Treatment and management
When used in conjunction with intravitreal injections, topical antibiotics are expected to minimize the risk of serious complications such as endophthalmitis. However, evidence-based guidelines for the use of antibiotics during intravitreal injection procedures are lacking. Furthermore, there is increasing evidence that topical antibiotics are ineffective prophylactics, which can increase the development of resistant organisms as well as costs.
Following an extensive review of the literature, the Vision Academy has provided an expert consensus opinion that topical antibiotics should not be used alongside intravitreal injections. We have also highlighted a need for education of ophthalmologists in order to reduce inappropriate antibiotic use and have provided a rationale for the use of antisepsis and aseptic techniques.
Although retinal vascular disorders may affect one eye first, many patients eventually present with bilateral disease, meaning both eyes require treatment with anti-VEGF agents. There is an increased burden associated with treating each eye at separate, staggered visits, with doubled clinic time and costs affecting both clinicians and patients. Nonetheless, the risks of bilateral anti-VEGF treatment have not been thoroughly evaluated.
The Vision Academy has provided expert recommendations for conducting bilateral injections, including clinical considerations that should help clinicians mitigate any risks associated with bilateral treatment.
A subfoveal hemorrhage is where blood from the retinal or choroidal circulation accumulates between the retinal pigment epithelium and the neurosensory retina, resulting in visual decline. There are various treatments that aim to remove or displace a hemorrhage.
The Vision Academy has provided best-practice recommendations for treating subfoveal hemorrhage, including imaging to determine prognostic factors and different treatment options.
Some patients with neovascular age-related macular degeneration (nAMD) have suboptimal responses to anti-VEGF therapy, potentially due to undertreatment, misdiagnosis of the underlying condition, or other factors such as advanced disease or complications. The Vision Academy has produced an algorithm to guide the treatment of patients with nAMD for whom further treatment can be considered futile. We have also developed expert recommendations for exploring key factors before the suspension of treatment in cases of futility.
Although the treatment of patients with diabetes should be a multidisciplinary effort, there is often a lack of communication between healthcare professionals from different disciplines, as well as between healthcare professionals and patients. The Vision Academy has explored the association between diabetic eye disease and other complications of diabetes, highlighting the need for coordinated care to enable optimal disease management and better patient outcomes.
The use of optical coherence tomography angiography (OCT-A) is expanding rapidly around the world; however, the technology is advancing faster than the community’s understanding of, and experience with, the technique. The Vision Academy has provided expert guidance on the role of OCT-A, including the opportunities, challenges, and limitations. We have outlined the utility and potential applications of OCT-A and presented recommendations for the most effective ways in which to implement the technique.
A retinal pigment epithelial (RPE) tear is a common occurrence in patients with nAMD and may develop spontaneously or following laser photocoagulation, photodynamic therapy, or intravitreal injection. Long-term visual acuity is frequently poor for these patients. As the number of patients with nAMD and associated anti-VEGF injections increases, addressing the challenges of preventing and treating RPE tear has become increasingly important in order to help preserve visual function.
The Vision Academy has provided expert recommendations for the management of RPE tear during anti-VEGF therapy. In addition to identifying risk factors for tear formation, we have provided guidance on diagnosing and monitoring an RPE tear, as well as its treatment.
Diabetic macular edema (DME) is a common complication in patients with poorly controlled diabetes mellitus. The Vision Academy aims to set out the key principles for the prevention and treatment of DME and has published a case study examining a patient presenting with center-involved DME and proliferative diabetic retinopathy. In this case study, we provide expert interpretation of real-world treatment decisions alongside current treatment guidelines.
Patients may face difficulties coping with their disease and learning to live with recurring intravitreal anti-VEGF injections. However, not complying with a treatment plan can aggravate vision loss and impact on the patient’s daily life. In collaboration with the nAMD Barometer, the Vision Academy aims to raise awareness of psychosocial and other factors affecting compliance with intravitreal anti-VEGF treatment. The resulting framework for assessing non-adherence and non-persistence aims to improve understanding to optimize outcomes in patients with nAMD.
When using flexible treatment regimens, anti-VEGF treatment should be individually adapted after disease activity and stability have been assessed in patients with nAMD. A primary marker of disease activity is the presence of fluid detected on OCT, with the location and the presence or absence of fluid also measures of treatment efficacy. However, emerging evidence shows that the concept that any fluid in any retinal location requires re-treatment needs to be nuanced.
The Vision Academy is working on expert guidance on defining disease state, monitoring fluid status, and the subsequent treatment of patients according to these parameters. We are reviewing the impact of residual fluid on treatment outcomes in nAMD and aim to provide recommendations for the assessment of fluid status and subsequent disease management.
Resources are coming soon!
Flexible treatment regimens, such as treat-and-extend, are commonly used in patients with nAMD. While often effective, implementation of such treatment regimens and subsequent outcomes can vary between studies and real-world clinical practice. As newer drugs with increased durability become available, there is a drive toward quickly achieving longer extensions between treatments to reduce the burden on patients and physicians.
Following our publication entitled "Fundamental principles of an anti-VEGF treatment regimen”, we are working on further expert guidance for the treatment of patients with nAMD, considering the most effective treatment patterns. We will summarize the newest aspects of nAMD management to help further refine current practice.
Resources are coming soon!
Common clinical experience and evidence from the literature suggest that intravitreal anti-VEGF injections are associated with a transient elevation in intraocular pressure (IOP) and, in a small percentage of patients, sustained long-term IOP elevation, which is potentially associated with a risk of the development or progression of glaucoma.
The Vision Academy is working on expert guidance on treating patients with sustained IOP elevation secondary to the use of anti-VEGF agents. We aim to provide recommendations for monitoring and treating sustained IOP elevations, and highlight the key areas regarding the impact of anti-VEGF treatment on IOP and the optic nerve that require further research.
Resources are coming soon!
Challenging clinical situations
Through collective expertise in areas with insufficient conclusive evidence, we seek to provide guidance on best clinical practice in key areas:
