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Clinical

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Although off-label repackaged bevacizumab syringes appear to satisfy an urgent clinical and financial need for patients with a variety of retinal disorders, they are known to be associated with considerable public health concerns due to the risks posed to patients from compounding pharmacies’ lack of compliance with a variety of FDA requirements.

Perspectives on intravenous bevacizumab repackaged for intravitreal use

Advantages of the molecular structure of aflibercept

Video content above is prompted by the following: 

Aflibercept 2 mg is considered the standard of care for retinal vascular diseases. Can you briefly explain the structure of the aflibercept molecule and its significance?

Panelists discuss how aflibercept’s molecular structure contributes to its clinical efficacy as a standard treatment for retinal vascular diseases.

clinical

Video Series

Evolution of anti-VEGF agents and unmet needs in retinal diseases

Anti-VEGF treatments have been available for age-related macular degeneration and diabetic macular edema for over a decade. Can you discuss how they have impacted patient outcomes and what barriers remain to achieving optimal results?

Panelists discuss how anti-VEGF therapies have dramatically improved visual outcomes in patients with age-related macular degeneration and diabetic macular edema over the past decade. Key challenges persist, including treatment burden, adherence, and identifying optimal dosing regimens for individual patients.

Evolution of Anti-VEGF Agents and Unmet Needs in Retinal Diseases

Aaron Nagiel, MD, PhD, gave an interview discussing the work that he and the team at Children’s Hospital Los Angeles (CHLA) have been doing in the retinal gene therapy space. This interview comes at the team celebrates its 100

Since 2018, Nagiel and his team at the Vision Center of CHLA have been treating these patients with the gene therapy, Luxturna, for the treatment of Leber congenital amaurosis (LCA). CHLA was the first center on the West Coast to administer this treatment after it was approved by the Food and Drug Administration in 2017.

, Nagiel shared how he found a path to working in pediatric retinal diseases and his firsthand experience seeing patients improve following treatment at CHLA. When it comes to determining if treatment is right for a patient, he shared the process that CHLA follows including the following eligibility criteria for treatment with Luxturna. He said, “patients must be older than 12 months and show mutations in both copies of a gene called 

. If a patient has one healthy copy of this gene, they don’t have the disease. We lean on CHLA’s Center for Personalized Medicine for this part of the screening. CHLA is one of the only pediatric medical centers with in-house genomic and molecular pathology support. This is critical because more than 300 genes can cause these retinal degenerations. We need to be sure beyond a doubt that patients have this particular form of LCA before we treat them.”

Nagiel spoke to the impact of preserving and restoring vision are significant. He said, "Some patients start observing significant improvements within the first week. They’re essentially seeing things that they could never have seen before. I've had patients who, during their first follow-up visit, can make out the fish in the fish tank for the first time. Parents have also told me the stories of their kids noticing a bird flying, or a cloud in the sky, for the first time in their lives.”

As this interview reflected on the progress in pediatric gene therapy thus far, Nagiel was also asked to comment on the future of the gene therapy space: “We continue to recruit people for several clinical trials advancing the leading edge of gene therapy treatment. There are a number of adults, for whom gene therapies weren’t available when they were young, who come to CHLA for treatment and also participate in these trials. Today, these diseases are often diagnosed in childhood, so there's no reason we should even be treating adults in the future. In 10 years, we hope that all patients with these diseases can be identified when they’re young, treated when they’re young—and experience life-changing vision improvements for their lifetimes.”

1. Children’s Hospital Los Angeles Celebrates 100th Retinal Gene Therapy Procedure. Children’s Hospital Los Angeles. December 6, 2024. Accessed December 9, 2024. https://www.businesswire.com/news/home/20241206063665/en/Children%E2%80%99s-Hospital-Los-Angeles-Celebrates-100th-Retinal-Gene-Therapy-Procedure

This interview comes at the Children's Hospital Los Angeles team celebrates its 100th retinal gene therapy procedure.

Aaron Nagiel, MD, PhD, gives interview on the impact of retinal gene therapy procedure conducted at Children's Hospital Los Angeles

AAO 2024: Fundus photography/OCT expediates care in the emergency department

Valerie Biousse, MD, from the Emory University in Atlanta, Georgia, shared insights on how ocular imaging in the emergency department can provide timely, accurate diagnosis while also benefiting the on-call ophthalmologists. She shared these thoughts at this year's AAO meeting held in Chicago, Illinois. 

Editor's note: The below transcript has been lightly edited for clarity.

I am Valerie Biousse, a neuro-ophthalmologist at Emory University in Atlanta. I am a big fan of having non-mydriatic fundus cameras in emergency departments, and we have a few presentations on this topic at the AAO meeting.

As you know, nobody really uses ophthalmoscopes in emergency departments anymore, and cameras are great because they facilitate the examination of the ocular fundus by non ophthalmologists, and they also allow for remote interpretation of the pictures by ophthalmologists. So instead of ophthalmoscopes, we have a camera connected to our electronic health record with an entirely automated process and integration of the camera into the ED flow. 

This has proven very useful, because the camera allows the ophthalmologist on call to make some diagnosis remotely, without in person consultation. So for example, if an acute central retinol artery occlusion is abuse on ocular imaging, we do not even come to the hospital anymore, and instead, we trigger a stroke alert, which prompts neurology to take care of the patient immediately, and not having to wait for an ophthalmologist to come to the emergency department or wait for pupillary dilation to look at the fundus is saving a lot of time, and it is allowing us to occasionally recommend treatment of acute central retinol artery oclusion with thrombolysis within just a few hours of vision loss, which is amazing. That has allowed us to design a nice stroke protocol, which has become standard of care at our institution. 

Another great use of the camera in the emergency department is when a patient has headaches or is sent to the emergency department to roll out papilledema, presumably from a neurologic disorder. In this case, we just review the pictures remotely, instead of having to come to the ED in the middle of the night for a fundus examination. We showed that this new flow has reduced the ED length of stay by at least 50% for patients sent to the ED mostly to rule out papilledema, and that more than 90% of patients were able to have papilledema ruled out remotely, without an in-person consultation. And you can imagine that this has made our on-call ophthalmologists, including our residents, very happy. So these are the main reasons why I think we really need to work at helping our emergency department colleagues implement such cameras in general emergency departments, especially given the anticipated worsening shortage of ophthalmologists and neuro-ophthalmologists in our country. 

Being able to provide adequate ophthalmic examinations in the ED, including remotely, with either implementation of e-consultation or teleophthalmology will become essential, and cameras will help us do that. To take the pictures are obtained directly by the ED staff, and anyone can do it. Currently, we have the technicians who are in charge of doing EKGs in the ED, they were trained. The training takes about 10 minutes. They take the pictures themselves, and that's why the key is to have a very user-friendly camera with only 1 button to push and the pictures happen. 

The interpretation is a little more complex. The pictures are readily available to the ED providers and to the neurologists on the electronic medical records. Some of them are comfortable reviewing the pictures themselves, and they interpret them without our help. And it's particularly useful when the pictures are normal. So for example, if all they want to do is rule out papilledema, then in most situations, they do it themselves, and they don't even call us. 

On the other hand, if the picture looks abnormal, they page us, and we review the pictures live for them so that they get an immediate interpretation. In all cases, I always reassure them. We tell them, "we have your back," because in all cases, 1 ophthalmologist reviews the pictures, usually within 24 hours, in order to double check that the original interpretation was correct and to be able to bill.

Valerie Biousse, MD, from the Emory University in Atlanta, Georgia, shared insights on how ocular imaging in the emergency department can provide timely, accurate diagnosis while also benefiting the on-call ophthalmologists.  

Videos

EURETINA 2024: Ali Erginay, MD, Red-Blue-Green (RGB) imaging modalities

Ali Erginay, MD, MD, spoke about the important developments in retinal imaging, specifically the Red-Blue-Green (RGB) imaging modalities during his interview with 

, which took place at the EURETINA 2024 meeting held in Barcelona, Spain, on September 19-22, 2024.

I'm Dr Ali Erginay. I'm working in [Lariboisière Hospital in] Paris. Our department specializes in retina and retinal imaging. So I had the chance to try, at the very beginning of time, Optos, and I could see all the evolutions of Optos. Recently, the most pronounced, most important development was the integration of RBG color wavelengths. It changed everything, because there were a lot of critics about OCT. People used to say that the images were a little bit greenish. And the critics were right, it was true, it was greenish. But with the addition of blue wave light, it changed everything, because colors became more beautiful.

At the beginning, we were very influenced by the beauty of the images. Then we realized that this was not only a question of beauty: The images were better, more detailed, to facilitate the diagnosis. In my presentation yesterday, I exposed our study that we did in Lariboisière Hospital. We have had chance to have both cameras, side by side. So we chosen about more than about 165 eyes of 200 patients, and we did the examination with both cameras, with 10 minutes of [inaudible]. We realized that with this filter, with this wavelength, with this laser, we could penetrate better. And we saw that with this new technique, you can have better images, even with the cataract. The presence of cataract is very important, because most of the diabetic patients have medium [inaudible]. So even with the cataract, we did 10-minute of intervals in the same patient. It was dramatically better. Even now, I can't explain it. So that's why we decided to do this study.

And we were not very surprised. The study showed us that we could better detect abnormalities, hemorrhages, microaneurysms and intraretinal micro abnormality earmarks better with the new system. Of course, when you detect all those lesions, you can do classification reading much better. And we saw the severity of diabetic patients were a little bit higher with the RGB system. So it's very important.

In conclusion, I can say that images are not only more beautiful, but it improves the diagnosis and detection of lesions. And it's not true only for diabetic patients. Even autofluorescein photos are better. If you have a geographic atrophy or whatever, even lesions in the periphery, retinal detachment, retinal holes, you see them better. The colors are better, and your diagnosis and detection of lesions getting better. So how can we ask for more?

There are a lot of exciting things [at EURETINA], first about new treatments. I saw that geographic atrophy is becoming at last, very dominant. Until now, we've been so focused on wet AMD. Now we are focused on geographic atrophies, and there are new treatments. That's a good thing. And genetic therapy is improving also. And then, third of course, imaging techniques, new machines, especially ultra wide field imaging, including OCT, OCT-A and color photos. Having all those cameras is not enough, because the population is growing. We're getting more and more, we have more and more patients. So artificial intelligence is developing also. They can be integrated into new machines, so they can be used for diagnosis and treatment decision. Those are the points that I like a lot.

Ali Erginay, MD, spoke about the important developments in retinal imaging, specifically the Red-Blue-Green (RGB) imaging modalities during his interview with Ophthalmology Times Europe, which took place at the EURETINA 2024 meeting held in Barcelona, Spain, on September 19-22, 2024.

EURETINA 2024: Ali Erginay, MD, speaks about Red-Blue-Green (RGB) imaging modalities

The Food and Drug Administration (FDA) announced its approval of 2 biosimilars as interchangeable with aflibercept 2 mg (Eylea).

The agency approved aflibercept-jbvf (Yesafili, Biocon Biologics) and aflibercept-yszy (Opuviz, Samsung Bioepis, Biogen). All 3 products are anti-vascular endothelial growth factor (VEGF) agents, administered intravitreally for neovascular age-related macular degeneration (nAMD). Aflibercept-jbvf and aflibercept-yszy are the first interchangeable biosimilars to aflibercept 2 mg.

In a news release, the FDA described the products as “interchangeable biosimilars,” suitable for treating patients with nAMD, macular edema following retinal vein occlusion, diabetic macular edema, and/or diabetic retinopathy. The news release went on to detail the safety profile for aflibercept-jbvf and aflibercept-yszy. 

“The side effects and adverse events observed in clinical studies of Yesafili and Opuviz are consistent with those observed with Eylea,” the agency wrote.

 “The most common (≥5%) of these side effects included conjunctival hemorrhage, eye pain, cataract, vitreous detachment, vitreous floaters, and increased intraocular pressure.”

Following the FDA approval of aflibercept 8 mg (EYLEA HD) in August 2023, Regeneron has placed a focus on the higher-dose product, recording $200 million in sales in the first quarter of 2024.

Aflibercept 8 mg also received EU marketing authorization from the European Commission in January of this year.

 Biocon Biologics Limited received marketing authorization approval in the UK for aflibercept-jbvf in November 2023.

FDA approves first interchangeable biosimilars to Eylea to treat macular degeneration and other eye conditions. US Food & Drug Administration. May 20, 2024. Accessed May 21, 2024. 

https://www.fda.gov/drugs/news-events-human-drugs/fda-approves-first-interchangeable-biosimilars-eylea-treat-macular-degeneration-and-other-eye

US FDA approves two biosimilars for blockbuster eye drug Eylea. Reuters. May 20, 2024. Accessed May 21, 2024. 

https://www.reuters.com/business/healthcare-pharmaceuticals/us-fda-approves-biocon-units-biosimilar-blockbuster-eye-drug-eylea-2024-05-20/

Hayes H. European Commission grants EU marketing authorisation for aflibercept (Eylea) 8 mg. Ophthalmology Times Europe. January 8, 2024. Accessed May 21, 2024. 

https://europe.ophthalmologytimes.com/view/european-commission-grants-eu-marketing-authorisation-for-aflibercept-eylea-8-mg

The agency approved Yesafili (Biocon Biologics) and Opuviz (Samsung Bioepis, Biogen) as biosimilars to Eylea (Regeneron Pharmaceuticals).

Szilárd Kiss, MD

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