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Intravitreal Injections: Can They Treat Everything?
Leonid Skorin, Jr., OD, DO, MS, FAAO, FAOCO
Mayo Clinic Health System in Albert Lea
skorin.leonid@mayo.edu
I.
Intravitreal Injections
A. Introduction
1. Between 1997 and 2007 – 5,000 annually
2. In 2007 – 800,000
3. Second to only cataract surgery in Europe and U.S.
II.
Macular Degeneration
A. Macugen (pegaptanib sodium)
1. Aptamer, decoy nucleic acid ligand
2. Selectively binds VEGF
3. Intravitreal injection every 6 weeks
4. Total 18 injections
5. All types of wet AMD
6. 70% lose less than 3 lines vision
7. 6% gain vision
B. Lucentis (ranibizumab)
1. Anti-VEGF antibody fragment
2. Intravitreal injection every 4 weeks
3. All types of wet AMD
4. 95% lose less vision
5. 34% gain vision
6. 40% ≥ 20/40
C. Avastin (bevacizumab)
1. Full-size anti-VEGF antibody
2. IV for metastatic colorectal cancer
3. All types of wet AMD
4. No large prospective study to judge efficacy and safety
5. Increased thrombolytic events – no MI or CVA within 6 months of its
use
6. Inform patient of its off-label use
D. Complications of Age-Related Macular Degeneration Treatment Trial
1. VA with Lucentis vs. Avastin equal over 1 year of trial
2. Lucentis better in decreasing retinal thickness
3. Adverse events: 24% for Avastin vs. 19% for Lucentis
4. Cost when used monthly over 1 year: Lucentis $23,400 vs. Avastin $595
E. Eylea (aflibercept)
1. 2mg monthly x 3 months then 2 mg every 8 weeks
2. Clinically equivalent to Lucentis
3. Adverse event profile similar to Lucentis
4. Blocks all isoforms of VEGF and placental growth factor
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5. Binds more tightly to VEGF than Lucentis or Avastin
6. Advantages:
a. unclogs clinic schedule
b. fewer injections – less cost and risk
c. fewer trips to office
d. reduces treatment burden
III.
Macular Edema from Vein Occlusion
A. Ozurdex (dexamethasone 0.7 mg implant)
1. Biodegradable
2. Lasts from 1 to 3 months
3. Treats both CRVO and BRVO
4. Noninfectious posterior segment uveitis
B. Lucentis
1. Approved for both CRVO and BRVO
C. Eylea
1. Approved for CRVO
IV.
Macular Edema from Diabetes
A. Lucentis (ranibizumab)
1. Approved for CME
2. Based on RIDE and RISE studies
V.
Vitreomacular Traction and Macular Holes
A. Jetrea (ocriplasmin)
1. Vitreolytic agent – VMA resolved 26.5%
2. Recombinant protease
3. Activity against fibronectin and laminin
4. Macular hole closure – 40.6%
VI.
Injection Guidelines
A. Pre-existing Conditions
1. Blepharitis, conjunctivitis
2. Glaucoma
3. Allergy to povidone iodine
4. Phakic vs. pseudophakic
5. Previous history of MI or CVA
B. Injection Complications
1. Optic nerve non-perfusion
2. Endophthalmitis
3. Retinal detachment
4. Intraocular hemorrhage
5. Cerebrovascular accident
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C. Endophthalmitis Signs/Symptoms
1. Pain
2. Decreased vision
3. Vitritis
4. Hypopyon – 78%
5. Present on average 3.4 days post-injection
D. Endophthalmitis Etiology
1. Streptococcus species – 30.8%
2. Aerosolization or droplet spread from saliva
3. Wear face mask
4. Avoid talking, sneezing, coughing
VII.
On the Horizon?
A. Iluvein (fluocinolone acetonide)
1. corticosteroid insert for diabetic macular edema