We are happy to announce that a new age-related macular degeneration (AMD) risk calculator is now available at MyVisonTest.com. This is our second risk calculator, and is based upon research published in the February 2010 edition of the Canadian Journal of Ophthalmology.

The new risk calculator is able to compute the probability that a person will develop geographic atrophy or neovascular AMD, given their smoking history and genotype information. The algorithm used by the calculator is based on research published over the past several years that closely ties certain genes with the risk of developing AMD.

Unfortunately, there is currently no easy was for people to obtain all the genotype information necessary to accurately calculate their risk of advanced AMD. It is disappointing that although there are numerous retail DNA testing services available, no single commercially available testing service is able to provide all the genotype information required by these risk calculators.

For the time being, the science has gotten ahead of what the market has to offer. But I am confident that the market will eventually catch up. This is a consequence of the extremely rapid progress being made in understanding the genetic basis of AMD. That is something that we can all be thankful for.

To access the calculator, visit myvisiontest.com and select AMD Risk Calculators in the left-hand column.

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A new study finds no significant difference in the short-term efficacy and safety of intravitreal Lucentis versus Avastin in treating wet myopic macular degeneration.

Choroidal neovacularization (CNV) secondary to pathologic myopia causes severe visual loss in young and middle-aged patients. Nearly 10% of patients with pathologic myopia develop CNV. Photodynamic therapy with verteporfin is currently the only approved and most widely used treatment for subfoveal CNV in pathologic myopia.

In this prospective, randomized study 32 eyes from 32 patients with myopic CNV were consecutively enrolled and randomly treated, in a 1:1 ratio, with intravitreal Lucentis (0.5 mg) or Avastin (1.25 mg) as needed, after the first injection. Patients were followed up for 6 months.

No statistically significant difference in the BCVA improvement, as well as in the foveal center thickness reduction, was found between groups during follow-up. Complete resolution of fluorescein leakage was observed in all 16 Avastin-treated eyes and in 15 out of 16 (93.7%) Lucentis-treated eyes. No ocular or systemic adverse effects from treatment were encountered.

The current study showed no difference in the efficacy of Lucentis versus Avastin in myopic CNV. Both drugs were similarly effective in improving visual acuity and reducing retinal thickness in the short term. No statistically significant difference in the mean number of injections required was found between groups.

The researchers did not observe any patient who developed retinal breaks or retinal detachment after injections. However, because patients with high myopia have an increased risk of developing retinal complications, detailed retinal examinations and prophylactic laser treatment would be advisable in high-risk eyes before intravitreal injections.

The investigators conclude that this study cannot determine a statistically significant difference in anti-VEGF treatment effect between Lucentis and Avastin for the treatment of CNV secondary to pathologic myopia

WHAT IT MEANS TO YOU: Safety is a greater concern in myopic CNV patients than AMD patients because of the possibility of pregnancy in women, and the higher risk of retinal detachment in highly myopic eyes. Intravitreal injection carries a number of inherent risks, including endophthalmitis and retinal detachment. Special care is required when injecting into highly myopic eyes because they are prone to developing retinal detachment. Drug exposure is always a concern when dealing with women of childbearing age. Although systemic exposure is minimal following intravitreal injection, the prolonged course of therapy that is often required warrants women be informed of the potential risks if they are attempting to conceive.

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Photodynamic therapy (PDT) is not effective in eyes with chronic central serous chorioretinopathy (CSC) without intense hyperfluorescence on indocyanine green angiography (ICGA).

CSC is commonly seen in young or middle-aged adults as localized detachment of the neurosensory retina. CSC is thought to be caused by abnormal choroidal circulation. ICGA reveals congested and dilated choroidal vein and capillaries, choroidal staining, and leakage. PDT for CSC has been reported to be efficacious in reducing subretinal fluid and increasing VA in most patients.

In this case series 32 eyes of 27 patients with chronic CSC and symptoms for at least 6 months were recruited. The minimum follow-up was 1 year. The total PDT energy was 36 to 42 mJ/cm(2). The baseline middle-phase ICGA findings were classified as intense, intermediate, or no hyperfluorescence depending on the degree of hyperfluorescence. The resolution of the subretinal fluid and recurrence rates were assessed in relation to each ICGA finding at baseline.

ICGA before PDT showed intense hyperfluorescence in 23 eyes (72%), intermediate hyperfluorescence in 6 eyes (19%), and no hyperfluorescence in 3 eyes (9%). The subretinal fluid resolved completely 3 months after 1 application of PDT in 23 eyes (100%) with intense hyperfluorescence, 6 eyes (100%) with intermediate hyperfluorescence, and no eyes (0%) with no hyperfluorescence. In the last group, the subretinal fluid did not resolve throughout the follow-up period despite additional applications of PDT

In the current study, the effectiveness of PDT differed depending on the variations in the hyperpermeability on ICGA at baseline. At 3 months, there was no subretinal fluid in any eyes with intense and intermediate hyperfluorescence; however, persistent subretinal fluid was seen in all 3 eyes (100%) with no hyperfluorescence. Subretinal fluid did not resolve despite additional application of PDT in eyes with no hyperfluorescence through the follow-up period. Thus, PDT seems to be less effective in eyes without hyperpermeability.

The investigators conclude that the success rate of PDT for CSC depends on the degree of hyperfluorescence seen on ICGA.

WHAT IT MEANS TO YOU: PDT appears to be effective in patients with chronic CSC. However, concerns remain that PDT might cause further RPE damage. This study utilized a reduced fluence protocol that has been reported to improve long-term outcomes of PDT. Half dose of verteporfin and a shorter irradiation time than the standard protocol may improve the safety of PDT for eyes with CSC.

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Compared with combination therapy of intravitreal triamcinolone (IVTA) plus photodynamic therapy (PDT), intravitreal Avastin (IVB) plus PDT was significantly more effective in maintaining and improving visual acuity and in reducing the number of treatment for patients with retinal angiomatous proliferation (RAP).

Retinal angiomatous proliferation has been described as a variant of exudative AMD, and represents 15% of all neovascular AMD in white patients. The natural course of RAP differs from typical exudative AMD and has poor visual outcomes. Recent studies have reported that combined therapy of IVTA plus PDT for RAP effectively resolves angiographic leakage and maintains or improves visual acuity (VA). Combined therapy of Avastin plus PDT is also reported to be effective for treating RAP.

This retrospective case series reviewed 25 treatment-naive eyes of 22 Japanese patients (11 men, 11 women) with RAP. Twelve eyes of 11 patients were treated with combined therapy of IVTA plus PDT. Thirteen eyes of 11 patients were treated with combined therapy of IVB plus PDT.

In 12 eyes treated with IVTA plus PDT, the mean best-corrected visual acuity (BCVA) levels at baseline and 12 months were 0.29 and 0.13, respectively. A significant decline in the mean BCVA from baseline was observed at 12 months. In 13 eyes treated with Avastin plus PDT, the mean BCVA levels at baseline and 12 months were 0.25 and 0.37. A significant improvement in the mean BCVA from baseline was observed. At 12 months, the difference in BCVA between the 2 groups was significant. The mean numbers of treatments at 12 months in the IVTA plus PDT group and the Avastin plus PDT group were 2.7 and 1.6, respectively. The difference between the 2 treatments reached significance. No complications developed.

The current study showed that combined treatment of Avastin plus PDT significantly improved the VA and reduced the number of treatments in patients with RAP compared with combined treatment of IVTA plus PDT during a 12-month follow-up. The mean BCVA improved significantly in eyes treated with Avastin plus PDT. Conversely, a significant decline in the mean BCVA from baseline was observed at 12 months in patients treated with IVTA plus PDT.

In conclusion, the results of the current study indicate that combined therapy of Avastin plus PDT was significantly more effective for maintaining or improving VA and reducing the number of treatments in patients with RAP compared with combined therapy of IVTA and PDT.

WHAT IT MEANS TO YOU: Avastin plus PDT is more effective than steroid plus PDT for RAP. While RAP is one of the more aggressive and more difficult to treat variants of wet AMD, progress is being made in the treatment of this condition. Combination therapy appears to be the key to managing this condition. We look forward to further progress in understanding and treating RAP.

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Photodynamic therapy (PDT) decreased the short term risk for vision loss in patients with polypoidal choroidal vasculopathy (PCV) with or without concomitant use of an intravitreal steroid (triamcinolone acetonide, IVTA).

PCV is a condition characterized by multiple, recurrent epithelial detachments (PED) due to leakage from abnormal choroidal lesions. ICGA is the diagnostic tool of choice for PCV and it has demonstrated that PCV affects the choroidal vasculature, causing formation of aneurysmal polypoidal lesions. PDT is the most commonly used treatment for perifoveal PCV, and studies have shown that PDT is generally effective in treating PCV.

The researchers performed a retrospective analysis of PCV patients who underwent PDT with or without IVTA with follow-up of 2 or more years.

Twenty-seven eyes of 27 patients were analyzed, with 12 eyes treated by PDT monotherapy and 15 eyes treated by combined PDT with IVTA. The baseline characteristics of both groups were similar. At 1 year, the mean logMAR BCVA for the PDT monotherapy group improved from 0.74 logMAR to 0.58 logMAR, whereas the combined PDT and IVTA group improved from 0.84 logMAR to 0.74 logMAR. At 2 years, the mean logMAR BCVA for the monotherapy and combined treatment groups were 0.62 logMAR and 0.84 logMAR, respectively, and the changes compared with baseline were not statistically significant. Patients who had combined PDT with IVTA were more likely to develop cataract requiring surgery and ocular hypertension.

The investigators conclude that PDT reduced the risks of visual loss in patients with symptomatic PCV in the short term but the effect might not be sustained after 1 year. The adjunctive use of steroids during PDT did not appear to result in additional benefit for treating PCV.

WHAT IT MEANS TO YOU: It has been reported that steroids are beneficial in patients undergoing PDT for AMD, but recent studies have called this into question. While it is possible that combination steroid/PDT therapy for AMD may have some benefits, such as decreasing the need for retreatment, the visual outcomes are now believed to be the same as PDT monotherapy. Now, the current study finds the same is true for PCV. It seems that the risk/benefit calculus is tipping away from use of steroids for patients undergoing PDT for either of these conditions.

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There is no difference in the VA outcomes after Avastin (bevacizumab) or Lucentis (ranibizumab) treatment for AMD.

Avastin is a drug very similar to Lucentis. Avastin is approved for the systemic treatment of certain cancers, but is not approved for injection into the eye. This "off-label" use of the drug has been reported to be effective at treating exudative AMD.

This retrospective study followed 452 patients with exudative AMD; 324 patients were treated with Avastin and 128 patients with Lucentis. All patients were followed for 1 year.

At 12 months, the distribution of VA improved in both groups with 22.9% of Avastin and 25.0% of Lucentis attaining >20/40. Improvement in vision was observed in 27.3% of the Avastin group and 20.2% of the Lucentis group. The mean number of injections at 12 months was 4.4 for Avastin and 6.2 for Lucentis. There were 8 (2%) deaths in the Avastin group and 4 (3%) in the Lucentis group. Two patients developed endophthalmitis in the Avastin group and the Lucentis group.

Comparing the mean VA, changes in VA, and VA loss and gain, there did not seem to be any great differences between the Avastin and Lucentis. Some investigators have suggested that Lucentis might act faster, but this study did not find any difference. The sample size of the current study does not have sufficient power to determine whether there are any differences in safety.

At 1 year, the number of injections varied between the 2 groups (4.4 vs 6.2 for Avastin vs Lucentis). This difference may be due in part to the belief that Avastin has a longer intraocular half-life. Interestingly, the number of injections is also greater during the first 6 months compared with the last 6 months. This may represent both physician's and patient's desires to stop treatment. This reduction of injections also seems to have reduced the VA.

WHAT IT MEANS TO YOU: This is yet another in a series of recent papers reporting on Avastin vs Lucentis comparisons. To date, no study has found any significant difference in clinical efficacy. However, like the current study, no study has been large enough, nor sufficiently long in duration to find small but potentially important differences in safety. While these smaller studies are helpful in reinforcing our clinical impression of equivalence of the two drugs, we will have to await CATT results to know if any important differences exist.

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Intravitreal Avastin is a promising new treatment for persistent central serous chorioretinopathy (CSC), according to a new study.

CSC is a disease of young and middle-aged adults. Research indicates that the disease process in CSC is diffuse and shows bilateral retinochoroidal dysfunction, even when the disease is manifesting clinically only in one eye. Though the cause of CSC remains unknown, it is believed that abnormalities in choroidal circulation make overlying retinal pigment epithelium dysfunctional, resulting in the development of a serous retinal detachment. Photodynamic therapy, laser photocoagulation and pharmacological agents have been used to treat CSC. However, these treatment options serve only to shorten the duration of symptoms and have no effect on the recurrence rate or the final visual acuity.

This prospective clinical study included 30 eyes of 30 patients with persistent, symptomatic CSC of at least 3 months duration. Fifteen eyes of 15 patients were treated with intravitreal injections of 2.5 mg Avastin (treatment group). Fifteen eyes of 15 patients with the same characteristics who declined treatment formed the control group.

Twelve (80%) eyes in the treatment group compared with 8 (53.3%) eyes in the control group showed morphologic restitution at 6 months. All 15 (100%) treated eyes had stable or improved vision, compared with 10 (66.6%) eyes in the control group. At 6 months, the mean central foveal thickness for the treatment group remained significantly lower compared to the control group, with 174 um and 297 um, respectively. Injection-related complications were not encountered.

The researchers conclude that intravitreal Avastin injection may be a new, promising treatment option for select patients with idiopathic persistent CSC. This is consistent with previously published research.

WHAT IT MEANS TO YOU: CSC is normally a self-limiting disease, resolving without treatment within a period of months. However, for those cases that are chronic, a safe and effective treatment is welcome. PDT has been the standard treatment for chronic CSC, but there are concerns regarding potential adverse effects, including chorioretinal atrophy. Anti-VEGF drugs may be a viable alternative, yet some patients may not welcome the idea of getting a needle in the eye. The ability to offer patients a choice, however, is progress.

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A self-management program directed at persons with age-related vision loss (ARVL) can improve overall health and low vision rehabilitation outcomes, according to a new study.

Chronic Disease Self-Management Programs (CDSMP) assist people in managing their disease/symptoms, as well as the emotional and daily consequences of living with a chronic condition, such as AMD. The overall aim of CDSMP programs is mastery of fundamental self-management tasks. Specific topics typically include exercising safely, coping with difficult emotions, and symptom management techniques. Research supports the effectiveness of CDSMP regardless of specific diagnosis.

Use of self-management in low vision services is limited, but a recent systematic review of education programs for macular degeneration found three protocols reported in four studies (n = 532). Effect sizes for the outcomes ranged from small to very large. Reported benefits include decreasing depression and anxiety, improved use of low vision aides and improved everyday functioning.

The current study involved a two-armed randomized controlled trial of older adults (n = 77) with ARVL compared 'usual care' provided by a not-for-profit community agency with an extended model of care (CDSMP). The primary outcome variable (participation in life situations) was measured using the Activity Card Sort. Secondary outcome measures examined general health and vision-specific domains.

This study demonstrated that CDSMP produced significantly better participation in life situations when compared with usual care. CDSMP was also successful in significantly reducing depression, increasing physical and mental health, generalized and domain-specific self-efficacy, and adjustment to ARVL. The improvements were still apparent at 12 weeks follow-up. The observed decline experienced by participants who received usual care over the short period of the study (20-24 weeks) is alarming. The addition of self-management appears to not only arrest decline but also increase participation in life situations.

The investigators conclude that addition of self-management significantly improved rehabilitation outcomes for older adults with ARVL.

WHAT IT MEANS TO YOU: Self-management techniques represent an important step forward in care of persons with chronic disease. While many multi-disciplinary low vision programs have long incorporated some features of self-management, broader recognition of effective self-management techniques will hopefully increase and expand their use by the low vision care community.

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Avastin was not detectable in untreated fellow eyes after contralateral intravitreal injection, according to a study published in Acta Ophthalmologica. A total of 18 eyes received intravitreal injections of 1.5 mg Avastin. Aqueous humour samples were obtained during uneventful cataract surgery at 1 to 28 days after injection. In untreated fellow eyes, the concentration of unbound Avastin was below the detectable limit of the ELISA (5 ng/ml) in all samples. The investigators conclude that there are no pharmacological indications of a significant amount of unbound Avastin in the anterior chamber of contralateral eyes in humans. Fellow untreated eyes can be used to gauge the amount of Avastin that is reaching the systemic circulation, and hence could cause adverse effects, such as changes in blood pressure or stroke. The present study provides empiric evidence that the amount of Avastin reaching the fellow eye after a single injection is undetectable.

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A single steroid injection was as effective as 3 monthly injections of Avastin for the treatment of diabetic macular edema, according to a study published in Ophthalmologica. Diabetic macular edema is usually treated with laser photocoagulation. Both steroids and Avastin have been reported to have beneficial effects in patients with diabetic macular edema. In a head-to-head comparison, the Diabetic Retinopathy Clinical Research Network did not find a benefit of intravitreal steroid relative to laser photocoagulation. A collective of 32 patients, who had been treated by a single 4.0-mg intravitreal triamcinolone injection (group 1), was matched to 32 patients who had received 3 injections of 1.25 mg of Avastin in 4-week intervals (group 2). There was no statistically significant difference between the two groups in visual acuity or central retinal thickness outcomes after 3 months of follow-up. The investigators conclude that a single triamcinolone injection may be as effective as 3 Avastin injections for the treatment of diabetic macular edema.

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Researchers demonstrate the feasibility of Macroesis, a proprietary alternating electrical current drug delivery system, for the transcleral delivery of Lucentis and triamcinolone acetonide in rabbit eyes in an article published in the British Journal of Ophthalmology. Researchers are adapting a proprietary technology known as Macroesis from Buckeye Pharmaceuticals. This non-invasive delivery technology uses alternating electrical current (AC) that enhances mobility of drugs through the tissue. The technology is akin to iontophoresis, a delivery platform that uses direct current (DC). The device is similar to a contact lens preloaded with an approved AMD drug that is inserted on the patient's eye and runs off of four AA batteries. Such a treatment could be performed in as little as five to 10 minutes in an outpatient setting, or perhaps even at home.

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Avastin was found to impair phagocytic activity of retinal pigment epithelial (RPE) cells cultured in a laboratory. The RPE is a layer of "nurse cells" located immediately adjacent to the photoreceptors. It provides the photoreceptors with nourishment and removes their waste products. The waste products are phagocytized, or consumed, by the RPE which then digests and excretes the waste. A porcine (pig) RPE cell cultures were prepared from fresh eyes, and treated with clinically relevant concentrations of Avastin or Lucentis. Proliferation was investigated in a proliferation assay, wound healing in a wound scratch assay and phagocytosis was investigated by feeding RPE cells latex beads. Avastin, and to a lesser extend Lucentis, impaired the proliferation of RPE cells, but neither affected wound healing. Avastin, but not Lucentis, reduced the phagocytotic function of RPE cells. The investigators conclude that Avastin reduces phagocytosis of RPE cells, which indicates possible long-term effects of repeated Avastin treatment. The study was published in Graefes Archive of Clinical and Experimental Ophthalmology.

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Older adults experience some benefit, but less than young adults, from training to use their peripheral vision to read text, according to a study published in Vision Research. Enhancing reading ability in peripheral vision is important for the rehabilitation of people with central visual field loss. Eighteen normally-sighted subjects, aged 55 to 76 years, were randomly assigned to training or control groups. Reading speeds were measured at 10 degrees above and below fixation. Training consisted of repeated measurements of visual-span profiles at 10 degrees below fixation. The control subjects did not receive any training. Perceptual learning enlarged the visual spans in both trained (lower) and untrained (upper) visual fields. Reading speed improved in the trained field by 60% when the trained print size was used. The training benefits for these older subjects were less than the benefits previously found for young adults. Despite the weaker training benefits, perceptual learning remains a potential option for low-vision reading rehabilitation among older adults.

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A clinical trial has found that saffron, the famous Indian spice, can improve vision in patients with AMD, according to new reports. The trials were conducted by Silvia Bisti of the University of Sydney. The trial participants showed significant vision improvements after taking a saffron pill for three months, she said. "Measurements using objective eye sight tests showed patient's vision improved after taking the saffron pill. When they were tested with traditional eye charts, a number of patients could read one or two lines smaller than before, while others reported they could read newspapers and books again." The trial was double blind and randomly controlled, involving 25 subjects over six months. Half the group were given a saffron pill for the first three months followed by a placebo, while the other half were given the pills in the reverse order. "All patients experienced improvements in their vision while taking the saffron pill," Dr Bisti said. "But when they stopped taking the pill the effect quickly disappeared."

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Combined treatment with intravitreal steroid and Avastin injection is effective for large retinal pigment epithelial detachment (PED) associated with neovascular AMD, according to a study published in Graefes Archive of Clinical and Experimental Ophthalmology. A PED occurs when fluid enters the space between the RPE and choroid. There is currently no effective treatment for PED, although PDT and anti-VEGF drugs have been used with some success. In this prospective case series, seven eyes with neovascular AMD associated with large PED were treated with intravitreal triamcinolone acetonide, followed by Avastin 1 week later. The average follow-up was 11 months. Average BCVA improved from 20/125 to 20/80. Angiography showed no leakage in four eyes, and decreased leakage in three eyes at the end of follow-up. The PED disappeared in four eyes, while it decreased in size in the remaining three. No RPE tear appeared during follow-up. Two eyes developed glaucoma. The investigators conclude that combined steroid plus Avastin therapy seems to be an effective and safe treatment for neovascular AMD associated with large PED.

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