Olufemi Oderinlo FRCSEd FWACS DRCOphth Patterns of practice of
anti-VEGF injections among ophthalmologist Eye Foundation Group.
All Rights reserved.
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INTRODUCTION Anti-VEGF injections have changed the face of both
medical and surgical retina practice world wide. These agents are
being used for many eye diseases, especially for wet form of AMD
(Age related Macular Degeneration), CNVM (Choroidal Neo Vascular
Membrane), Severe Diabetic Retinopathy, Macular Edema (swelling),
Vascular Blocks, Neovascular Glaucoma (NVG), Vitreous Hemorrhage,
etc. These retinal diseases, which were earlier considered
incurable, or had very poor results with existing treatments are
now being tackled with good results with anti-VEGF agents. Eye
Foundation Group. All Rights reserved.
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The anti-VEGF agents block the VEGF molecules and thus benefit
the patients by decreasing the abnormal and harmful new blood
vessels formation and by decreasing the leakage and swelling of the
retina. This leads to stabilization of vision and even improvement
in vision in many cases. As of now, there are four injections
available with us for treatment. These are Lucentis, Avastin and
Macugen. Afibercept has just recently been added to the list. These
injections are given intravitreally. The procedure is a very small
one, usually performed inside the operation theatre to maintain
strict asepsis. The patient is discharged within 10-15 minutes of
the procedure, and can resume his/her normal activities
immediately. Eye Foundation Group. All Rights reserved.
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AIM 1 To report the prevalent patterns of practice of antivegf
injections among ophthalmologist attending world ophthalmology
congress 2012 retina sessions 2 To report variations in the
patterns of practice for injection of antivegf injections among
ophthalmologists practicing in different regions of the world. Eye
Foundation Group. All Rights reserved.
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MATERIALS AND METHODS A questionnaire survey was done among
ophthalmologist attending retina sessions during the World
Ophthalmology Conference in Abu Dhabi from Febuary 15 th to 20 th
2012. Eye Foundation Group. All Rights reserved.
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RESULTS A total of 94 Ophthalmologist responded to the survey.
14 (14.9%) females and 80 (84.1%) males Eye Foundation Group. All
Rights reserved.
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TYPE OF INSTITUITION Eye Foundation Group. All Rights
reserved.
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LEVEL OF PRACTICE Eye Foundation Group. All Rights
reserved.
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LOCATION OF PRACTICE Eye Foundation Group. All Rights
reserved.
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Which AntiVEGF agent do you use most often. Lucentis
(Ranibizumab) or Avastin (Bevacizumab) Eye Foundation Group. All
Rights reserved.
Slide 11
Which disease processes do you treat more commonly with
antivegf agents : Eye Foundation Group. All Rights reserved.
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Which injection protocol do you follow mostly for Avastin Eye
Foundation Group. All Rights reserved.
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What dose of avastin do you use routinely per injection Eye
Foundation Group. All Rights reserved.
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What dose of lucentis do you use routinely per injection Eye
Foundation Group. All Rights reserved.
Slide 15
Preferred form of anaesthesia Eye Foundation Group. All Rights
reserved.
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Preferred location of giving injection Eye Foundation Group.
All Rights reserved.
Slide 17
Preferred site of injection Eye Foundation Group. All Rights
reserved.
Slide 18
Relationship between anti vegf used and type of instituition
Eye Foundation Group. All Rights reserved.
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Relationship between anti vegf used and location of practice
Eye Foundation Group. All Rights reserved.
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DISCUSSION Lucentis is approved for,Macula oedema : diabetic,
CRVO, BRVO, Exudative ARMD,CNVM from pathologic myopia. Approval is
a guide for antivegf use macula oedema, PDR and ARMD are all
indications for more than 75% of respondents. Monthly for 3 months
then prn was the preferred regime of injection in 55%.The PIER
study popularized this regimme unlike ANCHOR,MARINA that used
monthly injections for 24 months. 30% responded PRN alone, the need
to taylor treatment to disease process is very important. Eye
Foundation Group. All Rights reserved.
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ANAESTHESIA 78% of respondents use topical anaesthesia. A
recent randomised study actually concluded that Topical anaesthesia
was safe and effective for intravitreal injections The average
combined pain scores for both the anesthesia and the intravitreal
injection were 4.4 for the lidocaine pledget, 3.5 for topical
proparacaine, 3.8 for the subconjunctival lidocaine injection, and
4.1 for topical tetracaine. The differences were not significant (P
= 0.65). There were also no statistical differences in the
individual anesthesia or injection pain scores for each of the
groups. Subconjunctival lidocaine injection had the most side
effects Eye Foundation Group. All Rights reserved.
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INJECTION SITE 4% superotemporal, 34% inferotemporal
Pharmacologic evidence show that the superior retina/choroid area
near the site of the injection, tended to have higher
concentration. Non of the Large series RCTs implicated location of
injection as a cause of endophthalmitis, safety convinience and
sterility are main issues Eye Foundation Group. All Rights
reserved.
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DOSE In all major RCTs, there was no significant difference in
both doses of lucentis and avastin 85% of avastin users used 1.25mg
most likely for safety concerns Eye Foundation Group. All Rights
reserved.
Slide 24
Slide 25
Avastin was the preferred anti vegf used despite level and
location of practice or type of instituition. 79% responded they
use avastin more than lucentis Despite clinical concerns and
pharmacology, avastin is still the most widely used anti-vegf WHY ?
Cost ? Availability? Eye Foundation Group. All Rights
reserved.
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What effect will afibercept have on this equation. ? Eye
Foundation Group. All Rights reserved.
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CONCLUSION Anti vegf injections are more commonly given for
macula oedema and exudative age related macula degeneration. Most
ophthalmologist prefer to give injections monthly for 3 months and
then prn. Topical anaesthesia was preferred and the superotemporal
quadrant was the most common injection site. Avastin was the
preferred anti vegf used despite level and location of practice or
type of instituition. Eye Foundation Group. All Rights
reserved.
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THANK YOU Eye Foundation Group. All Rights reserved.
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REFERENCES Blaha GR, Tilton EP, Barouch FC, Marx JL.Randomized
trial of anesthetic methods for intravitreal injections. Retina.
2011 Mar;31(3):535-9. 2. Kim SJ, Toma HS. Ophthalmic antibiotics
and antimicrobial resistance a randomized, controlled study of
patients undergoing intravitreal injections.Ophthalmology. 2011
Jul;118(7):1358-63. Epub 2011 Mar 21. 3. Intravitreal Injections,
Focal Points, Volume XXVII, Number 8, September 2009 Eye Foundation
Group. All Rights reserved.
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REFERENCE Yoko Miura, Masafumi Uematsu, Mugen Teshima, Kiyoshi
Suzuma, Takeshi Kumagami, Hitoshi Sasaki, and Takashi Kitaoka.
Injection Site and Pharmacokinetics After Intravitreal Injection of
Immunoglobulin Journal of Ocular Pharmacology and Therapeutics.
February 2011, 27(1): 35-41 Ferrone PJ, Gray S, Saroj N, Singh A.
Endophthalmitis rate and utility of postinjection telephone contact
and clinical examination in detecting endophthalmitis after
ranibizumab injection. Presented at: Annual Meeting of the American
Society of Retina Specialists; December 1-5, 2007; Palm Springs,
CA. Jager RD, Aiello LP, Patel SC, Cunningham ET Jr. Risks of
intravitreous injection: a comprehensive review. Retina.
2004;24:676-698. Eye Foundation Group. All Rights reserved.