This document provides an overview of newer anti-VEGF therapies for treating retinal diseases involving abnormal blood vessel growth (neovascularization). It discusses the mechanisms and indications of established therapies like bevacizumab, ranibizumab, and aflibercept. It then summarizes several newer anti-VEGF agents currently in clinical trials, including conbercept, brolucizumab, abicipar pegol, and faricimab. These newer therapies aim to provide improved efficacy compared to existing options through mechanisms like inhibiting additional growth factors or requiring less frequent dosing. Ongoing clinical trials are evaluating their safety and ability to improve vision outcomes in conditions like wet age-related macular degeneration and diabetic
This document summarizes key details about three anti-VEGF drugs - ranibizumab, aflibercept, and bevacizumab. It provides information on their company, mechanism of action, molecular weight, half-life, licensed indications, formulation, and structure. The drugs are compared in terms of targeting specific VEGF isoforms and receptors. Clinical evidence suggests inhibition of VEGFR-1 provides no additional benefit over inhibition of VEGFR-2 for conditions like wet AMD and DME.
VEGF inhibitors are used to treat eye diseases characterized by abnormal blood vessel growth such as age-related macular degeneration and diabetic retinopathy. Bevacizumab, ranibizumab, aflibercept, and pegaptanib are VEGF inhibitor drugs administered via intravitreal injection that bind to VEGF and inhibit its activity. They have been shown to reduce vascular permeability and slow disease progression. Common side effects include hypertension, bleeding, and eye inflammation. VEGF inhibitors are an important treatment option for neovascular eye diseases.
This document provides information on evaluating preperimetric glaucoma through three main tests: scanning laser polarimetry (GDX), confocal scanning laser ophthalmoscopy (HRT), and optical coherence tomography. GDX uses scanning laser polarimetry to measure retinal nerve fiber layer thickness, while HRT uses confocal laser scanning to create 3D images and calculate stereometric parameters of the optic disc and cup. Both tests provide objective, rapid assessments of preperimetric glaucomatous damage before visual field loss occurs. Early diagnosis of preperimetric glaucoma allows for earlier treatment to delay disease progression.
The document discusses key findings from several DRCR protocols:
1. Protocol B compared IV steroids and laser for DME and found steroids were not superior and had more adverse events than laser.
2. Protocol I found ranibizumab with prompt or deferred laser had superior vision outcomes compared to laser alone for DME. TA plus laser had similar results to ranibizumab.
3. Protocol S showed ranibizumab was non-inferior to PRP for PDR and had better vision outcomes and less DME and progression than PRP. However, long term stability is still unknown.
4. The PROTEUS study found ranibizumab plus PRP was more
This document provides guidance on managing failing blebs after glaucoma surgery. It discusses risk factors for bleb failure, the histology of functioning vs failed blebs, typical appearances of failed blebs, identifying the cause of failure as internal or external blockage, and various management techniques. These include increasing digital pressure, medications, laser suture lysis, and bleb needling with or without anti-metabolites like mitomycin C or 5-fluorouracil to restore bleb function and control intraocular pressure. Complications of bleb needling are also reviewed.
This document discusses non-penetrating glaucoma surgery techniques that facilitate the drainage of aqueous humor through the trabecular meshwork and Schlemm's canal without opening the anterior chamber. It describes several procedures including deep sclerectomy, viscocanalostomy, canaloplasty, ab-externo trabeculectomy, and laser trabecular ablation. The goal is to bypass the highest resistance point to outflow in the juxtacanalicular meshwork. Advantages include lower risks of complications like hypotony compared to penetrating surgeries. Indications and contraindications are provided for various non-penetrating glaucoma procedures.
Wet AMD is caused by the growth of abnormal blood vessels under the retina (choroidal neovascularization, or CNV). There are three types of CNV based on their origin: type 1 from the choroid, type 2 between the RPE and retina, and type 3 from the deep retinal vessels. CNV causes leakage and bleeding that can damage the retina. Diagnosis involves imaging like OCT, FFA, and ICG to detect fluid, leaking vessels, or scarring. Treatment focuses on inhibiting CNV through anti-VEGF injections or photodynamic therapy.
This document provides information on giant retinal tears, including:
1. Giant retinal tears are defined as circumferential retinal tears greater than 90 degrees. They require urgent management to prevent further retinal detachment from proliferative vitreoretinopathy.
2. Causes include idiopathic, trauma, high myopia, and certain genetic conditions. Surgical procedures like LASIK and phakic IOLs can also cause giant retinal tears.
3. Vitrectomy is the standard treatment, involving removal of the vitreous gel, retinopexy, and an internal tamponade of long-acting gas or silicone oil to reattach the retina. Perfluorocarbon liquids help stabilize the retina
This document summarizes key details about three anti-VEGF drugs - ranibizumab, aflibercept, and bevacizumab. It provides information on their company, mechanism of action, molecular weight, half-life, licensed indications, formulation, and structure. The drugs are compared in terms of targeting specific VEGF isoforms and receptors. Clinical evidence suggests inhibition of VEGFR-1 provides no additional benefit over inhibition of VEGFR-2 for conditions like wet AMD and DME.
VEGF inhibitors are used to treat eye diseases characterized by abnormal blood vessel growth such as age-related macular degeneration and diabetic retinopathy. Bevacizumab, ranibizumab, aflibercept, and pegaptanib are VEGF inhibitor drugs administered via intravitreal injection that bind to VEGF and inhibit its activity. They have been shown to reduce vascular permeability and slow disease progression. Common side effects include hypertension, bleeding, and eye inflammation. VEGF inhibitors are an important treatment option for neovascular eye diseases.
This document provides information on evaluating preperimetric glaucoma through three main tests: scanning laser polarimetry (GDX), confocal scanning laser ophthalmoscopy (HRT), and optical coherence tomography. GDX uses scanning laser polarimetry to measure retinal nerve fiber layer thickness, while HRT uses confocal laser scanning to create 3D images and calculate stereometric parameters of the optic disc and cup. Both tests provide objective, rapid assessments of preperimetric glaucomatous damage before visual field loss occurs. Early diagnosis of preperimetric glaucoma allows for earlier treatment to delay disease progression.
The document discusses key findings from several DRCR protocols:
1. Protocol B compared IV steroids and laser for DME and found steroids were not superior and had more adverse events than laser.
2. Protocol I found ranibizumab with prompt or deferred laser had superior vision outcomes compared to laser alone for DME. TA plus laser had similar results to ranibizumab.
3. Protocol S showed ranibizumab was non-inferior to PRP for PDR and had better vision outcomes and less DME and progression than PRP. However, long term stability is still unknown.
4. The PROTEUS study found ranibizumab plus PRP was more
This document provides guidance on managing failing blebs after glaucoma surgery. It discusses risk factors for bleb failure, the histology of functioning vs failed blebs, typical appearances of failed blebs, identifying the cause of failure as internal or external blockage, and various management techniques. These include increasing digital pressure, medications, laser suture lysis, and bleb needling with or without anti-metabolites like mitomycin C or 5-fluorouracil to restore bleb function and control intraocular pressure. Complications of bleb needling are also reviewed.
This document discusses non-penetrating glaucoma surgery techniques that facilitate the drainage of aqueous humor through the trabecular meshwork and Schlemm's canal without opening the anterior chamber. It describes several procedures including deep sclerectomy, viscocanalostomy, canaloplasty, ab-externo trabeculectomy, and laser trabecular ablation. The goal is to bypass the highest resistance point to outflow in the juxtacanalicular meshwork. Advantages include lower risks of complications like hypotony compared to penetrating surgeries. Indications and contraindications are provided for various non-penetrating glaucoma procedures.
Wet AMD is caused by the growth of abnormal blood vessels under the retina (choroidal neovascularization, or CNV). There are three types of CNV based on their origin: type 1 from the choroid, type 2 between the RPE and retina, and type 3 from the deep retinal vessels. CNV causes leakage and bleeding that can damage the retina. Diagnosis involves imaging like OCT, FFA, and ICG to detect fluid, leaking vessels, or scarring. Treatment focuses on inhibiting CNV through anti-VEGF injections or photodynamic therapy.
This document provides information on giant retinal tears, including:
1. Giant retinal tears are defined as circumferential retinal tears greater than 90 degrees. They require urgent management to prevent further retinal detachment from proliferative vitreoretinopathy.
2. Causes include idiopathic, trauma, high myopia, and certain genetic conditions. Surgical procedures like LASIK and phakic IOLs can also cause giant retinal tears.
3. Vitrectomy is the standard treatment, involving removal of the vitreous gel, retinopexy, and an internal tamponade of long-acting gas or silicone oil to reattach the retina. Perfluorocarbon liquids help stabilize the retina
Vascular endothelial growth factors promote neovascularization and break the blood-retinal barrier. Anti-vascular endothelial growth factor (anti-VEGF) therapies block VEGF's actions, decreasing abnormal new blood vessel formation and retinal leakage/swelling. This stabilizes vision and may improve it. Bevacizumab, ranibizumab, and aflibercept are examples of anti-VEGF drugs used intravitreally to treat wet age-related macular degeneration, diabetic retinopathy, retinal vein occlusion and other conditions. While effective, anti-VEGF therapies require frequent injections and monitoring for side effects like increased intraocular pressure.
Anti-VEGF agents such as bevacizumab, ranibizumab, pegaptanib, and aflibercept are used to treat retinal diseases caused by abnormal blood vessel growth due to VEGF overexpression. They work by inhibiting VEGF to prevent new blood vessel proliferation and leakage. Common uses include treating wet age-related macular degeneration, diabetic retinopathy, retinal vein occlusions, and retinopathy of prematurity. Ranibizumab and aflibercept are approved by the FDA, while bevacizumab is commonly used off-label. Monthly intravitreal injections are typically required initially, then treatments are extended based on disease response. Adverse events include inflammation, increased intraocular pressure, and
Retinal vein occlusions are the second most common retinal vascular disease after diabetic retinopathy. Several studies have evaluated treatments for macular edema secondary to retinal vein occlusions. Anti-VEGF drugs like ranibizumab, aflibercept, and bevacizumab have been shown to significantly improve visual acuity and reduce macular thickness compared to observation or laser, with benefits maintained over 1-2 years. Dexamethasone intravitreal implants also provide initial benefits but effects are not sustained long-term and are associated with increased risks of cataract and elevated intraocular pressure.
Wide angle viewing field systems in vr surgerySamuel Ponraj
Wide angle viewing systems provide panoramic views of the retina during vitreous surgery. There are contact and non-contact systems. Contact systems include vitreous panfundoscopes, contact wide field lenses, advanced visual instrument systems, and reinverting operating lens systems. These provide good image resolution but require an inverter due to the inverted image and have risks of corneal trauma. Non-contact systems like the BIOM and Resight provide upright images without inversion but have poorer image quality. Newer non-contact systems aim to provide wide fields of view with upright high resolution images.
This document discusses ophthalmic viscosurgical devices (OVDs), including their history, properties, composition, classification, and uses. It begins by describing the introduction of sodium hyaluronate as the first OVD used in ophthalmic surgery in 1972. It then covers the ideal properties of an OVD and the rheological properties of viscosity, elasticity, coatability, and others. OVDs are classified as cohesive, dispersive, or viscoadaptive based on their molecular structure and behavior. The document discusses the advantages and uses of OVDs in cataract surgery, glaucoma surgery, keratoplasty, and other ophthalmic procedures. It concludes by outlining complications like
This document discusses the diagnosis of pre-perimetric glaucoma. It begins by defining pre-perimetric glaucoma as optic nerve abnormalities seen on structural tests with normal visual fields. It then discusses the need for early diagnosis before functional changes occur. Various functional tests are described like standard automated perimetry, short wavelength automated perimetry, frequency doubling technology, and others. Structural tests like confocal scanning laser ophthalmoscopy, optical coherence tomography, and their principles are summarized.
This document summarizes information about different gauge vitrectomy systems including 20 gauge, 23 gauge, and 25 gauge. It provides details on the instrumentation, techniques, advantages and disadvantages of each system as well as indications for microincision vitrectomy surgery. Key points include that 23 gauge combines benefits of 20 and 25 gauge, has better flow rates and maneuverability than 25 gauge, and is considered a potential future gold standard. Smaller gauge systems allow for reduced trauma, faster recovery, and greater flexibility for complex procedures.
This document summarizes recent advances in treating age-related macular degeneration (AMD). It discusses new drugs that aim to prevent retinal damage or slow AMD progression by inhibiting angiogenesis, inflammation, the complement pathway, oxidative stress, and retinal toxin accumulation. It also describes surgeries like maculoplasty and bionic eye implants, as well as rehabilitation techniques and low vision aids. Promising new drug classes discussed include anti-angiogenics, complement inhibitors, neurotrophic factors, and antioxidants.
Vitreous substitutes are substances used during vitreoretinal surgery to re-establish intraocular volume, assist with separating membranes from the retina, and manipulate and flatten detached retina. They are also used postoperatively as long-term tamponading agents to maintain the retina in apposition. Common vitreous substitutes used include balanced salt solution, air, viscoelastic fluids, silicone liquid, and perfluorocarbon liquids. Gases such as air, SF6, and C3F8 are employed during retinal detachment surgery to provide internal tamponade and are chosen based on their duration, expansion properties, and buoyancy effects. Complications can include increased intraocular pressure, lens opac
AUTHOR DR RUPALI TYAGI, CO-AUTHOR 1 DR SHUBHA NAGPAL, CO-AUTHOR 2 DR NEELAM PUTHRAN, CO-AUTHOR 3 DR VARSHA KULKARNI MS OPHTHALMOLOGY BHARATI HOSPITAL BHARATI VIDYAPEETH UNIVERSITY PUNE
Glaucoma drainage devices are implants used to drain aqueous humor from the anterior chamber to control intraocular pressure. They consist of a silicone tube extending from the anterior chamber to a plate beneath the conjunctiva. Open tube designs like Molteno and Baerveldt and flow-restricted designs like Ahmed are commonly used. GDDs are generally used when filtering surgeries have failed or are likely to fail. While they effectively lower IOP, complications can include hypotony, elevated IOP, migration or erosion of the device, and diplopia. Long-term studies show success rates of 65-85% in maintaining IOP control.
This document summarizes anti-VEGF drugs used to treat retinal diseases caused by abnormal blood vessel growth. It discusses the role of VEGF in these diseases and introduces several anti-VEGF drugs including pegaptanib, bevacizumab, ranibizumab, and aflibercept. It provides details on the mechanism of action, safety profiles, and costs of these drugs and compares the efficacy and safety of bevacizumab and ranibizumab based on studies like CATT. The document serves as an educational reference on anti-VEGF therapies for retinal specialists.
Laser retinal therapy uses lasers to treat various retinal conditions:
1. Pan-retinal photocoagulation uses lasers like argon to treat diabetic retinopathy by reducing retinal ischemia.
2. Macular edema is treated with focal or grid laser photocoagulation targeted at leaking microaneurysms or diffuse areas of leakage.
3. Retinal tears and detachments are treated preventatively with laser barrage surrounding tears to stimulate proliferation and adhesion.
Optical coherence tomography in glaucoma - Dr Shylesh DabkeShylesh Dabke
This document discusses optical coherence tomography (OCT) in evaluating glaucoma. It begins by outlining the importance of early glaucoma detection to prevent vision loss. OCT is described as the most appropriate technology for detecting glaucoma as it can assess retinal nerve fiber layer (RNFL) thickness before visual field or optic disc changes occur. RNFL thinning is an early sign of glaucoma. The document then provides details on OCT technology and analysis of RNFL thickness, optic nerve head, and macula to diagnose and monitor glaucoma. RNFL analysis, especially of the inferior quadrant, is highlighted as the most useful OCT assessment for detecting early glaucoma.
This document provides information on anti-VEGF drugs used in ophthalmology. It discusses the role of VEGF in various eye diseases and conditions. It summarizes the properties, mechanisms of action, administration, and safety profiles of major anti-VEGF drugs including bevacizumab, pegaptanib, and ranibizumab which are used to treat wet age-related macular degeneration, diabetic retinopathy, and other retinal diseases by inhibiting abnormal blood vessel growth and leakage caused by VEGF.
This document discusses potential complications of trabeculectomy, both intraoperative and postoperative. Intraoperative complications include buttonholing of the conjunctiva, scleral flap tears, lens injury, vitreous prolapse, hyphema, and suprachoroidal hemorrhage. Postoperative complications can be early such as hypotony, elevated intraocular pressure, choroidal effusions or late such as thin blebs, infections, and cataracts. Management strategies are provided for addressing complications depending on the specific issue.
This document discusses choroidal neovascularization (CNV), which is the abnormal growth of blood vessels from the choroid into the retina or subretinal space. It is a cause of vision loss and the main feature of exudative age-related macular degeneration. The document defines CNV and lists various conditions that can cause it. It then focuses on CNV caused by age-related macular degeneration, covering risk factors, pathogenesis, symptoms, diagnostic findings on fluorescein angiography and OCT, and various treatment options including anti-VEGF drugs, photodynamic therapy, and laser photocoagulation.
Multifocal choroiditis is a recurrent inflammatory eye condition characterized by small, randomly distributed chorioretinal scars that predominantly affects young to middle-aged females. It can cause decreased vision, photopsia, and scotomas. While fluorescein angiography may not detect active lesions, indocyanine green angiography is highly sensitive for finding new areas of choriocapillaris nonperfusion. Treatment typically involves corticosteroids, though recurrence is common.
This document discusses various vitreous substitutes and intraocular gases used to replace the vitreous humor after surgery. It describes the anatomy and composition of the natural vitreous and ideal properties for substitutes. Common substitutes discussed include gases like air, sulfur hexafluoride and perfluorocarbons; liquids like silicone oil, perfluorocarbon liquids and semi-fluorinated alkanes; and experimental polymers and implants. The document compares different options and provides details on how each works, associated complications, and appropriate uses.
This document discusses potential neuroprotective strategies for glaucoma. It begins by explaining that glaucoma involves the loss of retinal ganglion cells and their axons, and that while elevated intraocular pressure is a risk factor, progression can still occur when pressure is lowered. Neuroprotection aims to protect these cells from degeneration. Several potential neuroprotective approaches are then described, including NMDA antagonists to reduce excitotoxicity, anti-apoptotic agents to block cell death pathways, currently used drugs that may have neuroprotective effects, antioxidants to reduce free radicals, calcium channel blockers, neurotrophic factors, gene therapy targeting apoptotic factors, and immunomodulators.
EMERGING APPROACHES TO COMBINATION THERAPIES IN AMD & DME - RegeneronHealthegy
This document discusses combination therapies for treating wet age-related macular degeneration (AMD) and diabetic macular edema (DME) that involve adding anti-PDGF or anti-Ang2 antibodies to aflibercept. For wet AMD and DME, monotherapy with anti-VEGF drugs like aflibercept only helps about 30-40% of patients gain 3 lines of vision and maintain a dry retina long-term. The document describes early clinical trial results of combining aflibercept with rinucumab (anti-PDGF) and with nesvacumab (anti-Ang2), which showed these combinations were well tolerated and may provide synergistic effects to improve vision outcomes over aflibercept
1. VEGF is a growth factor that promotes abnormal blood vessel growth in the retina and is responsible for many retinal diseases. Anti-VEGF drugs like ranibizumab (Lucentis), bevacizumab (Avastin), and pegaptanib (Macugen) block VEGF to inhibit this blood vessel growth and treat retinal diseases.
2. While ranibizumab, Avastin, and pegaptanib are all anti-VEGF drugs, they differ in their structure and dosing. Ranibizumab and Avastin are antibodies while pegaptanib is a nucleic acid. Avastin costs $45 per dose while ranibizumab costs over $1500.
3. Clinical trials found ranib
Vascular endothelial growth factors promote neovascularization and break the blood-retinal barrier. Anti-vascular endothelial growth factor (anti-VEGF) therapies block VEGF's actions, decreasing abnormal new blood vessel formation and retinal leakage/swelling. This stabilizes vision and may improve it. Bevacizumab, ranibizumab, and aflibercept are examples of anti-VEGF drugs used intravitreally to treat wet age-related macular degeneration, diabetic retinopathy, retinal vein occlusion and other conditions. While effective, anti-VEGF therapies require frequent injections and monitoring for side effects like increased intraocular pressure.
Anti-VEGF agents such as bevacizumab, ranibizumab, pegaptanib, and aflibercept are used to treat retinal diseases caused by abnormal blood vessel growth due to VEGF overexpression. They work by inhibiting VEGF to prevent new blood vessel proliferation and leakage. Common uses include treating wet age-related macular degeneration, diabetic retinopathy, retinal vein occlusions, and retinopathy of prematurity. Ranibizumab and aflibercept are approved by the FDA, while bevacizumab is commonly used off-label. Monthly intravitreal injections are typically required initially, then treatments are extended based on disease response. Adverse events include inflammation, increased intraocular pressure, and
Retinal vein occlusions are the second most common retinal vascular disease after diabetic retinopathy. Several studies have evaluated treatments for macular edema secondary to retinal vein occlusions. Anti-VEGF drugs like ranibizumab, aflibercept, and bevacizumab have been shown to significantly improve visual acuity and reduce macular thickness compared to observation or laser, with benefits maintained over 1-2 years. Dexamethasone intravitreal implants also provide initial benefits but effects are not sustained long-term and are associated with increased risks of cataract and elevated intraocular pressure.
Wide angle viewing field systems in vr surgerySamuel Ponraj
Wide angle viewing systems provide panoramic views of the retina during vitreous surgery. There are contact and non-contact systems. Contact systems include vitreous panfundoscopes, contact wide field lenses, advanced visual instrument systems, and reinverting operating lens systems. These provide good image resolution but require an inverter due to the inverted image and have risks of corneal trauma. Non-contact systems like the BIOM and Resight provide upright images without inversion but have poorer image quality. Newer non-contact systems aim to provide wide fields of view with upright high resolution images.
This document discusses ophthalmic viscosurgical devices (OVDs), including their history, properties, composition, classification, and uses. It begins by describing the introduction of sodium hyaluronate as the first OVD used in ophthalmic surgery in 1972. It then covers the ideal properties of an OVD and the rheological properties of viscosity, elasticity, coatability, and others. OVDs are classified as cohesive, dispersive, or viscoadaptive based on their molecular structure and behavior. The document discusses the advantages and uses of OVDs in cataract surgery, glaucoma surgery, keratoplasty, and other ophthalmic procedures. It concludes by outlining complications like
This document discusses the diagnosis of pre-perimetric glaucoma. It begins by defining pre-perimetric glaucoma as optic nerve abnormalities seen on structural tests with normal visual fields. It then discusses the need for early diagnosis before functional changes occur. Various functional tests are described like standard automated perimetry, short wavelength automated perimetry, frequency doubling technology, and others. Structural tests like confocal scanning laser ophthalmoscopy, optical coherence tomography, and their principles are summarized.
This document summarizes information about different gauge vitrectomy systems including 20 gauge, 23 gauge, and 25 gauge. It provides details on the instrumentation, techniques, advantages and disadvantages of each system as well as indications for microincision vitrectomy surgery. Key points include that 23 gauge combines benefits of 20 and 25 gauge, has better flow rates and maneuverability than 25 gauge, and is considered a potential future gold standard. Smaller gauge systems allow for reduced trauma, faster recovery, and greater flexibility for complex procedures.
This document summarizes recent advances in treating age-related macular degeneration (AMD). It discusses new drugs that aim to prevent retinal damage or slow AMD progression by inhibiting angiogenesis, inflammation, the complement pathway, oxidative stress, and retinal toxin accumulation. It also describes surgeries like maculoplasty and bionic eye implants, as well as rehabilitation techniques and low vision aids. Promising new drug classes discussed include anti-angiogenics, complement inhibitors, neurotrophic factors, and antioxidants.
Vitreous substitutes are substances used during vitreoretinal surgery to re-establish intraocular volume, assist with separating membranes from the retina, and manipulate and flatten detached retina. They are also used postoperatively as long-term tamponading agents to maintain the retina in apposition. Common vitreous substitutes used include balanced salt solution, air, viscoelastic fluids, silicone liquid, and perfluorocarbon liquids. Gases such as air, SF6, and C3F8 are employed during retinal detachment surgery to provide internal tamponade and are chosen based on their duration, expansion properties, and buoyancy effects. Complications can include increased intraocular pressure, lens opac
AUTHOR DR RUPALI TYAGI, CO-AUTHOR 1 DR SHUBHA NAGPAL, CO-AUTHOR 2 DR NEELAM PUTHRAN, CO-AUTHOR 3 DR VARSHA KULKARNI MS OPHTHALMOLOGY BHARATI HOSPITAL BHARATI VIDYAPEETH UNIVERSITY PUNE
Glaucoma drainage devices are implants used to drain aqueous humor from the anterior chamber to control intraocular pressure. They consist of a silicone tube extending from the anterior chamber to a plate beneath the conjunctiva. Open tube designs like Molteno and Baerveldt and flow-restricted designs like Ahmed are commonly used. GDDs are generally used when filtering surgeries have failed or are likely to fail. While they effectively lower IOP, complications can include hypotony, elevated IOP, migration or erosion of the device, and diplopia. Long-term studies show success rates of 65-85% in maintaining IOP control.
This document summarizes anti-VEGF drugs used to treat retinal diseases caused by abnormal blood vessel growth. It discusses the role of VEGF in these diseases and introduces several anti-VEGF drugs including pegaptanib, bevacizumab, ranibizumab, and aflibercept. It provides details on the mechanism of action, safety profiles, and costs of these drugs and compares the efficacy and safety of bevacizumab and ranibizumab based on studies like CATT. The document serves as an educational reference on anti-VEGF therapies for retinal specialists.
Laser retinal therapy uses lasers to treat various retinal conditions:
1. Pan-retinal photocoagulation uses lasers like argon to treat diabetic retinopathy by reducing retinal ischemia.
2. Macular edema is treated with focal or grid laser photocoagulation targeted at leaking microaneurysms or diffuse areas of leakage.
3. Retinal tears and detachments are treated preventatively with laser barrage surrounding tears to stimulate proliferation and adhesion.
Optical coherence tomography in glaucoma - Dr Shylesh DabkeShylesh Dabke
This document discusses optical coherence tomography (OCT) in evaluating glaucoma. It begins by outlining the importance of early glaucoma detection to prevent vision loss. OCT is described as the most appropriate technology for detecting glaucoma as it can assess retinal nerve fiber layer (RNFL) thickness before visual field or optic disc changes occur. RNFL thinning is an early sign of glaucoma. The document then provides details on OCT technology and analysis of RNFL thickness, optic nerve head, and macula to diagnose and monitor glaucoma. RNFL analysis, especially of the inferior quadrant, is highlighted as the most useful OCT assessment for detecting early glaucoma.
This document provides information on anti-VEGF drugs used in ophthalmology. It discusses the role of VEGF in various eye diseases and conditions. It summarizes the properties, mechanisms of action, administration, and safety profiles of major anti-VEGF drugs including bevacizumab, pegaptanib, and ranibizumab which are used to treat wet age-related macular degeneration, diabetic retinopathy, and other retinal diseases by inhibiting abnormal blood vessel growth and leakage caused by VEGF.
This document discusses potential complications of trabeculectomy, both intraoperative and postoperative. Intraoperative complications include buttonholing of the conjunctiva, scleral flap tears, lens injury, vitreous prolapse, hyphema, and suprachoroidal hemorrhage. Postoperative complications can be early such as hypotony, elevated intraocular pressure, choroidal effusions or late such as thin blebs, infections, and cataracts. Management strategies are provided for addressing complications depending on the specific issue.
This document discusses choroidal neovascularization (CNV), which is the abnormal growth of blood vessels from the choroid into the retina or subretinal space. It is a cause of vision loss and the main feature of exudative age-related macular degeneration. The document defines CNV and lists various conditions that can cause it. It then focuses on CNV caused by age-related macular degeneration, covering risk factors, pathogenesis, symptoms, diagnostic findings on fluorescein angiography and OCT, and various treatment options including anti-VEGF drugs, photodynamic therapy, and laser photocoagulation.
Multifocal choroiditis is a recurrent inflammatory eye condition characterized by small, randomly distributed chorioretinal scars that predominantly affects young to middle-aged females. It can cause decreased vision, photopsia, and scotomas. While fluorescein angiography may not detect active lesions, indocyanine green angiography is highly sensitive for finding new areas of choriocapillaris nonperfusion. Treatment typically involves corticosteroids, though recurrence is common.
This document discusses various vitreous substitutes and intraocular gases used to replace the vitreous humor after surgery. It describes the anatomy and composition of the natural vitreous and ideal properties for substitutes. Common substitutes discussed include gases like air, sulfur hexafluoride and perfluorocarbons; liquids like silicone oil, perfluorocarbon liquids and semi-fluorinated alkanes; and experimental polymers and implants. The document compares different options and provides details on how each works, associated complications, and appropriate uses.
This document discusses potential neuroprotective strategies for glaucoma. It begins by explaining that glaucoma involves the loss of retinal ganglion cells and their axons, and that while elevated intraocular pressure is a risk factor, progression can still occur when pressure is lowered. Neuroprotection aims to protect these cells from degeneration. Several potential neuroprotective approaches are then described, including NMDA antagonists to reduce excitotoxicity, anti-apoptotic agents to block cell death pathways, currently used drugs that may have neuroprotective effects, antioxidants to reduce free radicals, calcium channel blockers, neurotrophic factors, gene therapy targeting apoptotic factors, and immunomodulators.
EMERGING APPROACHES TO COMBINATION THERAPIES IN AMD & DME - RegeneronHealthegy
This document discusses combination therapies for treating wet age-related macular degeneration (AMD) and diabetic macular edema (DME) that involve adding anti-PDGF or anti-Ang2 antibodies to aflibercept. For wet AMD and DME, monotherapy with anti-VEGF drugs like aflibercept only helps about 30-40% of patients gain 3 lines of vision and maintain a dry retina long-term. The document describes early clinical trial results of combining aflibercept with rinucumab (anti-PDGF) and with nesvacumab (anti-Ang2), which showed these combinations were well tolerated and may provide synergistic effects to improve vision outcomes over aflibercept
1. VEGF is a growth factor that promotes abnormal blood vessel growth in the retina and is responsible for many retinal diseases. Anti-VEGF drugs like ranibizumab (Lucentis), bevacizumab (Avastin), and pegaptanib (Macugen) block VEGF to inhibit this blood vessel growth and treat retinal diseases.
2. While ranibizumab, Avastin, and pegaptanib are all anti-VEGF drugs, they differ in their structure and dosing. Ranibizumab and Avastin are antibodies while pegaptanib is a nucleic acid. Avastin costs $45 per dose while ranibizumab costs over $1500.
3. Clinical trials found ranib
VEGF is a growth factor that promotes abnormal blood vessel growth in the retina and causes vision loss. Anti-VEGF drugs like ranibizumab (Lucentis), bevacizumab (Avastin), and pegaptanib (Macugen) work by blocking VEGF and stopping this blood vessel growth. Ranibizumab was designed specifically for eye injections and has a short half-life, while bevacizumab was designed for cancer but is also used "off-label" in the eye. Clinical trials found that both drugs are effective in treating wet AMD, diabetic retinopathy, and other retinal diseases, but ranibizumab may have a slightly lower risk of rare side effects due to its shorter exposure in
Brolucizumab is a humanized monoclonal antibody fragment that binds to and inhibits VEGF-A. It has a smaller molecular weight and longer half-life than ranibizumab and bevacizumab. Studies have shown brolucizumab to be non-inferior to aflibercept in treating wet AMD and DME, with some anatomical outcomes favoring brolucizumab. The risk of intraocular inflammation is higher with brolucizumab compared to aflibercept. Case reports have demonstrated effectiveness of brolucizumab in recalcitrant macular edema from CRVO and in treating PCV.
This document discusses new treatments for age-related macular degeneration (AMD), which is a leading cause of blindness. It outlines several anti-inflammatory therapies, anti-oxidative stress therapies, visual cycle modifying agents, and choroidal blood flow enhancing agents that are being studied in clinical trials to treat dry AMD. It also discusses emerging therapeutic options for wet AMD such as anti-platelet-derived growth factor agents, new anti-VEGF drugs, and sustained drug delivery devices. Finally, it reviews several new intraocular lens designs that aim to improve vision for patients with AMD through magnification or image displacement.
This document discusses anti-VEGF drugs, which block VEGF to inhibit abnormal blood vessel growth in retinal diseases. VEGF stimulates angiogenesis and vascular permeability. Anti-VEGF drugs like bevacizumab, ranibizumab, and pegaptanib work by binding to VEGF and preventing its interaction with receptors. They are administered via intravitreal injections and used to treat wet AMD, diabetic retinopathy, and other retinal conditions involving neovascularization or edema.
The document summarizes several new and emerging anticonvulsant drugs in development or recently approved. Brivaracetam is a cleaner version of levetiracetam with fewer side effects. Fenfluramine is being developed for Dravet syndrome. Cenobamate has shown significant efficacy in phase 2 trials and may be approved in 2018. Epidiolex contains highly purified cannabidiol and has shown efficacy in reducing seizures in phase 3 trials. Everolimus is now approved as an adjunctive treatment for seizures caused by tuberous sclerosis complex based on positive phase 3 results. Fish oil supplementation has also shown promise in reducing seizure frequency. Ganaxolone targets GABA receptors and may be safer than benz
This document discusses new drugs and therapies for glaucoma that are currently in development. It outlines several novel drug targets and mechanisms of action that are being investigated, including ROCK inhibitors, adenosine receptor agonists, BkCa channel modulators, siRNAs, cannabinoids, and local calcium channel blockers. It also discusses neuroprotective strategies such as antioxidants, memantine, neurotrophic growth factors, gene therapy, and stem cell therapy that aim to prevent further neural damage in glaucoma. Overall, the document provides an overview of the many innovative approaches that are being researched to better treat glaucoma beyond current first-line therapies.
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This document discusses intravitreal injections for the treatment of retinal diseases like diabetic macular edema. It provides details on drugs used like Avastin, Lucentis, and triamcinolone including dosages and frequency of injections. While Avastin and Lucentis are both VEGF inhibitors, Avastin is not FDA approved for intraocular use. Laser therapy may still be used as an adjunct treatment or for extrafoveal areas. Proper injection technique involves using a 30-gauge needle for Avastin and Lucentis and 27-gauge for triamcinolone through the pars plana 3.5-4mm from the limbus.
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বাংলাদেশের অর্থনৈতিক সমীক্ষা ২০২৪ [Bangladesh Economic Review 2024 Bangla.pdf] কম্পিউটার , ট্যাব ও স্মার্ট ফোন ভার্সন সহ সম্পূর্ণ বাংলা ই-বুক বা pdf বই " সুচিপত্র ...বুকমার্ক মেনু 🔖 ও হাইপার লিংক মেনু 📝👆 যুক্ত ..
আমাদের সবার জন্য খুব খুব গুরুত্বপূর্ণ একটি বই ..বিসিএস, ব্যাংক, ইউনিভার্সিটি ভর্তি ও যে কোন প্রতিযোগিতা মূলক পরীক্ষার জন্য এর খুব ইম্পরট্যান্ট একটি বিষয় ...তাছাড়া বাংলাদেশের সাম্প্রতিক যে কোন ডাটা বা তথ্য এই বইতে পাবেন ...
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2. HISTORY
• In 1948, MICHAELSON proposed FACTOR X which was responsible for iris and retinal
neovascularization seen in ischemic retinopathies.
• In 1989, Leung at al isolated endothelial mitogen from pituitary follicular cells,
termed it vascular endothelial growth factor(VEGF)
• Elevated levels of VEGF was seen in ocular fluids in patients with active neovascular
ocular disease when compared with ocular fluids with no neovascularization.
3. WHAT ARE VEGFS??
• VEGF is a member of the platelet-derived growth factor (PDGF) family.
• The VEGF gene family is constituted of VEGF-A, VEGF-B, VEGF-C, VEGF-D and placenta
growth factor (PlGF), located on chromosome 6p12.
• Hypoxia has been shown to be a major inducer of VEGF gene transcription.
• As a response to metabolic distress, the retinal pigment epithelium (RPE) and the
retina produce various factors, particularly VEGF, which induce new vessels
proliferation.
4. 1.
• VEGF bind to its receptors on endothelial cells
2. • Promotes metalloproteinases production by endothelial cells
3.
• leads to endothelial cell proliferation
4.
• new blood vessel growth
5. • thus plays a key role in angiogenesis
6. • powerful agonist of vascular permeability
7.
• causes vascular leakage by formation of fenestrations in microvascular
endothelium
8.
• leading to macular edema
Thus, inhibition of VEGF activity is key to treatment of macular edema and prevention of progressive
capillary non-perfusion, especially in diabetic retinopathy and retinal vein occlusions.
6. BEVACIZUMAB
• In 1997, trial was initiated by Genetech for development of AntiVEGF AVASTIN
(BEVACIZUMAB), which got FDA approval in February2004 for treatment of COLON
CANCER in combination with chemotherapy.
• Bevacizumab is FDA approved for use in non-squamous non-small cell lung cancer
• Bevacizumab has a FDA indication for glioblastoma(Brian cancer)
• Bevacizumab use in ophthalmology is off-label, meaning it is not FDA approved for
ocular use
MECHANISM OF ACTION - Bevacizumab binds to soluble VEGF and inhibits the
binding of VEGF molecules to its receptors on the surface of endothelial cells
• Reduction in activity of VEGF inhibits angiogenesis and vascular permeability.
7. DOSAGE
• Intravitreal injections for retinal pathologies are typically administered at 4-6 week
intervals, although this varies widely based on disease and response
• The typical dose is 1.25mg in 0.05ml in adults,and half that dose in babies
• It is supplied in 100 mg and 400 mg preservative-free, single-use vials with a volume
volume of 4 mL or 16 mL of bevacizumab (25 mg/mL).
8. RANIBIZUMAB
• Genetech generated LUCENTIS which was proven effective by 2 trials –
MARINA (MINIMALLY OCCULT/CLASSIC TRIAL OF AntiVEGF ANTIBODY RANIBIZUMAB
IN THE TREATMENT OF NEOVASCULAR AMD)
ANCHOR (AntiVEGF antibody for treatment of predominantly classic choroidal
neovascularization in AMD)
• Trials proved ranibizumab to be effective in improving VA in all forms of choroidal
neovascularization.
• It was approved by FDA in 2006.
9. MECHANISM OF ACTION
• Ranibizumab binds to the receptor-binding site on VEGF-A, which inhibits
the binding of VEGF molecules to their receptors on the surface of
endothelial cells.
DOSAGE
• The approved dose of intravitreal ranibizumab injection is either 0.3 or 0.5
mg in 0.05 ml once a month for up to 3 months.
• Dosing recommendations vary according to indications.
10. AFLIBERCEPT
• It was approved by FDA in November 2011 based on VIEW STUDY.
MECHANISM OF ACTION
• Aflibercept is a soluble decoy receptor that binds vascular endothelial growth
factor-A (VEGF-A), VEGF-B and placental growth factor (PIGF).
• It is called a decoy receptor as VEGF does not bind to its original receptors and
mistakenly binds with aflibercept, thereby reducing VEGF's activity.
DOSAGE
The approved dose of intravitreal aflibercept injection (IAI) is 2.0mg in 0.05ml.
11. PEGAPTANIB
• FDA approved MACUGEN for treatment of ARMD, which became first
Antiangiogeneic theapy for ocular neovascularization.
MECHANISM OF ACTION
Pegaptanib specifically binds to the 165 isoform of VEGF, a protein that plays a critical
role in angiogenesis and increased permeability
DOSAGE
Pegaptanib is administered in a 0.3 mg dose once every six weeks
by intravitreal injection.
12. Anti VEGF Brand name Type Action Dose Vitreous
half-life
Pregatanib Macugen Aptamer Binds to VEGF 165 isomer 0.3mg/0.05ml 2.73 days
Bevacizumab Avastin Humanized
monoclonal
antibody
Forms protein complex by
binding directly to VEGF
1.25-2.5mg /
0.05ml
4.9 days
Ranibizumab Lucentis Monoclonal
antibody fragment
Stronger binding to VEGF-A
( 140 times more than
Bevacizumab)
Can penetrate internal
limiting membrane and
access the subretinal space
0.5mg / 0.05ml 9 days
Aflibercept Eyelea Recombinant fusion
protein
Contains VEGF binding
portions of the extracellular
domains of VEGFR-1 and
VEGFR-2, fused to the Fc
portion of human
immunoglobulin G
2mg / 0.05ml 3.63 days
(rabbit)
14. NEXT GENERATION THERAPEUTICS
• Conbercept
• Brolicuzumab
• Abicipar pegol
• Faricimab
• KSI-301
• OPT 302
• X-82
• Ranibizumab port delivery system
• Gene therapy delivery
15. CONBERCEPT
• A recombinant VEGF receptor protein used for treatment of wetARMD.
• It inhibit activity of all VEGF isoforms and PIGF.
• PANDA-1 and PANDA-2phase III trails compared
AIM – To compare mean change in BCVA at end of 36weeks.
However the study could not meet its primary aim.
0.5mg CONBERCEPT every 12weeks
1mg CONBERCEPT every 12weeks
2mg AFLIBERCEPT every 8weeks
16. • Study done by Cui and Lu compared conbercept for AMD treatment –
• AIM – To measure BCVA and central retinal thickness
• Conclusion – Conbercept shows more effects on long term BCVA in AMD patients then
Triamcinolone(after 3 months)
TTT (after 6 months)
Therapeutic effect of conbercept was similar to ranibizumab
• Conbercept reduces concentration of serumVEGF during period of treatment(1month)
ranibizumab triamcinolone
bevacizumab
TTT(traditional
transpupillary
thermotherapy)
17. • PHOENIX STUDY done by Liu et all –
• At 3months, BCVA improved in conbercept group than in sham group.
CONCLUSION - 3 montly dose of conbercept followed by quarterly dosage was highly
effective in AMD.
0.5mg of CONBERCEPT
once montly for first
3months
Once quarterly until
12th month
CONBERCEPT
GROUP
SHAM GROUP
0.5mg of SHAM once
montly for first 3months
Once quarterly until
12th month
18. BROLUCIZUMAB
• Single chain antibody fragment that inhibits all isoforms of VEGF-A
• Smallest AntiVEGF with molecular weight of 26kDa.
• Small size leads to fast systemic clearnce, lower systemic exposure, better tissue
penetration and a much higher molar dose in same volume can be delivered.
• HAWK AND HARRIER STUDY – 2 years randomized study
AIM – compare efficacy of brolucizumab with aflibercept in neovascular AMD
DOSING –
HAWK HARRIER
TWO DOSES OF BROLUCIZUMAB (3MG
and 6mg) with 2mg aflibercept
6mg brolucizumab with
2mg aflibercept
19. • Primary endpoint – mean BCVA change at week 48.
• Secondary endpoint – change in BCVA and central sub field thickness(CSFT), intra
and sub retinal fluid and disease activity at week16.
RESULTS – In HAWK STUDY, brolucizumab was found to be noninferior.
Decrease disease activity at week 16, with 6mg of brolucizumab
than with aflibercept.
• In HARRIER STUDY, Decrease disease activity at week 16, with 6mg of
brolucizumab than with aflibercept.
CONCLUSION – Brolucizumab offers less frequent intravitreal injections in eyes
treated for neovascular AMD.
20. ABICIPAR PEGOL
• It’s a ankyrin repeat protein which inhibits all isoforms of VEGF-A
• SEQUOIA AND CEDAR STUDY – Patients with neovascular AMD were divided into
3groups –
CONCLUSION- Abicipar demonstrated non-inferiority compared to ranibizumab with
less frequent injections in terms of improving BCVA.
3monthy abicipar 2mg
injections, followed by
every 8weeks
Montly ranibizumab
injections
2montly abicipar 2mg
injections, followed by
every 12weeks
21. • THE MAPLE STUDY –
• Modified formulation of 2mg abicipar was used in this study.
• 123 neovascular AMD patients were randomized to treatment by 2MG ABICIPAR or
SHAM.
RESULTS – Modification of abicipar decreased rate of imflammation to 8.9%.
22. • THE REACH STUDY –
• It was a multicentre RCT in patients with newly diagnosed neovascular AMD
BCVA and CRT were similar in abicipar groups when compared with ranibizumab.
Abicipar 1mg ranibizumab
Abicipar 2mg
23. FARICIMAB
• It’s a bispecific antibody which targets two factors :
VEGF
Angiopoietin-2
• PHASE I CLINICAL TRAIL –
24 patients of neovascular AMD refractory to 3 or more AntiVEGF injection in past
6months were included in the study.
RESULT - overall favourable safety profile with evidence of BCVA and anatomical
improvement was seen.
24. • THE AVENUE TRAIL –
273 patients of newly diagnosed nAMD were included in this study.
Ranibizumab 0.5mg
every 4 weeks
Faricimab
6mg/ranibizumab
0.5mg combination
Faricimab 6mg
every 8 weeks
Faricimab 6mg
every 4weeks
Faricimab 1.5mg
every 6weeks
25. • BOULEVARD TRIAL – A 36week RCT with 229 patients of DME.
Newly diagnosed
patients(168)
Previously treated
patients(61)
6mg of
FARICIMAB
1.5mg of
FARICIMAB
0.3mg of
RANIBIZUMAB
0.3mg of
RANIBIZUMAB
6mg of
FARICIMAB
26. RESULT – 6mg of faricimab was superior to 0.3mg ranibizumab in terms of VA, greater
central subfoveal thickness reduction and diabetic retinopathy severity score
improvement.
27. KSI-301
• It’s a humanized AntiVEGF antibody (similar to ranibizumab)
• It is by far the largest AntiVEGF drug. Its size and clinical dose creates an equivalent
molar dose seven times that of ranibizumab.
DAZZLE STUDY – Currently a phase IIB/III study is investigating efficacy and safety of
repeated injections in 368 patients with nAMD given at 12, 16, 20 week interval
following initial 3 loading doses.
It was compared to aflibercept at 8week intervals following 3loading montly doses.
28. OPT-302
• It targets VEGF-C and VEGF-D to play a role in nAMD pathogenesis.
• A phase1/2a study showed in newly diagnosed patients, i.v injections of both OPT-
302 (2mg) and ranibizumab (0.5mg) given every 4weeks resulted in VA gain and
reduction in macular thickness when compared to ranibizumab alone.
29. X-82
• It’s a ORAL antiPDGF and VEGF-A inhibitor.
• A phase 2 APEX STUDY tested x-82 at 50mg, 100mg and 200mg doses compared to
placebo.
• Change in VA from baseline to 52weeks was the primary outcome.
• Study showed that patients who received 200mg had better improvement in VA
than the placebo group.
30. RANIBIZUMAB PORT DELIVERY SYSTEM
• It is a permanent, surgically implanted intraocular device which may be refilled.
• It is currently approved for WetAMD and has ongoing clinical trails for DME and DR.
• It contain high concentration ranibizumab formulation(100mg/ml) which slowly
diffuses to vitreous at appropriate intervals and for extended treatment duration.
31. • LADDER TRIAL – The visual and anatomical results were comparable between
ranibizumab PDS and traditional intravitreal injections.
• ARCHWAY TRIAL – PDS was non-inferior with 100mg/ml surgical implant compared
to montly ranibizumab injections.
COMPLICATIONS – Vitreous haemorrhage
32. GENE THERAPY DELIVERY
• There are many active gene therapy trials going on –
REGENxBIO has multiple gene therapy trials for wetAMD.
It is modified adenoviral vector containing genetic package, which through process of
transfection, enables RPE cells to produce modified ranibizumab like molecule.
It has reduced the number of AntiVEGF injections required.
ADVERUM BIOTECHNOLOGIES using viral vector intravitreally for expression of
Aflibercept with positive phase I results, now moving to Phase II.
33. REFERENCES
• DOS Times, volume28,July-august2022
• American Academy Of Ophthalmology
• Yanoff Ophthalmology
THANK YOU