MyVisionTest News Archive
Apr 18, 2008
Retinal experts debate when and how to treat Wet AMD
A panel of experts discussed controversial issues surrounding the treatment of AMD at the Retina 2008 meeting. Below are excerpts from the transcript published by ONS Supersite.
Retina is making history because intravitreal injections are now No. 3 on the list of ophthalmic procedures coded for Medicare reimbursement, following cataract with IOL and Nd:YAG laser.
When to re-treat
Dr. Kaiser: I always get a fluorescein angiography at baseline. I do not get them at follow-up visits unless I am deciding whether to switch treatments. For follow-up visits, I get an OCT.
Dr. Kaiser: I like to be more proactive, rather than waiting for the fluid to come back before treating. So I use a “treat-and- extend” paradigm and would treat the patient again at this visit and then see him back in 2 months instead of a month. If they come back in 2 months and they are still dry, I would hit them again and see them back in 3 months. If they are wet at 2 months, then I know I cannot go beyond 2 months, treat again and see them in 2 months or less. By using this paradigm, I minimize the visits and injections and hopefully maximize the outcome.
Dr. Reichel: We cannot predict the future. Hopefully the CATT trial will teach us that there is going to be a subgroup of patients where there is minimal treatment. There is going to be another subgroup of patients we are going to have to treat every month.
History of anticoagulants
Dr. Fekrat: I usually do not change their anticoagulants because I tell them it does not make them bleed, but if they are going to bleed, they will bleed more.
Dr. Puliafito: Dr. Brown, do you think that patients who take aspirin are more likely to have a big subretinal hemorrhage associated with AMD?
Dr. Brown: I do not think so. I do not think anybody has shown that at all.
Dr. Kaiser: The issue here is, does the anticoagulation increase the risk of a bleed, period. And the answer is probably not, but if you have a bleed, it is just going to be larger. Personally, if a patient told me, “I’m taking aspirin,” I would let them continue the aspirin. And if they are taking Coumadin, I would definitely continue the Coumadin. I do not think that we are going to be stopping the natural history. I always tell patients, “The eye doesn’t work if the heart doesn’t work.” So I leave them on it.
Reduced-fluence PDT
Dr. Kaiser: The way PDT works is related to the amount of oxygen in the area around where the photochemical reaction is occurring. The oxygen is necessary to produce the singlet oxygen and free radicals that produce the angio-occlusion. If you talk to PDT researchers, they think that we are giving patients a dramatic overdose with our standard PDT treatment, in that we are using up the oxygen right at the beginning of the reaction. So we are getting actually less of an effect than we would want. And so by reducing the fluence, we theoretically are getting more of an effect with less damage to the retina.
Dr. Kaiser: Despite all of the studies, I still start with Lucentis monotherapy. That is, unless the patient has said to me specifically they cannot come back because they have transportation issues or they are coming from a foreign country. In those patients, I would consider doing combination therapy with PDT right off the bat. But typically, I do not switch to combo until I see that the patient is not doing well with monotherapy.
Interval of treatment
Dr. Puliafito: When is it safe to see a patient every 3 months vs. every 6 weeks? Anybody want to take this?
Dr. Reichel: I do not think anyone knows.
Dr. Kaiser: I will take a stab at that. There is no way to know, but one of the things that Philip J. Rosenfeld, MD, PhD, has shown us is that patient re-treatment rates fall into a pattern. If you can figure out that patient’s pattern, then you could feel pretty comfortable following them at that interval. So if a patient needs treatment every 3 months, you can feel pretty comfortable seeing them at 3-month intervals. But you cannot get to that interval until you have worked up to it by treating and extending. You cannot just suddenly say to a patient at baseline that you will see them in 3 months.
Dr. Schwartz: Also, an intelligent, observant patient can often be trusted to come back when they are symptomatic vs. the majority of patients who cannot be trusted. So there are patients who you can get into a comfort zone with.
Read more...
OSN SuperSite
Tags: photodynamic therapy, anticoagulants, CATT, wet AMD, aspirin, Lucentis
Retina is making history because intravitreal injections are now No. 3 on the list of ophthalmic procedures coded for Medicare reimbursement, following cataract with IOL and Nd:YAG laser.
Dr. Kaiser: I always get a fluorescein angiography at baseline. I do not get them at follow-up visits unless I am deciding whether to switch treatments. For follow-up visits, I get an OCT.
Dr. Kaiser: I like to be more proactive, rather than waiting for the fluid to come back before treating. So I use a “treat-and- extend” paradigm and would treat the patient again at this visit and then see him back in 2 months instead of a month. If they come back in 2 months and they are still dry, I would hit them again and see them back in 3 months. If they are wet at 2 months, then I know I cannot go beyond 2 months, treat again and see them in 2 months or less. By using this paradigm, I minimize the visits and injections and hopefully maximize the outcome.
Dr. Reichel: We cannot predict the future. Hopefully the CATT trial will teach us that there is going to be a subgroup of patients where there is minimal treatment. There is going to be another subgroup of patients we are going to have to treat every month.
History of anticoagulants
Dr. Fekrat: I usually do not change their anticoagulants because I tell them it does not make them bleed, but if they are going to bleed, they will bleed more.
Dr. Puliafito: Dr. Brown, do you think that patients who take aspirin are more likely to have a big subretinal hemorrhage associated with AMD?
Dr. Brown: I do not think so. I do not think anybody has shown that at all.
Dr. Kaiser: The issue here is, does the anticoagulation increase the risk of a bleed, period. And the answer is probably not, but if you have a bleed, it is just going to be larger. Personally, if a patient told me, “I’m taking aspirin,” I would let them continue the aspirin. And if they are taking Coumadin, I would definitely continue the Coumadin. I do not think that we are going to be stopping the natural history. I always tell patients, “The eye doesn’t work if the heart doesn’t work.” So I leave them on it.
Reduced-fluence PDT
Dr. Kaiser: The way PDT works is related to the amount of oxygen in the area around where the photochemical reaction is occurring. The oxygen is necessary to produce the singlet oxygen and free radicals that produce the angio-occlusion. If you talk to PDT researchers, they think that we are giving patients a dramatic overdose with our standard PDT treatment, in that we are using up the oxygen right at the beginning of the reaction. So we are getting actually less of an effect than we would want. And so by reducing the fluence, we theoretically are getting more of an effect with less damage to the retina.
Dr. Kaiser: Despite all of the studies, I still start with Lucentis monotherapy. That is, unless the patient has said to me specifically they cannot come back because they have transportation issues or they are coming from a foreign country. In those patients, I would consider doing combination therapy with PDT right off the bat. But typically, I do not switch to combo until I see that the patient is not doing well with monotherapy.
Interval of treatment
Dr. Puliafito: When is it safe to see a patient every 3 months vs. every 6 weeks? Anybody want to take this?
Dr. Reichel: I do not think anyone knows.
Dr. Kaiser: I will take a stab at that. There is no way to know, but one of the things that Philip J. Rosenfeld, MD, PhD, has shown us is that patient re-treatment rates fall into a pattern. If you can figure out that patient’s pattern, then you could feel pretty comfortable following them at that interval. So if a patient needs treatment every 3 months, you can feel pretty comfortable seeing them at 3-month intervals. But you cannot get to that interval until you have worked up to it by treating and extending. You cannot just suddenly say to a patient at baseline that you will see them in 3 months.
Dr. Schwartz: Also, an intelligent, observant patient can often be trusted to come back when they are symptomatic vs. the majority of patients who cannot be trusted. So there are patients who you can get into a comfort zone with.
Read more...
OSN SuperSite
