Global trends in retina: How surgeons are practicing in 2018

When it comes to first-line anti-vascular endothelial growth factor (VEGF) agents for the treatment of age-related macular degeneration (AMD), the overwhelming majority of retina specialists in Africa/Middle East (n = 198) and the United States (n = 740) choose bevacizumab (79.3% and 70.2%, respectively).

First-line choice in the remaining regions of the world (Asia/Pacific [n = 223], Central and South America [n = 188], and Europe [n = 298]) is aflibercept, according to results from the 2018 Global Trends in Retina survey.

In those regions where bevacizumab was the first choice, aflibercept was the second choice. In those regions where aflibercept was the first choice, bevacizumab was the second choice with the exception of Central and South America, where ranibizumab was preferred over bevacizumab.

Rishi P. Singh, MD, chairman of the International Affairs Committee of the American Society of Retina Specialists, said this year 922 members from 42 retina societies around the world participated.

A total of 15 questions were posed to the international members that were also asked in the annual Preferences and Trends (PAT) Survey, which garnered 743 responses, he said.

Not all respondents answered all questions, he said.

Age-Related Macular Degeneration

"The majority of us will consider switching anti-VEGF agents due to an inadequate response anywhere from three to six injections," he said, with percentages ranging from 91.4% in the Africa/Middle East region to 78.1% in the United States.

A desire for long-acting or sustained delivery treatments was deemed "the greatest unmet need" in neovascular AMD treatment in all regions except the United States and Asia-Pacific, where reduced treatment burden was considered the greatest unmet need (in 73.2% and 69.1% of respondents, respectively).

Respondents were asked about treatment recommendations for a submacular hemorrhage due to AMD, where the patient had a visual acuity of 20/200.

In the United States, Central and South America, and Asia/Pacific, anti-VEGF injection therapy was recommended most often (in 54.8%, 54.5%, and 34.5%, respectively). In the Africa/Middle East region, physicians prefer to treat with vitrectomy with tissue plasminogen activator injection (37.1%); in Europe, there was virtually no preference between the two procedures.

Diabetic Macular Edema

Respondents were asked about the treatment/management of a 30-year-old type 1 diabetic patient with high-risk proliferative diabetic retinopathy, excellent vision (20/20), and no macular edema. Given those parameters, respondents in the Africa/Middle East, Asia/Pacific and European regions would perform a complete pan retinal photocoagulation treatment in two or more sessions (51.8%, 54.3%, and 51.9%, respectively).

In Central and South America, 43.1% of respondents prefer an anti-VEGF injection in conjunction with PRP treatment in two or more sessions. In the United States, there was no clear preference between those two treatment options.

Respondents were also asked about Protocol U, the Diabetic Retinopathy Clinical Research Network's phase II study evaluating the efficacy of the dexamethasone implant in combination with anti-VEGF therapy for the treatment of persistent diabetic macular edema (DME). In Protocol U, top-line results at month 6 showed no significant difference in VA outcomes between the two treatment arms, with mean improvements of 2.7 letters in the combination arm and 3 letters in the monotherapy arm.

There was, however, a significantly greater reduction in retinal thickness in the combination group, with mean central subfield thickness decreases of 110 µm with combination therapy compared with 62 µm with monotherapy.

In the Global Trends Survey, more respondents in the Africa and Middle East, Asia/Pacific, and United States were unlikely to alter their management, while respondents in Central and South America and Europe were more likely to continue anti-VEGF injections prior to switching to a corticosteroid. In each region, fewer than 30% of respondents would choose to switch to a corticosteroid earlier over continuing anti-VEGF injections.

Retinal Vein Occlusion

For patients with mildly symptomatic central retinal vein occlusion, minimal thickening on OCT, and very good vision (20/25), most regions responded they would either observe or defer treatment until the macular edema or vision worsened.

However, in the Africa/Middle East region, 48.4% of respondents would immediately initiate anti-VEGF therapy, "as most eyes will worsen," Dr. Singh said.

Surgical Devices

With the exception of U.S.-based respondents, most surgeons have not yet used 3-D heads-up visualization systems, but for those who have used it, more find it useful than not. In the United States, 36.3% of the respondents have used the device and found it helpful, Dr. Singh said. Only 17.8% of U.S. respondents said they had used the device in the operating room but did not find it helpful.

The majority of respondents in all regions have not yet tried intraoperative OCT. However, when respondents had tried it, opinions were split about its usefulness, Dr. Singh said.

For instance, in the Africa and Middle East region, 17.9% of respondents did not find it useful for macular surgery compared with 1.7% who did find it useful.

In Asia/Pacific region, 8.6% found it useful for macular surgery compared to 6.1% who did not. In Central and South America, 3.4% found it useful for macular surgery compared to 5.7% who did not. In Europe, 10.7% found it useful for macular surgery compared to 9.1% who did not. In the United States, 4.4% found it useful for macular surgery compared to 8.0% who did not.

Few surgeons have tried "no face-down" positioning after macular hole surgery, and small percentages of respondents indicated they had tried it and now incorporate it into their practice (13.3% in Africa/Middle East, 9.7% in Asia/Pacific, 17.5% in Central and South America, 16.9% in Europe, and 13.1% in the United States).

Most surgeons will learn a new surgical technique via an online video less than 24 hours before first performing it, he noted.

"I do this all the time," Dr. Singh said, acknowledging that in the United States, the percentages were closer than they were in any other region (with 53.8% of respondents using online video and 46.2% who do not).

Pneumatic retinopexy is not commonly performed, with the majority of respondents in each region noting they perform the procedure less than once a month. In Europe, there was almost the same percentage of respondents who perform pneumatic retinopexy less than once a month (44.1%) as the percentage of those who never perform it (41.3%). In the United States, 26.2% of respondents perform the procedure 1-3 times a month.