY NEWS

Fellows: Why They Chose Retina

Their Plans, Priorities, and Practice Selections

■ Retinal Physician recently surveyed a number of second-year fellows to see why they chose retina as their specialty, what they were looking for in a practice, and why they feel this is a good time to be entering the retina field.

Michael J. Davis, MD, chose the subspecialty for two reasons. On a personal level, his grandmother has macular degeneration and has lost much of her vision. She was diagnosed before the anti-VEGF era.

“I have seen her struggle with vision loss, and this prompted my interest in helping patients like her,” says Dr. Davis, a vitreoretinal surgery fellow at Illinois Retina Associates/Rush University Medical Center. On a professional level, he sees vitreoretinal surgery as one of the most challenging subspecialties in the field of ophthalmology.

Growing up, Arghavan Almony, MD, was told she would lose her vision.

Dr. Davis sought a challenging specialty.

“My mother — an incredible and very accomplished woman — has counting-fingers vision and significantly reduced visual fields. She was incorrectly diagnosed with Best's disease, and my younger brother and I thought we would suffer the same fate,” explains Dr. Almony, a fellow at the Barnes Retina Institute.

Each year, she and her brother would breathe a sigh of relief as their eye doctor told them that their dilated fundus examination was normal. They never had ERGs or EOGs and didn't realize these should be part of the evaluation. Once in college, with proper evaluation, she realized she had nothing to worry about in terms of inheriting her mother's poor vision.

“I chose retina because I know how precious sight is and I want to have the skills to save vision in my patients. For patients that we can't help yet, I want to be the person that supports them, gives them hope, and provides resources for them,” says Dr. Almony.

Kyle Alliman, MD, says that “the breadth and nature of the pathology seen on a routine basis” is what drew him to retina. “Both medical and surgical retinal diseases often require innovative problem-solving skills that greatly appealed to me,” says Dr. Alliman, who will soon return to his home state of Iowa, joining the Wolfe Eye Clinic in West Des Moines.

Dr. Davis says that the main reason he chose the practice he's joining is that it is a relatively young practice with a great deal of opportunity for growth. He did not interview for academic positions, but rather focused on private practice groups that had a strong interest in research and other academic endeavors.

Dr. Almony's mother has severe vision loss.

Tushar Ranchod, MD, a fellow at Associated Retinal Consultants in Royal Oak, Mich., says that now is a good time to get into retina because of the growing elderly and diabetic populations.

“In addition, there is a policy shift towards supporting high-value therapies and reducing incentives to provide expensive low-impact treatments,” says Dr. Ranchod. “In quality-of-life terms, the therapies provided in our field — preventing blindness or improving visual acuity — are highly beneficial to both patients and society, and there is a growing literature supporting this concept.”

“I would expect that in the span of my generation's career, we will experience unrivaled growth and development in our subspecialty. I think one would be hard-pressed to find a more progressive discipline in all of medicine,” concludes Dr. Alliman.

Medical Offices: Rent Space or Buy?

This May Be a Good Time to Purchase a Property.

BY JERRY HELZNER, SENIOR EDITOR

The market for medical buildings has been a stable niche in a badly slumping commercial real estate market. The building pictured is used only as an example and is not for sale. PHOTO COURTESY OF NOVAMED

■ With interest rates about as low as they are likely to go and prices for commercial real estate scraping bottom, retina practices that have been leasing space may be thinking about buying their own building. In addition, practices that are ready to expand may be contemplating adding a satellite office. With the exception of newly formed practices, this may be the perfect time to purchase a medical building.

“In a difficult commercial real estate market, medical buildings are a safe, recession-proof niche,” says Jessica Ruderman, director of research services for Real Capital Analytics, which monitors all aspects of the commercial real estate market worldwide. “Given the positive demographics for ophthalmology, the long-term nature of relationships with patients and the potential of millions more people to be covered by health insurance, medical buildings represent the safest type of asset and should be attractive to mortgage lenders.”

Ms. Ruderman says that nationally the prices of medical buildings have fallen somewhat over the past two years but at nowhere near the rate of other types of commercial real estate. Also the pace of medical building transactions has held up much better than the rest of the office-building marketplace and now makes up about 11% of all office building sales.

“This should be a good time for ophthalmology practices to buy a building because who knows when you will get these prices again ” says Ms. Ruderman.

The one exception: business consultants say that newly formed practices are better off renting. Physicians' energies should be focused on staffing, purchasing state-of-the-art equipment and adding to their patient base.

By leasing space at the outset, a newly formed practice can determine if the location is one that will be suitable over the longer term. In addition, given current market conditions, a landlord may be willing to offer several months of free rent or interior improvements in order to land a good tenant.

Leasing has several other advantages, such as being able to deduct rent as a business expense. However, all leases are different and a practice should be aware of any responsibility to pay for utilities, property taxes, insurance and/or minor repairs.

Once a practice has decided to purchase a building, a few other factors come into play. The following should be considered:

■ Location. In the past, a location near a hospital was considered prime. Now, with many more procedures being performed on an outpatient basis, a location near an ophthalmic surgery center may be preferable.

■ Size of the property. Do you want a building for your sole use or do you want to lease some of your space to other medical providers? Being a landlord can be a headache but close proximity to other providers such as primary care can help in obtaining referrals.

■ Type of property. Condo properties offer ownership but with many restrictions such as limited possibilities for future expansion. Condo deals should be thoroughly scrutinized as they have not always worked out well for medical practices.

IN BRIEF

■ Othera drug: dry AMD data. Othera Pharmaceuticals had positive visual-function results from a phase 1/2 trial of OT-551 conducted at the National Eye Institute in patients with bilateral geographic atrophy. OT-551 is a topically dosed, small molecule that acts on oxidative stress and disease-induced inflammation. In the NEI trial, 10 subjects with advanced dry AMD in both eyes were enrolled.

All subjects received 0.45% OT-551 daily for 24 months in one eye, which was randomly chosen. The untreated fellow eye served as a control in the study. A statistically significant difference in favor of OT-551 was observed in the primary endpoint, mean change in BCVA, at the end of 24 months (mean change in BCVA for dosed eye of 13.3 letters gained vs. 7.6 letters lost for fellow eye control). No other meaningful differences between study eyes and fellow eyes were observed in other endpoints. In the NEI trial and in all studies of OT-551 to date, there have been no drug-related serious adverse events.

The absence of significant effect on the rate of GA lesion enlargement indicates the need for further study concerning the efficacy of OT-551 as a treatment for GA, said Wai T. Wong, MD, PhD, clinician-scientist, Retinal Diseases, at the NEI and principal investigator for the study.

■ B+L launches AR EDS 2 vitamins. B+L is introducing PreserVision Eye Vitamin and Mineral Supplement AREDS 2 formula. This builds on the original AREDS formula, replacing beta-carotene with lutein (10 mg) and zeaxanthin (2 mg) and adding omega-3 fatty acids (l000 mg) per daily dosage. Scientific studies show that the inclusion of high levels of omega-3 fatty acids, lutein, and zeaxanthin in the diet of at-risk individuals supports eye health and reduces the risk of being afflicted with AMD.

■ Oral drug in LCA trial. QLT Inc. has announced encouraging interim results from the first three subjects enrolled in a phase lb clinical proof-of-concept study of its orally administered drug for the treatment of Leber's congenital amaurosis (LCA). The drug, known as QLT091001 is a synthetic retinoid replacement for 11-cis-retinal, a key biochemical component of visual function.

The trial will evaluate the safety profile and effects on retinal function in eight pediatric subjects (age 5 to 14 years) diagnosed with LCA due to inherited deficiency of retinal pigment epithelium protein 65 (RPE65) or lecithin:retinol acyltransferase (LRAT). Based on positive results from the first two pediatric patients, an adult patient was added to the study. Subjects receive daily oral doses of QLT091001 for seven days at the Montreal Children's Hospital at the McGill University Health Centre.

After seven days of treatment, all of the subjects experienced clinically relevant improvements in one or more visual function parameters, including BCVA, Goldmann visual field, and/or retinal sensitivity as measured by full-field sensitivity threshold testing, reports QLT. Subjects have also reported improvement in visual performance related to daily living. The onset of visual changes was rapid and there was progressive improvement beyond the seven days of treatment, with some effects persisting for up to four months after treatment.

■ Alimera Sciences goes public. Alimera Sciences, which specializes in the development and commercialization of prescription ophthalmic pharmaceuticals, issued publicly traded stock in April. The offering was priced at $11 a share and trades under the NASDAQ symbol ALIM.

Alimera is currently focused on retinal diseases, with its sustained-release implant lluvien for DME in late-stage clinical trials.

■ Iridex buys RetinaLabs product lines. Iridex said it has acquired certain assets from RetinaLabs, Inc., a privately held company based in Atlanta. RetinaLabs develops and markets retinal instrumentation and consumables used to perform vitreo-retinal procedures in the operating room and in surgery centers.

■ Topcon in new headquarters. Topcon Medical Systems, which makes retinal cameras, OCT instrumentation, and other devices used by retinal specialists, has relocated its US corporate headquarters from Paramus, NJ, to 111 Bauer Drive, Oakland, NJ 07436.

The company said the relocation, in line with strong business growth and development, necessitated the shift to a more spacious building. The company says the new, modern facility will enable Topcon to further broaden its infrastructure, streamline business operations and consistently deliver innovative solutions within the ophthalmic industry.

A green-sensitive office building, Topcon's new corporate head office is equipped with eco-friendly and energy-efficient features, including recycled materials, low voltage lighting, and sensors. The company's phone and fax numbers, and Web address will remain the same: Phone:_20l-599-5l00, Fax: 201-599-5248, Web: www.topconmedical.com.

■ Luveniq granted priority review. Lux Biosciences, Inc. says it has been given priority review status by the FDA for its investigational drug Luveniq (LX211) oral voclosporin for the treatment of noninfectious uveitis involving the intermediate or posterior segment of the eye. The FDA had previously fast-tracked the drug.

■ Anti-VEGF for DME. The much-awaited results of a major government-sponsored study show that treating DME with ranibizumab, plus laser treatment if needed, appears to result in better vision than laser treatment alone. The data, released by the Diabetic Retinopathy Clinical Research (DRCR) Network, was published in Ophthalmology online, the journal of the American Academy of Ophthalmology.

DRCR Network investigators studied 854 eyes (691 participants) at 52 clinical centers across the US, and compared four treatment modalities: ranibizumab plus prompt laser treatment, ranibizumab plus deferred laser treatment (provided at 24 weeks or later, if indicated), a corticosteroid (triamcinolone) eye injection plus prompt laser treatment, or prompt laser treatment alone.

At the one year follow-up, patients who had received ranibizumab with prompt or deferred laser treatment had, on average, significantly better visual acuity than the group treated with laser alone. Also, significantly more patients in the ranibizumab-treated groups gained vision and fewer suffered vision loss.

At the one year follow-up, nearly 50% of study patients who received the new combined treatment had substantial improvement in vision, compared with 28% who received laser treatment alone.

“The results appear to be applicable to most people who have DME in the center of the macula with some vision loss, whether the person has Type 1 or Type 2 diabetes, is old or young, or is a woman or a man,” said Neil M. Bressler, MD, of Wilmer Eye Institute, the chair of the nationwide DRCR Network.

■ Alcon to sell Synergetics products. Alcon will pay Synergetics $32 million for the right to market a range of Synergetics' ophthalmic products and to settle all litigation between the two companies.

Synergetics products used in vitreoretinal surgery include light sources, surgical instruments, lasers and laser probes. The company manufactures both disposable and reusable instruments for vitreoretinal surgery.

■ Iridex introduces new laser. Iridex Corporation has begun shipping its new IQ 532 laser systems. The IQ 532 is a high-power, 532 nm, dual port multipurpose laser system for use in treating such sight-threatening eye diseases as diabetic retinopathy, AMD, and glaucoma.

“The time and effort we invested to perfect our core system platform and obtain regulatory approval for a family of laser products has made it possible to introduce the IQ 532 green laser within one year of shipping the IQ 577 yellow laser,” commented Theodore A. Boutacoff, president and CEO of Iridex. “Continuing with this platform approach, we look forward to the timely introduction of additional systems currently under development.”

As with the IQ 577, the IQ 532 features dual-port laser output as well as a graphic, touchscreen interface. Dual-port connectivity provides the physician with added convenience and efficiency by permitting the exchange of multiple delivery devices with one-touch speed and simplicity. Iridex says setup and use of the IQ 532 system for surgery is easy and intuitive, thanks to its ergonomic design and user interface.

■ Eye radiotherapy granted CE mark. Oraya Therapeutics, Inc. said it has been awarded the CE mark for its stereotactic radiotherapy system that delivers low-energy X-rays for the treatment of wet AMD.

The one-time radiation treatment is given in conjunction with an anti-VEGF drug regimen, and with the expectation that visual acuity outcomes for the treated patients will be maintained with significantly less frequent drug injections as compared to the sham control group. About 150 patients from up to 10 sites will participate in a second European trial with approximately one-third of those subjects receiving a sham exposure and the remainder receiving a radiation dose of either 16 or 24 Gy.

In an earlier study of the device, more than 60 patients were treated and subsequently monitored, with the earliest patients now approaching 18 months since treatment. Oraya says results from that study have shown the potential for meaningful visual outcome improvements as well as a substantive reduction in the required drug regimen.

■ Stem cells to treat Stargardt's. Advanced Cell Technology has been granted orphan drug status by the FDA for its human trial employing embryonic stem cells to treat Stargardt's Disease.

The 12-patient phase 1/2 study uses stem cells to recreate RPE that support the photoreceptors needed for vision. These cells are often the first to die off in Stargardt's Disease and AMD, which in turn leads to loss of vision. RP

Errata
In the article “Surgery for Primary Rhegmatogenous Retinal Detachment” in the March 2010 issue, the first author was misidentified. The author who should have been credited is Steven D. Schwartz, MD, of the Jules Stein Eye Institute at UCLA.
In the April 2010 Coding Q&A column, the coding for the vitreoretinal surgeon should be reversed. The pars plana vitrectomy (67036) should be coded first to maximize reimbursement. The removal of lens material (66850) procedure should be coded second.

Retinal Physician, Issue: May 2010