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AOA 2023: The skinny on intravitreal injections for retinal diseases

Article

Over the past decade the progress in retinal disease treatments has exploded with increased numbers of approved pharmaceutical compounds, resulting in more options for treating retinal disease with intravitreal agents and more are in the pipeline.

Elderly man examined by an ophthalmologist (Adobe Stock / sebra)

Patients need to be educated on what conditions intravitreal treatment is approved for and the importance of ongoing treatment for chronic retinal diseases. (Adobe Stock / sebra)

Reviewed by Jay M. Haynie, OD, FAAO, FORS

Intravitreal injections have become the mainstay of treatment for many retinal diseases. Early on, according to Jay M, Haynie, OD, FAAO, FORS, they were the exclusive treatment for patients with severe intraocular infections, such as endophthalmitis, and infectious cytomegalovirus retinitis. Now many retinal diseases are benefiting from intravitreal treatment. Haynie described the current, ever-changing landscape at the 2023 American Optometric Association annual meeting held in Washington, D.C.

Over the past decade the progress in this area has exploded with increased numbers of approved pharmaceutical compounds, resulting in more options for treating retinal disease with intravitreal agents and more are in the pipeline.

However, this technologic explosion does not come without challenges, Haynie commented.

Patients must be educated on specifics of their insurance coverage. “Just because we can treat it does not mean that insurance will cover it—or cover it fully,” he said.

In addition, payers may institute “step therapy,” which requires the use of potential less expensive alternatives before authorizing and approving the use of brand-named options.

Optometrists also are reminded that complications with intravitreal treatment can develop, and that while rare, they can be visually devastating. These complications include vitreous hemorrhages and hyphema, which are both rare; endophthalmitis, with an incidence rate of less than 1%; retinal tears or detachment at less than 3%; and uveitis, which is highly variable.

Currently available treatments

Faricimab ( Vabysmo , Genentech) and brolucizumab (Beovu, Novartis) both have received FDA approval to treat wet age-related macular degeneration (AMD) and diabetic macular edema (DME).

The biosimilars that have entered the market are ranibizumab-nuna (Byooviz, Biogen Inc. and Samsung Bioepis Co., Ltd.), which was approved for wet AMD and macular edema secondary to retinal vein occlusion (RVO) and myopic choroidal neovascularization (CNV), and ranibizumab-eqrn (Cimerli, Coherus BioSciences, Inc.) approved to treat wet AMD and macular edema secondary to RVO, DME, diabetic retinopathy (DR), and myopic CNV.

Cost is another issue, Haynie said, with intravitreal implants such as the fluocinolone acetonide implant (Illuvien, Alimera Sciences) 8,800.00 and the fluocinolone acetonide implant (Yutiq, Alimera Sciences) at the high end pushing close to $9,000 per unit for the retina clinic. This is in contrast to a dose of bevacizumab (Avastin, Genentech) at $27.00.

He also pointed out variability in drug coverage, including billing infrastructure characterized by a possible delay in reimbursements to providers.

Patient adherence

This is perhaps the most important area. Patients need to be educated on what conditions intravitreal treatment is approved for and the importance of ongoing treatment for chronic retinal diseases. Treatment may have to continue for years or the rest of their lives. “Importantly, intravitreal injections have saved vision,” Haynie stated.

Referral patterns

Different diseases need different attention. Patients who have AMD with subretinal fluid and cystoid macular edema on imaging or any new symptoms need treatment as soon as possible. Retina specialists generally begin with 3 monthly injections followed by treat-and-extend and as-needed protocols.

Those with stable proliferative diabetic retinopathy (PDR) should be evaluated every 3 to 6 months depending on disease control, and those with stable or absence of diabetic macular edema (DME) every 6 months. Severe non-proliferative diabetic retinopathy (SNPDR) should be referred for widefield angiography because the degree of severity can be underestimated by clinicians.

RVO may need treatment for several years and it is common for the retina practice to see these patients until the retinal edema resolves and is stable for 6 months; annual examinations then are appropriate. A referral for macular edema secondary to a branch RVO is less urgent, but that may depend on the status of the fellow eye or the severity noted on clinical examination. Central RVO (CRVO) should be considered an emergent referral as we know that the natural history of a CRVO can result in severe loss of vision and secondary glaucoma in some cases.

Uveitis is treated with steroids and the intraocular pressure monitored monthly during treatment; following that annually or as-needed if new symptoms arise.

Patients with central serous should institute lifestyle changes and be examined annually or as-needed with new symptoms.

“There is no question that management of retinal disease will continue to evolve as more treatments become available.” Haynie said. “We are no longer losing the battle to these diseases like we have in the past but rather are in a position of saving vision for our patients.”

He said he looks forward to drugs with longer treatment durations to lessen the treatment burden for patients and practices, and also encourages communication with retina specialists to determine the appropriate times to refer retinal disease for management.

“Stay current with the times and embrace changes,” Haynie said.

Jay M. Haynie, OD, FAAO, FORS

Jay M. Haynie, OD, FAAO, FORS

Jay M. Haynie, OD, FAAO, is in private practice in Washington State with offices in Tacoma, Olympia, and Kennewick, WA.
E: DrJay@soundretina.com
Haynie is on the advisory board of Appellis Pharmaceuticals and Iveric BIO, a consultant for for Topcon HealthCare, and considered a Key Opinion Leader for MacuHealth.
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