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Transcript of CNV updates
What’s New in CNVCNV
Mohamed ELShafieAssistant lecturer of
ophthalmologyKafr ELShiekh university
CNVCNV
CNV
Growth of abnormal
blood vessels in the choroidal
layers, these abnormal vessels
can rupture the retinal layers
causing deterioration of vision
at the affected regions
Risk factorRisk factor
A- Personal risk factors: A- Personal risk factors: ARMD, pathologic myopia, lightly pigmented populations, higher BMI, family history,.. ect
Risk factor B- Environmental and nutritional risk factors: B- Environmental and nutritional risk factors: smoking, light exposure, cataract surgery, dietry fat intake.
C-Systemic diseases:C-Systemic diseases: HTN, DM & others i.e CVD
Clinical PictureClinical Picture
SymptomsSymptoms
SignsSigns
Loss of central vision, visual distortion, Loss of central vision, visual distortion, visual field defects, loss of contrast visual field defects, loss of contrast
sensitivitysensitivity . .
Hemorrhage, macular edema, subretinalHemorrhage, macular edema, subretinalfluid, PED, chorioretinal folds.fluid, PED, chorioretinal folds.
Clinical investigation of Clinical investigation of CNVCNV
OCTOCTFAFA
Angiographic classification of CNVAngiographic classification of CNV..
Type 1 Choroidal Neovascularization ( occult ) : Type 1 Choroidal Neovascularization ( occult ) :
Early stages are Early stages are poorly delineated poorly delineated with fluoresceinwith fluorescein Late stages are stained with irregular margins.Late stages are stained with irregular margins.
Angiographic classification of CNVAngiographic classification of CNV..
Type 2 choroidal Neovascularization (classic) : Type 2 choroidal Neovascularization (classic) :
Early fluorescein angiogram its seen as Early fluorescein angiogram its seen as well delineated well delineated vascular patternvascular pattern..
Late stages it stained with indistinct Late stages it stained with indistinct margins.margins.
Assessment of CNV by OCT.
Differentiation between types of CNVDifferentiation between types of CNV
OCT measurement of macular thicknessOCT measurement of macular thickness
Differentiation between types of CNVDifferentiation between types of CNV
Showing disrupted reflections from (RPE/choriocapillaris) with poorly defined boundaries.
Showing disrupted reflections from (RPE/choriocapillaris) with well-defined boundaries.
Occult Occult CNVCNV
Classic Classic CNVCNV
Comparison between OCT & FA in detection of macular Comparison between OCT & FA in detection of macular oedemaoedema
OCT (n =
46)FA (n = 46)
P
No % No %
Diffuse28 60.9 20 43.5
<0.001
*
Cystoid18 39.1 8 17.4
Insignificant or no
leak
0 0 18 39.1*Significant P < 0.05
Study included Study included 46 eyes of 38 patients attending
the outpatient clinics of Mansoura ophthalmic center.the outpatient clinics of Mansoura ophthalmic center.
What’s New in TTTWhat’s New in TTT
10. Topical Pazopanib
• Csaky (2015):– Multicenter, 1yr, Phase 2b RCT of 510 patients
with subfoveal CNV secondary to AMD– Lucentis given as-needed to patients taking drops
–Pazopanib is not effective in reducing treatment burden of Lucentis
Csaky, et al. Ophthalmology 2015;122:579Csaky, et al. Ophthalmology 2015;122:579
Pazopanib did not significantly reduce the need for Lucentis injections (primary outcome)
What’s New in AMDWhat’s New in AMD
9. Implantable Miniature Telescope10. Drug Pipeline
• The FDA approved in 2010 for patients 75yrs and older with stable severe-to-profound vision impairment caused by bilateral end-stage AMD.
• Marketed as CentraSight
Implantable Miniature Telescope
Retinal Prosthesis
FDA grants Argus II retinal prosthesis from Second Sight, Inc “compassionate use” status for severe end-stage RP
Retinal ProsthesisRunner-U
p
What’s New in AMDWhat’s New in AMD
8. Aspirin9. Implantable Miniature Telescope10. Drug Pipeline
• Prevent of cardiovascular events, reduce the risk of some cancers, reduced risk of Alzheimer's disease.
• Adverse effects of aspirin – Gastrointestinal hemorrhage,
worsen hypertension, renal failure, aggravate asthma, hemorrhagic stroke
– Each year 16,500 deaths are related to aspirin and NSAID use
Seshasai SR, et al. Arch Intern Med. 2012;172:209-16
Aspirin & CNVHarmful Effect
Feman (1972)Bloome (1978)Kingham (1988)
Lewis (1988)AREDS (2000)Klein (2012)
de Jong (2012)Cheung (2013)
Liew (2013)Ye (2014)
No EffectMPS Group (1986)MPS Group (1990)
Klein (1991)Hirvela (1996)Klein (2001)
Douglas (2007)Rudnicka (2010)
Protective EffectChristen (2001)Christen (2009)
What’s New in AMDWhat’s New in AMD
7. Lifestyle8. Aspirin9. Implantable Miniature Telescope10. Drug Pipeline
What’s Good for the Heart
Is also Good for the Eye!
Lose weightDon’t smoke
Exercise regularly– Gopinath (2015): No significant difference in 10yr
smoking cessation rates between smokers with and without AMD (AMD: 25%, non-AMD: 20%)
-Munch (2013): Being physically active ≥7hrs/wk decreased the risk of large drusen compared to 0-2 hrs/wk
What’s New in AMDWhat’s New in AMD
6. Sunlight7. Lifestyle8. Aspirin9. Implantable Miniature Telescope10. Drug Pipeline
• Delcourt (2014): Individuals with the highest and lowest exposure levels were at increased risk of early AMD compared with medium exposure.
- The adult lens absorbs nearly 100% of light below 400nm–Cataract surgery results in increased exposure to short-wavelength light and this may increase the risk of photochemical damage to the retina–Inconsistent association with AMD risk
Runner-Up
Kessel (2015): Surgery did not increase risk of progression to CNV within 6-12 months Recommend patients with AMD and visually significant cataract are offered cataract surgery
What’s New in AMDWhat’s New in AMD
5. Lutein6. Sunlight7. Lifestyle8. Aspirin9. Implantable Miniature Telescope10. Drug Pipeline
• Macular Pigment– Lutein and zeaxanthin are the major components of
macular pigment– Macular pigment may protect the retina from
photochemical damage by absorbing blue light.
• Lutein supplementation may decrease the risk of AMD progression
in persons with low dietary intake.
What’s New in AMDWhat’s New in AMD
4. Fish5. Lutein6. Sunlight7. Lifestyle8. Aspirin9. Implantable Miniature Telescope10. Drug Pipeline
• Fish oil is rich in omega-3 long-chainpolyunsaturated fatty acids (LCPUFA).
• Christen (2011)– Consumption of 1 or more of fish per week associated with a 40% lower risk of developing CNV.
What’s New in AMDWhat’s New in AMD
3. Anti-VEGF medications4. Fish5. Lutein6. Sunlight7. Lifestyle8. Aspirin9. Implantable Miniature Telescope10. Drug Pipeline
• Which is better: Lucentis or Avastin?– Both drugs have the same mechanism of action,
but very different structures– Lucentis is much more expensive than Avastin
• Dosing regimens– Monthly dosing produces best outcomes but has
greatest treatment burden– Treat and extend currently most popular strategy
–Visual results of Avastin were equivalent to Lucentis at both monthly and PRN dosing
-Lucentis produced greater decreases in macular thickness at both monthly and PRN dosing.
-Serious systemic adverse events were more frequent with Avastin than with Lucentis
–Mean gain in vision was greater with monthly dosing vs PRN dosing for both drugs
Aflibercept (Eylea)• Recombinant fusion protein • Be approved by the FDA for treating patients
with CNV (2011).• The recommended dose for EYLEA is 2 mg
monthly for 3 months, followed by injection once every 2 months.
What’s New in AMDWhat’s New in AMD
2. Genetics3. Anti-VEGF medications4. Fish5. Lutein6. Sunlight and Cataract Surgery7. Lifestyle8. Aspirin9. Implantable Miniature Telescope10. Drug Pipeline
– Attempts to predict the risk of developing advanced AMD .
– Determine response to medication.
Genetic testing services use risk models to calculate your Genetic testing services use risk models to calculate your risk of contracting various disorders based on genotyperisk of contracting various disorders based on genotype
Shastry BS. Discovery Medicine. Aug 2011Shastry BS. Discovery Medicine. Aug 2011
What’s New in AMDWhat’s New in AMD1. Vitamins2. Genetics3. Anti-VEGF medications4. Fish5. Lutein6. Sunlight7. Lifestyle8. Aspirin9. Implantable Miniature Telescope10. Drug Pipeline
• Vitamin D:– Has antiangiogenic, antioxidant and anti-inflammatory
effects
– Itty (2014): Vitamin D deficiency is a potentially modifiable risk factor for the development of CNV.
• B vitamins:– Capable of significantly lowering serum levels of
homocysteine
–Gopinath (2013): Taking vitamin B supplements decreased risk of developing AMD by 47%
What’s New in AMDWhat’s New in AMD1. Vitamins2. Genetics3. Anti-VEGF medications4. Fish5. Lutein6. Sunlight7. Lifestyle8. Aspirin9. Implantable Miniature Telescope10. Drug Pipeline
Thank You!Thank You!