INNOVATION
TREATMENTTREATMENT REGIMEN ANTI-VEGF
OCT from February versus May: Delayed treatment has resulted in an increase of subretinal fluid and an increased treatment and monitoring regimen. [Photo credit: Dr. Paisan Ruamviboonsuk]
Coronavirus Side Effects
Treatment Regimens and Missed Anti-VEGF Injections by Brooke Herron
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t this point, nearly everyone is feeling the pandemic’s effects in some form or another. Families have lost loved ones, many have lost jobs, and uncertainty seems to lurk around every corner. In ophthalmology, clinics and hospitals have been shuttered, except for emergencies. As a result, some patients may experience vision loss due to delayed treatment. Dr. Paisan Ruamviboonsuk, former president of the Royal College of Ophthalmologists of Thailand and assistant director of the Centre of Medical Excellence at Rajavithi Hospital, in Bangkok, Thailand, is witnessing this first-hand. He’s recently returned to the clinic and is seeing patients again. Dr. Ruamviboonsuk shared details from one case: “I saw
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a patient yesterday who had received more than 40 anti-VEGF injections at this point. Recently, we’ve been able to extend his injections to every eight to 10 weeks — however, any longer than that, and a small amount of subretinal fluid would return.” The patient’s last injections were in early February; he was due for his next treatment in mid-April. “Somehow, the appointment was postponed due to the pandemic,” he continued. “Now, about 12 weeks after the last injection, there is a tremendous amount of subretinal fluid. “The patient was injected yesterday, but we need to see him again in four weeks, instead of 10 weeks like the last time,” said Dr. Ruamviboonsuk, adding that he expects to see more cases like this in the next few months.
| June/July 2020
Guidelines aim to preserve sight and safety
For patients with neovascular (or wet) age-related macular degeneration (nAMD), maintaining a regimen of intravitreal anti-VEGF injections is crucial to slowing the progression of the disease. Currently, there is no cut-anddry regimen: Injections can be given monthly, every two or three months (extended-fixed), or as needed (pro re nata, PRN). More recently treat-andextend (T&E) is being used, where treatment intervals are extended as long as there are no signs of disease progression.1 However, in the midst of the pandemic, expert organizations and physicians have come together to set treatment guidelines for these patients. The Vision Academy, supported by Bayer, is an international group of retina physicians working together to provide recommendations where the literature is inconclusive. Together, they have devised a set of anti-VEGF guidelines2 for ophthalmologists to follow, noting that the “practicality and risk–benefit of a treatment approach should be carefully considered to minimize patient exposure and preserve sight.” For example, they recommend that patients with nAMD (especially those in the first two years of treatment)