UPFRONT: The Challenge of Undertreatment in Retina


There is no question the field of retina shifted with the advent of anti-VEGF injections. Instead of hot or cold laser, injections became the new norm. Practices evolved to keep up with the massive change in volume as every new patient placed on an anti-VEGF regimen created an exponential increase in visits and injections. Suddenly, the right number of retina specialists to treat our patients … was not enough. So, we adapted: adding providers, using ancillary injection nurses, creating injection clinics, and expanding offices.

Unfortunately, not all of our changes produced the same results as those in the clinical trials. In this issue, we look at why patients lose vision despite therapy and at the numerous real-world studies of anti-VEGF agents in AMD. The stark reality is that unless injections are given as frequently as they were in the clinical trials, our outcomes are nowhere near as good. Undertreatment is a real issue and not one that just “big pharma” would have us believe.

This does not come as a surprise, because we all know the gold standard is fixed dosing, not as-needed dosing. CATT conclusively proved this fact. Yet, as humans, we need to see things more than once to believe. Repetition is required for comprehension. Despite the ever-mounting evidence that our results are not as good, we continue to believe that our way is better. There are still those who firmly believe that PRN treatment is the best. I admit that there are a handful of patients who need only a few injections and then none, and finding those patients is impossible without a PRN regimen. But the vast majority of patients would get undertreated to find the 1 or 2 patients who don’t need many injections. What are we to do?

In this issue we also explore 2 new anti-VEGF agents that hope to reduce this problem — abicipar pegol and conbercept. Both hold the promise of every-3-month dosing. They achieve this goal using several approaches, including better VEGF binding characteristics and larger size (and thus longer half-life). How they will fit into are armamentarium remains to be seen, but dosing 4 times a year is something our practices can handle. Future therapies will hopefully move beyond quarterly dosing with similar results.

With the approval of anti-VEGF agents for the treatment of diabetic retinopathy, the injection conundrum may become even more complex. Notwithstanding the DRCR Protocol S results favoring anti-VEGF over laser, if we can’t get patients with wet AMD to receive the appropriate number of injections, we have almost no chance in the diabetic population. This raises the question: what about laser photocoagulation? In this issue, we look at the role of laser in our ever-changing retinal vascular world.

It is a very exciting time to be a retina specialist. Studies have shown we have dramatically reduced the risk of legal blindness with our therapies. New pathways, new polymers, new devices, and even “permanent” solutions with gene therapy are all on the horizon. RP

Listen to episodes of Straight From the Cutter’s Mouth with discussion of Retinal Physician articles.