Anti VEGF

Options in the management of CNV

1)Observation occult CNV also requires close follow – up .every 3 month 2) Laser coagulation 3) Surgery 4) Triamcinolone 5) Anti angiogenic drugs (lucentice,Avastin)6) PDT & TTT7) Diet rich antioxidantswith severe AMD) .(217 cases)

Used for:

1) Wet Macular degeneration

2) Diabetic retinopathy

3) Rubeosis iridis

4) CRVO

VEGF and diabetic eye disease

1) Diabetic retinopathy remains the major cause of blindness in working – eye adults in the world.

2) It appears to be different retinopathy phenotype and many eyes may remain with minimal retinopathy changes and good vision for an entire lifetime.

Inhibition of the enzyme

PK- C (proteinkinas-c) (angiogenesis

factor) with ruboxistaurin represents

a particularly exciting therapeutic

approach it works at the early stages

of the diabetic retinal disease when

the disease is still reversible.

(Intravitreal) SteroidsHave been used with some success in advanced situations of chronic diffuse diabetic macular edema.

Are effective only in the short term and are associated with complications such as cataract and glaucoma.

The combination of

intravitreal steroid with

laser therapy has been

shown is another

interesting alternative.

VEGFAn increase in VEGF (vasoendothelial growth factor) has been repeatedly demonstrated in the vitreous of advanced case of diabetic retinopathy

VEGF INHIBITORS 1) (Avastin) Bevacizumab.

2) (Macugen) or pegaptanib sodium.

3) (lucentis) or Ranibizumab

Avastin costs less than 150 $

Per treatment compared with 2000$ per treatment for lucentis.

Anti-VEGFFreeman:

Anecdotaly the Anti _ VEGF drugs have proven.

Very useful in treating proliferative diabetic retinopathy.

Anti-VEGF It is proven that is effective in wet macular degeneration and there is a growing consensus that this will be true in diabetes and retinal vascular disease.

Moderate NPDR with CSME

Rubeosis Iridis

BRVO

Avastin or Lucentis

1) Reduce macular edema in diabetic pts.

2) Reduce or stop proliferative retinopathy

The big problem with these drugs is that they have to be given on an on going basis

These drugs don't cure any thing.

They reduce VEGF

Anti VEGF

When the drug wears off the patients need injections every four to six weeks.

ChallengeThe challenge is to deliver these drugs in away that would suppress VEGF chronically we don't know how to do this yet.

Kenalog(Triamcinolone)

and anti- VEGF causes

actual vision

improvement.

Laser + subtenon

injection of Kenalog

(steroid) stabilize the

vision.

Stabilize the vision

If you stabilize vision when patient is still at 20/30 that patient is going to do better than someone in whom the diagnosis is delayed and vision is worse.

Laser problem

Loosing

peripheral and

night vision

Avastine injections monthly

Treated patients

1) Showed better visual acuity

2) Greater reductions in retinal thickness

3) Reduced need for PRP

4) Regression of Neovascularization

5) Microaneurysms and hemorrhage

improvement

Bevacizumab (Avastin) is in clinical trial for treatment of diabetic macular edema and retinopathy at centers in IRAN , Mexico & Venezuela

Ruboxistaurin

Ruboxistaurin is a drug that is administered in tablet form and also produced promising early results.

However, it is now uncertain whether Eli Lilly will

continue to develop the drug, following a recent FDA

decision mandatimy three years of additional clinical

trials.

Remote diabetic retinopathy screening by:

1) Digital imaging

2) Non-mydriatic exams.

3) Internet

Genome-wide scan of native Americans suggests genetic loci for diabetic retinopathy

Macugen

in addition to PDT pegaptanib sodium injection ( macugen) is proven to preserve

visual acuity regardless of CNV ,type , lesion size or baseline visual acuity

70% of 1186 patients who had 0.3mg of macugen every 6 weeks

lost fewer than 3 lines of vision on the eye chart compared with 55% of patients in the control group a

27% treatment benefit

Ranibizumab ( Lucentis ) is another anti VEGF compound

that has recorded very positive initial results

Ranibizumab

Approximately 95% of patients maintained or improved vision at one year compared to 62%

of those in the control. Control group demonstrated substantial

decrease in mean visual acuity from base line to 12 months

New agents under investigation

1)Avastine ( bevacizumb)

2) Squalamine lactate

3) Aminosterol ( extracted from dogfish) shark

4) Tyrosine

5) Gene therapy

We have increasing options for treatment of CNV but we have to bring all our clinical experience to bear in deciding what combination

of approaches will work best for our patients