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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.

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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.

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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.

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Preferred site of injection Eye Foundation Group. All Rights reserved.

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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.

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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.