Eric Tourville

Real-world assessment of intravitreal dexamethasone implant (0.7 mg) in patients with macular edema: the CHROME study.

Background The purpose of this study was to evaluate the real-world use, efficacy, and safety of one or more dexamethasone intravitreal implant(s) 0.7 mg (DEX implant) in patients with macular edema (ME). Methods This was a retrospective cohort study of patients with ME secondary to retinal disease treated at ten Canadian retina practices, including one uveitis center. Best-corrected visual acuity (BCVA), central retinal thickness (CRT), intraocular pressure (IOP), glaucoma and cataract surgery, and safety data were collected from the medical charts of patients with ≥3 months of follow-up after the initial DEX implant. Results One hundred and one patient charts yielded data on 120 study eyes, including diagnoses of diabetic ME (DME) (n=34), retinal vein occlusion (RVO, n=30; branch in 19 and central in 11), and uveitis (n=23). Patients had a mean age of 60.9 years, and 73.3% of the study eyes had ME for a duration of ≥12 months prior to DEX implant injection(s). Baseline mean (± standard error) BCVA was 0.63±0.03 logMAR (20/86 Snellen equivalents) and mean CRT was 474.4±18.2 μm. The mean number of DEX implant injections was 1.7±0.1 in all study eyes; 44.2% of eyes had repeat DEX implant injections (reinjection interval 2.3–4.9 months). The greatest mean peak changes in BCVA lines of vision occurred in study eyes with uveitis (3.3±0.6, P<0.0001), followed by RVO (1.3±0.5, P<0.01) and DME (0.7±0.5, P>0.05). Significant decreases in CRT were observed: −255.6±43.6 μm for uveitis, −190.9±23.5 μm for DME, and −160.7±39.6 μm for RVO (P<0.0001 for all cohorts). IOP increases of ≥10 mmHg occurred in 20.6%, 24.1%, and 22.7% of DME, RVO, and uveitis study eyes, respectively. IOP-lowering medication was initiated in 29.4%, 16.7%, and 8.7% of DME, RVO, and uveitis study eyes, respectively. Glaucoma surgery was performed in 1.7% of all study eyes and cataract surgery in 29.8% of all phakic study eyes receiving DEX implant(s). Conclusion DEX implant(s) alone or combined with other treatments and/or procedures resulted in functional and anatomic improvements in long-standing ME associated with retinal disease.

Canadian expert consensus: optimal treatment of neovascular age-related macular degeneration.

BACKGROUND New therapeutic approaches, particularly anti-vascular endothelial growth factor (anti-VEGF) therapies, prevent, and in some cases reverse, vision damage caused by age-related macular degeneration (AMD). Unequal access to care across Canada remains a problem for many retina specialists and their patients. OBJECTIVE To develop a consensus concerning the management of patients with exudative age-related macular degeneration (AMD). DESIGN Consensus document. PARTICIPANTS Ten Canadian retina specialists. METHODS The development of a consensus among Canadian experts concerning optimal treatment of AMD began with a review of the clinical evidence, daily practices, existing guidelines, and current national and international approvals and policies. The experts met on June 29, 2010, in Quebec City to discuss their findings and to propose strategies for consensus. RESULTS The result of this expert panel is a consensus proposal for Canadian ophthalmologists and retina specialists who are treating patients with or at risk for developing neovascular AMD. CONCLUSIONS The consensus provides guidelines to aid retina specialists in managing exudative AMD. Currently, ranibizumab is the only agent with sufficient Level I evidence and a Health Canada-approved indication for the treatment of wet AMD. Bevacizumab has been shown to be noninferior in preserving and improving visual acuity when compared to ranibizumab. Potential safety differences between the 2 drugs remain to be elucidated. The positioning of ranibizumab in this therapeutic area will be further defined as additional data for existing and emerging therapies become available. Until then, this agent remains the therapy of choice for individuals with neovascular AMD.

Optimal Treatment of Retinal Vein Occlusion: Canadian Expert Consensus.

Background: The availability of new therapeutic approaches, particularly intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapies, has prompted significant changes to the established treatment paradigms for retinal vein occlusion (RVO). Better visual outcomes and significantly lower rates of adverse events have been noted in multiple large randomized clinical trials and have led to a new standard of care for this sight-threatening condition. Objective: To develop an expert consensus for the management of RVO and associated complications in the context of recent clinical evidence. Methods: The development of a Canadian expert consensus for optimal treatment began with a review of clinical evidence, daily practice, and existing treatment guidelines and algorithms. The expert clinicians (11 Canadian retina specialists) met on February 1, 2014, in Toronto to discuss their findings and to propose strategies for consensus. Results: The result of this expert panel is a consensus proposal for Canadian ophthalmologists and retina specialists treating patients presenting with RVO. Treatment algorithms specific to branch and central RVO (BRVO and CRVO) were also developed. Conclusions: The consensus provides guidelines to aid clinicians in managing RVO and associated complications in their daily practice. In summary, laser remains the therapy of choice when neovascularization secondary to RVO is detected. Adjunctive anti-VEGF could be considered in managing neovascularization secondary to RVO in cases of vitreous hemorrhage. Intravitreal anti-VEGF should be considered for symptomatic visual loss associated with center-involving macular edema on optical coherence tomography. Patients with BRVO and a suboptimal response to anti-VEGF could be treated with grid laser, and those with CRVO and an inadequate response to anti-VEGF may be candidates for intravitreal steroids.

Prospective randomized trial: outcomes of SF6 versus C3F8 in macular hole surgery

OBJECTIVE To compare macular hole (MH) closure and visual acuity improvement after vitrectomy using SF6 versus C3F8 gas tamponade. The secondary purposes were to report the cumulative incidence of cataract development at 1 year after MH surgery and the proportion of complications. DESIGN Prospective, randomized study. PARTICIPANTS Thirty-one patients were prospectively randomized to the SF6 group and 28 patients to the C3F8 group. METHODS Preoperative data included MH minimum diameter, Early Treatment Diabetic Retinopathy Study (ETDRS) best corrected visual acuity (BCVA), cataract staging, and intraocular pressure (IOP) measurement. Postoperative data included optical coherence tomography confirmation of the closure at 6 weeks and 1 year, and ETDRS BCVA and cataract development/extraction, both 1 year after the MH surgery. RESULTS Primary MH closure was achieved in 93.3% in the SF6 group and 92.9% in the C3F8 group. Mean ETDRS BCVA improved by 17.7 letters in the SF6 and 16.9 letters in the C3F8 group. The difference in cumulative incidence of cataract development and extraction between both groups was not statistically significant. Regardless of the dye used, similar results were achieved. Finally, the proportion of adverse events was similar in both groups. CONCLUSIONS MH surgery with SF6 gas achieves results similar to C3F8 in terms of visual acuity improvement, MH closure, cataract development/extraction, and adverse events.

Contemporary Management of Diabetic Retinopathy in Canada: From Guidelines to Algorithm Guidance

Recent advances in the therapeutic options and approaches for diabetic retinopathy (DR) and diabetic macular edema (DME) have resulted in improved visual outcomes for many patients with diabetes. Yet, they have also created many clinical dilemmas for treating ophthalmologists and retina specialists, including treatment selection, initiation, frequency and duration. With this in mind, a panel of Canadian retina specialists met and discussed the current clinical evidence as well as specific situations and scenarios commonly encountered in daily practice. They also shared their experiences and therapeutic approaches. This document, containing a consensus on treatment algorithms for various clinical scenarios, is the result of their lengthy and in-depth discussions and considerations. The intent is to provide a step-by-step approach to the treatment of DR and DME. Although clinicians are encouraged to use and refer to these algorithms as a guide for various situations, they are not meant to be a replacement for sound clinical judgment.

Bevacizumab and ranibizumab for neovascular age-related macular degeneration: a treatment approach based on individual patient needs

OBJECTIVE To compare the efficacy of intravitreal bevacizumab and ranibizumab for the treatment of neovascular age-related macular degeneration using an as-needed treatment regimen. DESIGN Retrospective chart review. PARTICIPANTS One hundred and ninety two eyes of 184 patients. METHODS Patients received an initial treatment of 3 monthly intravitreal injections of ranibizumab or bevacizumab and retreatment is individually considered for each patient on the basis of optical coherence tomography, angiography, and clinical examination. RESULTS Fifty eyes treated with ranibizumab and 142 eyes treated with bevacizumab were included. The average age of the patients at baseline was 76.9 ± 8 years and 76.4 ± 8 years in the ranibizumab and bevacizumab group respectively. Mean visual acuity improved from 0.69 to 0.55 logMAR at 12 months in the ranibizumab group and from 0.70 to 0.67 logMAR in the bevacizumab group. At 12 months, 92% of eyes treated with ranibizumab had lost fewer than 0.3 logMAR, as compared with 83% in the bevacizumab group. The ranibizumab group received a mean of 4.92 injections, compared to 4.75 injections in the bevacizumab group over 12 months. After the first 3 injections, 20% of patients in the ranibizumab group and 26% in the bevacizumab group never needed another injection. CONCLUSIONS An approach based on clinical onset and choroidal neovascularization progression at angiography may provide benefit by reducing the number of intravitreal injections required.

Real-world utilization of ranibizumab in wet age-related macular degeneration patients from Canada

Age-related macular degeneration (AMD) affects more than 2 million Canadians and is associated with significant impairment. Although AMD is a degenerative condition linked to aging, the most progressive form is associated with increased vascular endothelial growth factor (VEGF), a potent angiogenic mediator. This has resulted in the development and widespread use of anti-VEGF agents, such as ranibizumab, which was approved for use in wet AMD by the U.S. Food and Drug Administration in 2006 based on the findings from 2 key studies (ANCHOR and MARINA) that demonstrated sustained improvement in visual acuity with monthly dosing. However, some less frequent dosing schedules (such as quarterly) are not as effective. It is therefore important to monitor ranibizumab use in reallife settings in order to assess outcomes in relation to actual prescribing patterns. AURA was a retrospective, observational study that monitored the real-world utilization of ranibizumab in practices across 8 countries (Canada, France, Germany, Ireland, Italy, the Netherlands, the United Kingdom, and Venezuela). In this study, consecutive wet AMD patients who were prescribed ranibizumab by their physicians and who started treatment between January 1 and August 31, 2009, were included and followed up for up to 2.5 years. Resource utilization (number of ranibizumab injections and monitoring visits) and change in visual acuity (measured by Early Treatment Diabetic Retinopathy Study [ETDRS] letters or Snellen with conversion to a standardized letter count) were assessed in accordance with routine clinical practices. A guiding sample size of 399 patients per country was required to estimate the change in visual acuity; however, as Canada recruited 188 patients, the data are presented as descriptive statistics. Two-year outcomes were reported for the effectiveness analysis set (patients who received Z1 dose of anti-VEGF treatment and had Z1 postbaseline assessment of visual acuity for the treated eye). To account for missing data, mean change in visual acuity was assessed using a

Effect of air and sulfur hexafluoride (SF6) tamponade on visual acuity after epiretinal membrane surgery: a pilot study

OBJECTIVE The aim of this study was to compare visual acuity improvement after epiretinal membrane (ERM) surgery using air and sulfur hexafluoride (SF6) tamponade. Secondary objectives were to evaluate Visual Function Questionnaire (VFQ) scores and central retinal thickness (CRT) changes. DESIGN This was a prospective, randomized study. PARTICIPANTS Thirty-two patients were prospectively randomized, 19 to the air group and 13 to the SF6 group. METHODS This study has enrolled patients with ERM from clinical practice of 4 vitreoretinal surgeons. Preoperative and postoperative data included best-corrected visual acuity (BCVA) with the use of the Early Treatment Diabetic Retinopathy Study (ETDRS) chart, VFQ scores, CRT, and cataract staging. Pars plana vitrectomy with ERM peeling was performed on all patients, either with partial air tamponade or with complete SF6 tamponade. RESULTS Mean BCVA improved by 0.07 logMAR (3.5 ETDRS letters) in the air group and by 0.09 logMAR (4.5 ETDRS letters) in the SF6 group (p = 0.58). There was no statistically significant difference between the groups with regard to BCVA, VFQ scores, and CRT. The groups had similar rates of cataract progression and adverse events. CONCLUSIONS ERM peeling with partial air tamponade or with complete SF6 tamponade have similar outcomes in terms of BCVA, VFQ scores, CRT, cataract development, and adverse events.

Incidence of postoperative hypotony in 25-gauge vitrectomy: oblique versus straight sclerotomies

OBJECTIVE To compare the incidence of hypotony after oblique and straight sclerotomies in 25-gauge transconjunctival sutureless vitrectomy (TSV). DESIGN Retrospective, comparative, interventional case series. PARTICIPANTS Two hundred seventy-five eyes of 250 patients. METHODS We reviewed 275 consecutive cases of 25-gauge TSV. Oblique incisions were performed on 141 eyes and straight incisions on 134 eyes. RESULTS On postoperative day 1, there was no significant difference in the incidence of hypotony (9.9% vs. 9.2%; p = 0.85) between oblique and straight incisions. The type of incision showed no statistical effect on hypotony in eyes filled with fluid (p = 0.91) or air-gas (p = 0.81). Hypotony was significantly reduced using air-gas endotamponade (4.8%) as compared to fluid-filled eyes (20.0%; p = 0.0001). CONCLUSION Oblique incisions do not reduce the incidence of postoperative hypotony in fluid-filled eyes or with air-gas tamponade. Air-gas tamponade use results in a 4-fold reduction in the incidence of hypotony.