PracticeUpdate: What is your typical approach to a newly diagnosed patient with wet AMD?
Dr. Lewen: For me, I tend to start the majority of my patients on bevacizumab, which is Avastin, and it's an off-label use, so I make sure that I have a conversation with patients about that fact and that they understand that it is an off-label use of the medication. For me, I tend to favor a treat-and-extend approach where I'll treat my patients with three initial monthly loading doses, and then once their macular edema resolves, I like to extend the treatment interval out sequentially. I have some patients that prefer a PRN or treat-as-needed approach, but that then requires more frequent follow-up appointments, which, in the coronavirus era, has been particularly challenging because, as we all know, elderly patients fall into a particularly high-risk category of patients. Both with new patients, but also with many of my return patients, this is, of course, a very challenging area of balancing good eye care with general health, public health, and keeping our patients and our staff as healthy as can be.
That's one area with the coronavirus that I've found to be particularly challenging. With patients that are established and on a certain treatment schedule, we've been bringing them in at their scheduled visits, but trying to limit their time in the clinic as much as possible. With patients who have been on a treat-as-needed approach, I've had a conversation with them about potentially shifting to a treat and extend, just to try to limit how much they have to come into the clinic and leave their homes.
Dr. Freeman: We had read an article a while back where a lot of the patients that were being treated were actually just being treated, they were not being assessed, so dilated exams were not necessarily done. This was in a peer reviewed journal, so it wasn't something that somebody just decided to come up with. Two things: one is I think that you followed that kind of approach. Were you concerned at all, or did you let patients know that if something happened that was out of the norm, they should come in, you would do then the full assessment?
Dr. Lewen: That's correct. Yes, and this is where telemedicine, even though in the retina side of things, we haven't, at least in my practice, been able to incorporate telemedicine to the same extent as some of my colleagues, but one way that I have been able to work that in is, especially early on when there was a lot of uncertainty, I would contact my patients who were scheduled to come in, especially the dry macular degeneration patients, and if they were completely asymptomatic and at their baseline, if it seemed appropriate, we pushed their visit off as much as we felt we safely could.
For the patients with wet macular degeneration, we just tried to let them know that the visits are going to be a little different. In many instances, as long as they were otherwise asymptomatic, we deferred dilation. In some instances, we even deferred OCT imaging, simply to have them come in, check their vision, check their pressure, and if their vision was at their baseline, they got their treatment and they left the clinic. The patients also very much seem to appreciate the fact that we were trying to take care of their eyes, but also take care of their general health as well.
Dr. Freeman: Do you see any new treatments coming down the pike that we should be thinking about?
Dr. Lewen: Yeah, so we just recently had our annual meeting for the American Society of Retina Specialists, and there were some wonderful presentations about some of these new molecules in clinical trials and also some devices. There are a couple molecules that are currently being tested for dry macular degeneration, looking to delay the rate of progression of geographic atrophy. They haven't been shown to reverse changes, but there are some promising data to suggest that they may be effective in delaying the rate of progression. Those molecules are, at least the ones that were presented were injected into the eye intravitreally. In the area of wet macular degeneration, we have had some progress. Recently, there was a new molecule called brolucizumab, but the trade name is Beovu, that was shown to have equal efficacy as our other anti-VEGF agents, but perhaps would have a longer treatment interval.
There are some other molecules in clinical trials that have demonstrated perhaps a longer treatment interval. But with some of those molecules, there have been some reports of significant intraocular inflammation that have, unfortunately, caused some of those trials to then, or the evaluation of those molecules to then need further investigative work to get them to be as safe as can be. One other thing is a device that's actually surgically implanted into the vitreous cavity. This is called the port delivery system, and it's essentially a small reservoir that's surgically implanted and can then be refilled in the clinic, but then it might last upwards of 6 months in between times of filling up that reservoir.
Those are some of the things that I'm most excited about. There are also some developments in home monitoring devices. Something like a home OCT device. I don't believe that's going to be available anytime soon to the general public, but just in this era of telemedicine, work from home, limit how much people have to go to the hospital or to the clinic, these are some things that might actually find that their development is actually accelerated because of the current public health crisis.
Dr. Freeman: Great. Well, listen, you have been very instructional, and for that I thank you. Hopefully, our listenership enjoyed this as much as I did, so thank you for sharing.
Dr. Lewen: Thank you very much for having me. It was a privilege talking to you, Dr. Freeman.
Dr. Freeman: Thank you, Dr. Lewen.