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American Academy of Ophthalmology |
November 15, 2020 |
The 2020 AAO Annual Meeting is providing plenty of discussion, between presenters coming to us from their own homes, and also with attendees through the chat feature! |
Retina Imaging in Pediatrics
Cynthia Toth, MD, Duke University, talked about new imaging technologies, for use in older children such as children in clinic, and in infants. She said in clinic, ultrawidefield fundus imaging is extremely valuable as is handheld OCT and tabletop OCT, with the techniques varying based on age and the ability of the child to cooperate and fixate. She suggests avoiding long wait times and using illuminated toys or cell phones as fixation targets. A stepstool can be used for tabletop systems if needed. Because it can be difficult to do an ophthalmoscopic retinal exam in a moving young child, it may be easier to get information from ultrawidefield images. Color photos and ultrawidefield SLO are especially useful in diseases with peripheral pathology. Other novel imaging modalities are in the applications of UBM, or portable OCT and investigational OCT angiography. Dr. Toth said her group has used infant OCT imaging systems at the bedside since 2008 but more recently has tried swept-source OCT in an NIH-funded study, Baby STEPS (Study of Eye-brain development in Preterm infantS). The OCT handpiece used in the study is lighter than the commercial device and does not contact the eye, and pupil dilation is not mandatory. Dr. Toth said early findings from Baby STEPS demonstrate how OCT aids in identifying challenges in neurovascular development in preterm infants, and that thoughtful use of imaging is essential for robust pediatric retinal assessment.
Post-COVID procedures
Natalie Loyacano, COMT, ROUB, OSA, OCSR, (F)ATPO, and Joanne Mansour, OCSR, hosted a very interesting question and answer session about steps they have considered or taken as their practices recover from the slow down caused by the COVID-19 pandemic. Attendees were able to ask questions through the chat feature during the presentation. It was discussed that patient volume has returned to pre-COVID levels, following a spike in volume that occurred as patients made up missed appointments. Any injection patients that stopped coming in are being encouraged to return. It’s important to document if patients choose not to come in, and to document efforts you made to suggest they come in, to avoid potential liability. Some patients and staff have trouble wearing masks, and mask-wearing can increase difficulty in communication, so steps should be taken to make everything easier. Plastic inserts that go under the mask can help staff members breathe more easily, and staff and doctors can speak more slowly and loudly, etc. Patients should keep their masks on as much as possible during the procedures, and doctors can add tape just above the mask so their patient’s breath doesn’t go up to the eye, to avoid endophthalmitis. They suggested doing as much as possible in the parking lot instead of bringing the patient in right away, and very importantly wiping everything down after every patient. Another tip was to not let supplies get too low, as purchasing may require more lead time. And finally, do things to let staff know they’re appreciated during this time; buy lunch for the office, or in some way recognize them as doing a good job.
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Cell Therapy for Atrophic AMD |
Allen Ho, MD, of Wills Eye and Mid-Atlantic Retina, said cell therapy continues to move forward for patients with atrophic AMD. He noted that the FDA is tightening regulation of unregulated stem cell clinics and most trials in humans are using embryonic stem cell RPE cell lines, which have been well tolerated to date. There are refinements in surgical delivery techniques and surgical delivery tools, and early positive signals for visual function and OCT architecture are being observed. Dr. Ho said there is more problem-solving to do, but the 2020 report is cautiously optimistic.
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Faricimab Trial in Patients with DME |
Karl Csaky, MD, PhD, Retina Foundation of the Southwest, Dallas, discussed the results of the BOULEVARD trial, comparing the efficacy of faricimab with ranibizumab in treatment-naïve patients with DME. He specifically discussed exploring the Ang-2 signaling in vascular stability. The results demonstrated improved efficacy and durability outcomes compared with standard ranibizumab treatment, and suggest a potential benefit of the simultaneous suppression of Ang-2 and VEGF-A. Dr. Csaky said more importantly the aspects underlying this have now been demonstrated for the first time in humans. Phase 3 programs are under way to compare faricimab with aflibercept in DME.
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IRIS Registry Analysis of GA Secondary to AMD |
Ehsan Rahimy, MD, of Palo Alto, CA, presented the results of an analysis of the AAO IRIS registry, evaluating geographic atrophy secondary to AMD in real-world clinical practice. Dr. Rahimy said a detailed description of the real world disease progression of GA is essential as new agents are being developed to treat it. He said this is the largest retrospective database study of the natural history of GA progression to date, and that it’s important to note a large proportion of patients did not return for follow up after 2 years. Visual acuity is generally not greatly impaired for patients with GA at their first clinical visit related to this disease. Dr. Rahimy said eyes with good vision at baseline tend to lose more letters in the first 2 years compared to eyes with poor vision at baseline, and progression to nAMD occurs much more frequently if nAMD is present in the other eye.
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Targeted Therapy for Choroidal Melanoma |
Carol Shields, MD, of Wills Eye Hospital, said AU-011 is a targeted therapy for choroidal melanoma that can be distributed by intravitreal or suprachoroidal administration. It is a viral nanoparticle bioconjugate that specifically binds to heparin sulfate on the tumor cell surface, and is then laser-activated to disrupt the tumor cell membrane leading to necrosis and an anti-tumor immune response. A phase 2 suprachoroidal delivery study initiated in August 2020, with primary objectives of safety and tolerability, determined the highest tolerated regimen and established efficacy in the randomized expansion phase. Three single-dose cohorts have been completed and the safety profile to date is favorable. Multiple-dose cohorts are expected to be enrolled early in 2021. Dr. Shields closed saying that AU-011 has the potential to be the first targeted therapy for the treatment of small choroidal melanoma and indeterminate lesions.
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Bioelectronic Artificial Sight |
Mark Humayun, MD, PhD, University of Southern California, said advanced eye implants such as retinal prostheses and visual cortical prostheses often include electronics, and that possible future electronic devices could include electronic IOLs that change focus, and electronic devices to help tear production. He discussed several approaches for visual restoration, both retinal and non-retinal, and said most of these technologies have been aimed at use in inherited retinal degenerations that lead to loss of photoreceptors, covered under the broad term retinitis pigmentosa. Dr. Humayun explained that bioelectronic solutions bypass damaged neurons, they are agnostic of the genetic defect and bypass the affected photoreceptors, and they stimulate groups of neurons. He said visual prostheses provide useful restoration of some vision, and said the Argus II epiretinal prosthesis is approved in the US and Europe for IRDs, and a visual cortical prosthesis, Orion, is being developed. A subretinal prosthesis, Pixium, is in early stage clinical trials. Dr. Humayun says surgical technique and placement is critical, and training with the device is important as well. Improvements in both hardware and software are being pursued to improve these technologies further.
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Retina Cafe |
Jennifer Lim, MD, Amani Fawzi, MD, Jeffrey Heier, MD, and Reginald Sanders, MD, had a very interesting conversation about a number of topics in the Academy Café: Retina. They discussed home monitoring, management of diabetic patients, desires for upcoming AMD treatments (long-term drug delivery and gene therapy are strong interests), and said geographic atrophy treatment is the “next frontier”. They also discussed appropriate situations for use of a scleral buckle, and the use of brolucizumab in certain situations. The panel wrapped up with a brief statement from each about the COVID-19 pandemic. The panelists said it has helped the field become stronger in terms of safety and efficiency, and allowed growth through breaking down preconceived notions. It also showed that the thirst for continued learning and sharing of information is so great it caused opportunity to create these virtual meetings.
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It’s not over yet! There’s one more day full of informative talks and interaction! |
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