Advancements in the Management of Macular Edema following Retinal Vein Occlusion - Episode 9
Expert perspectives on the ongoing unmet needs in the management of macular edema following retinal vein occlusion.
Rishi P. Singh, MD: Let’s talk about some of the unmet needs. We talked about all the things we already know about this condition. What are the unmet needs you would say in retinal vein occlusion management at this given stage?
Jayanth Sridhar, MD: We have wonderful treatment options, we’ve got to start there. I’d be very grateful. It’s a lot easier to be a retina specialist treating a retinal vein occlusion now than it was 20 years ago. We don’t achieve perfection. One of the things we talked about at the beginning was we say OK, you’re going to get your vision better, but we don’t promise that they’re going to get them back to baseline. One big unmet need is, can we reverse some of the initial damage? There’s something there in some of these patients that even if you capture them early and treat them early, they don’t get back to their baseline visual acuity. Maybe they have disorganization of the retinal layers which term drill. That’s the anatomic feature. But the point is that the retinal tissue has experienced something where it does not function at the same level as it did previously. For our patients that’s the biggest unmet need. The second unmet need is what do we do with those patients who cannot come off treatment? They are grateful that they have options. They just wish that their option didn’t include a needle in their eye every couple of months for what they see is the foreseeable future. We have drugs, obviously for other conditions in trials now that offer benefits that may be more sustained release. Maybe something involving gene therapy. None of those are being targeted directly at vein occlusion in relation to other retinal vascular disease to be looked at. For me those would be the 2 biggest unmet needs. Can you get back to baseline, restore some normal retinal architecture? Can you get to the point where the patient no longer needs…more of these patients can get off treatment completely?
Rishi P. Singh, MD: I would agree. I’ve been working on some artificial intelligence [AI] ways of predicting who needs chronic therapy and one of the things you’ll see from my research in 2022 will be some of our research focusing on the AI-based interpretation of where we may be able to determine who will require a higher low frequency of injections based upon some of the clinical trial data. And the answer is there are some predictive factors that we see there. They’re very few but there are some. And they’re the anatomical change between day 0 and week 4 and week 8. That’s really the ones that are predictive of the future results. For that I think we’re going to learn a lot about how we might be able to predict the chronicity of these patients. But you’re right. Predicting the chronicity, the future need for injections is always difficult to do. I would see the other unmet need. A topic we didn’t even discuss today is around ischemic vein occlusions. Those patients who have the worst of the worst come in with count fingers, hand motion, vision and totally nonperfused retinas. We don’t have an acute way of managing these patients even when they present to our office these cases. That’s an unmet need I would say regarding that. The last unmet need is around determining in the younger patient what the cause of this is. Obviously, the older person we can blame it on atherosclerosis or blood pressure related issues. The younger patients, I’m sure you see them too. I get patients all the time—that young patient, healthy individual, marathon runner, athlete. Not obese. Not any risk factors. No coagulopathies. And subsequently they have a vein occlusion. You’re then managing that and that can be devastating especially for a young patient who has many years ahead in their lives. There’s another unmet need that probably we need to factor and summarize at some point as well with all of that stuff that we’re doing. Let’s share some final thoughts on vein occlusion and I can add mine as well.
Jayanth Sridhar, MD: It’s been a pleasure talking to you. I always learn a lot talking to you about retinal vein occlusion. We have great drugs that work. Anti-VEGF works. Steroids work. We still employ laser in certain scenarios. We have great treatment options. I’m excited to see your research. There’s a lot to look forward to in the future. I would end but one thing I think just to reiterate for people out there who are treating these patients, keep an eye on your central retinal vein occlusion patients. I feel like that was one I mentioned already, but that was one of the things myself and other people, when they left training and went into practice, those are the patients that I found myself undertreating when I first started and realized very quickly that you need to be vigilant and continue treatment, at least with current therapies in those patients. That would be my one takeaway to reemphasize that point. That point gets lost sometimes. Something that wasn’t so apparent to me when I came out into training.
Rishi P. Singh, MD: I would say that that’s also very important to understand. This idea of the past couple years of anti-VEGF therapy has taught us a lot about how to manage those patients. The idea of scattered laser coagulation doesn’t work. It’s not necessary for these patients. A lot of retina specialists still do that thinking it’s beneficial. A good follow-up and management of the complications is obviously key to success in these patients. I know that a lot of these patients may develop some other related activities or issues and that can be devastating when they occur. But still, we can manage those well for the most part. I would say that again while the drugs may look similar to us at face value, as we’ve seen from some of the recent studies. We’ve seen some major differences regarding their effectiveness and what the clinical trial data shows. And that’s something we can all take with some grain of salt knowing that we necessarily need to find the right agent for the right patient per se because there’s differences in the agents for each patient.
Jayanth Sridhar, MD: Just to add on what you said about complications. On one hand scattered laser photo coagulation you referenced does not seem to decrease injection burden in macular edema. But if you have a patient who is [at] risk for any vascular complications, multiple trials have shown anti-VEGF works up to a point but with cessation of therapy, gaps in therapy we saw with the pandemic. Those patients are at high risk for neovascularization of the iris and CRVOs [central retinal vein occlusion] and posterior neovascularization of the branch. Don’t be afraid to use scattered laser in those patients with ischemic occlusions as they are the ones who can really benefit. Not necessarily to treat their macular edema but to prevent complications of the occlusion.
Rishi P. Singh, MD: Thank you all for watching this HCPLive® Peers & Perspectives. If you enjoyed this content, please subscribe to our e-newsletter to receive upcoming Peers & Perspectives and other great content right in your inbox. Thank you for watching.
Transcript edited for clarity.