Advancements in the Management of Macular Edema following Retinal Vein Occlusion - Episode 7
Two experts discuss real-world treatment and observation of patients with macular edema after retinal vein occlusion.
Jayanth Sridhar, MD: Let’s transition to what we do in the real world. It’s not just about efficacy. There is a durability component that’s important. It’s hard for patients to come in for visits. There may be durability differences between these drugs that would not be picked up in the study, such as SCORE2. As you said it’s a monthly treatment with both drugs but my question for you is let’s say you have [a] new patient come in, they have a vein occlusion macular edema. Let’s take insurance issues off the table, do you initiate treatment that first day, what drug do you start with and what do you tell the patients in terms of how often we are going to do this? When am I going to see you back?
Rishi P. Singh, MD: Great question. Again, the one piece you didn’t tell me about was your vision. If their vision is 20/20 or 20/25, I will observe that patient because I am not sure there is a clinical benefit especially in the younger patients. A lot of them have resolve macular edema over time just by getting a single injection or watching for that matter for the first couple of injections and seeing how their response is. The patient’s vision factors into that discussion. I look at the vision and determine is the vision person who has count fingers vision or worried about nonperfusion. Is that person who has 21/100 visual acuity, which is a perfused nonischemic retinal vein occlusion, which is ready for prime time and ready for studies and how I determine treatment or is it a patient who has really good vision where I might tend to observe and see how they do over time. How about you? What is your threshold for treating these patients?
Jayanth Sridhar, MD: Vision is super important. Even if they have mild macular edema, but they are happy that it is asymptomatic, vision is in the good range then I don’t necessarily jump to treatment. But I will schedule that visit for a month and repeat the OCT [optical coherence tomography] because some of these patients can tip over and get worse. Same goes for the patient with vein occlusion, no macular edema, sometimes they will get referred to me and I will say, you know what, we don’t necessarily know if you are going to get macular edema, your vision is very good, let’s watch you closely, and have the conversation about treatment. If they do have macular edema and it is significant, their vision is down then I will usually initiate treatment. I tend to initiate bevacizumab [Avastin] in a lot of these patients. Insurance ties into some of that. I don’t have an opposition to starting with other drugs as you referenced from LEAVO that there may be a benefit to using ranibizumab [Lucentis] and aflibercept but what I tend to tell patients as we are going to start with this drug, and I am going to reassess you in a month, and we are probably going to do monthly injections for the first couple of months, maybe up to 3 months. But, like you said, if the edema completely goes away then we might change that plan. The other thing I will tell them it’s a little different, there are branch retinal vein occlusion [BRVO], I will sometimes say look if we get out to 3 months and the edema is completely gone based on older data there is about a third chance that you may not need continued therapy, but there is a chance we will need continued therapy at a longer duration or if you’re not having a full response at that point I will usually offer another anti-VEGF [vascular endothelial growth factor] and I will talk about that upfront. CRVO [central retinal vein occlusion] I am more cautious about talking to them and stopping therapy. They tend to be more resistant to complete cessation and a lot of those patients need prolonged therapy even if it’s extended. I don’t know if you detect the same difference between these 2 entities.
Rishi P. Singh, MD: Absolutely. With CRVO it has a higher rate of VEGF production and VEGF vitreous levels. It makes total sense that you may need more frequent injections with CRVO versus BRVO patient. I would add to that. I think the method of treatment must be discussed. We just did analysis of all the treat and extend studies out for retinal vein occlusion. There are very few out there. Though the vast majority of retinal specialist according to things like SPAT [INAUDIBLE] and others use treat and extend format for these patients. I tend to do PRN [pro re nata] form just as starters to see how their response is and how they are progressing and how they are doing. And then I titrate based upon if they are chronic frequent fliers, need constant injections, it’s time to start to consider more of treat and extend approach. But if there are 1 or 2 injections in a year because I did PRN approach and they are doing great and they know the signs and symptoms to watch out for, I could not let them go and I don’t treat them proactively. I don’t know what your thoughts on that are.
Jayanth Sridhar, MD: It’s a great point especially we all have the home run injection patient. You give them 1 injection, they come back in a month, they are super happy, vision is great. The edema is completely gone. Do you need to continue treat and extend versus the PRN approach, maybe you watch them and see them back in a month? Both are reasonable, but it does sometimes help to test and see what kind of vein occlusion it is. How are they going to behave over time? I think the other interesting thing to think about, if you do use treat and extend approach is how aggressive are you about recurrent intraretinal fluid [IRF]. We know from other conditions it is macular degeneration, maybe we don’t need to be as aggressive as we previously thought but recurrent IRF in a vein occlusion patient, obviously it depends on the vision degree but let’s say you are a patient who has been extended forward to 6 to 8 years realize that they have extended over time. And now they have a little bit of intraretinal fluid, but the vision is still good. Do you intervene? Do you want them back in a month? What’s your take? How aggressively to titrate those patients?
Rishi P. Singh, MD: Again, if the vision is good, I tend to watch this patient at least initially. They must develop some level of chronicity before I am willing to continue therapy indefinitely. It just depends on the patient. I am making sure that we hit that goal for them. Ultimately, Jay, a lot of us when we look at this, we always say is the vision sufficient for ADL [activities of daily living]. If your patient is 20/25 or 20/30 and they can do things they want to do and they don’t have any detriment or they have no concerns around it, I just continue watching them at that point if their macular edema is resolved or minimal and not the difference there.
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Transcript edited for clarity.