RETINA INSIGHT. Age related macular degeneration (AMD) is a chronic, eye. Practice News!

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1 Excellence Compassion Vision RETINA INSIGHT Practice News Mandeep S. Dhalla, MD has accepted the responsibility of serving as the President of the Broward County Ophthalmology Society. He is looking forward to engaging with our colleagues, and discussing ways in which we can all improve eye care delivery in South Florida. Lawrence S. Halperin, MD recently became the first international member to join the Israeli Vitreoretinal Society. He is also actively engaged with the AAO and is currently the ASRS Chair of the Federal Affairs Committee. Eduardo Uchiyama, MD will be joining the Retina Group of Florida in September He currently practices with the Uveitis service at the Massachusetts Eye and Ear Infirmary-Harvard Medical School. He will bring special expertise in the management of ocular inflammatory conditions. Age related macular degeneration (AMD) is a chronic, eye disease that causes progressive deterioration of central reading vision. It affects the specialized area of the retina called the macula, which is the focusing point of vision in the back of the eye. In the United States, AMD is the most common cause of vision loss in the elderly and affects millions of people worldwide. Wet AMD is characterized by new blood vessel formation in the macula resulting in bleeding and leakage of fluid underneath the center of vision. Dry AMD is characterized by the deposition of material called drusen in the macula. More advanced cases of dry AMD result in tissue loss and significant deterioration of central vision. While there has been significant progress in the treatment of wet AMD, no such treatment exists for dry AMD to date. Thus, early diagnosis and preventing disease progression are critical for maintaining central vision. 1

2 Prevention of AMD Progression Current Formula AREDS II Recommendation Vitamin C, 500mg Vitamin E, 400 IU Lutein, 10mg Zeaxanthin, 2mg Zinc, 80mg Copper, 2mg The National Eye Institute (NEI) conducted a large randomized, clinical trial to investigate the effects of anti-oxidants and zinc on preventing the progression of AMD. The Age Related Eye Disease Study (AREDS 1) included over 3600 participants followed for over 6 years from 1995 to The study revealed that intake of high levels of antioxidants and zinc reduced the risk of developing advanced AMD by 25%. The results were promising and clearly demonstrated that these vitamins significantly reduced the rate of disease progression. However, concerns were raised about the link between betacarotene and lung cancer in smokers. Additionally, some reported gastrointestinal upset and genitourinary complications associated with high levels of zinc. The NEI then conducted a follow up study to investigate the effects of removing the beta-carotene, reducing the concentration of zinc, and adding lutein, zeaxanthin and omega-3-fatty acids to the original formula. The AREDS 2 trial included over 4000 participants followed for 5 years randomized to one of several treatment groups. The results, demonstrated that lowering the dose of zinc and adding omega-3-fatty acids to the original formula did not significantly alter the risk of AMD progression. The addition of lutein and zeaxanthin reduced the risk of AMD progression by 10%. A subgroup analysis demonstrated that the addition of lutein and zeaxanthin was most beneficial in those with a low dietary intake of these carotenoids. Finally, removing beta-carotene and adding lutein and zeaxanthin to the formula reduced the risk of progression by nearly 20%. The researches suggested that lutein and zeaxanthin are thus a safe and effective alternative to beta-carotene. 2

3 TOGA Clinical Trial: Doxycycline for AMD Clinical Trials Highlight: Geographic Atrophy The wet or exudative form of AMD is responsible for the majority of severe vision loss in the older population and has undergone a complete transformation in management over the past years due to the advent of anti-vegf treatment. However, over this time there has not been similar progress made in the treatment of the dry form of AMD, which can also result in severe vision loss secondary to progressive RPE atrophy. Currently, there is growing interest to investigate potential therapies for dry macular degeneration. A form of dry AMD, called geographic atrophy or GA is responsible for the most severe vision loss in patients with dry AMD. Doxycycline is a broad-spectrum antibiotic in the tetracycline class with anti-inflammatory properties used for the treatment of rosacea and various bacterial infections. Its potent anti-inflammatory properties may therapeutically impact dry AMD progression and is currently being studied to investigate whether the rate of GA progression can be slowed. This is a randomized, controlled phase II/III clinical trial of daily oral doxycycline (Oracea ), or the TOGA study. The TOGA study is open to male and female patients between age 55 and 85 with best-corrected visual acuity between 20/20 and 20/400 and GA size between 0.5 and 7.0 disc areas in the study eye. Noteworthy exclusion criteria include any history of wet AMD, any history of certain ocular surgeries, or high myopia in the study eye. We are currently recruiting patients for this study in Retina Group of Florida s Boca Raton office. Participation in the study requires 8 clinic visits and 4 phone calls over a 2 and a half year period and the drug cost is fully covered. Lampalizumab GX29185: Anti-Factor D This is a Phase 3 randomized, controlled, double-masked, sham-controlled study investigating intravitreal lampalizumab for the treatment of geographic atrophy due to age-related macular degeneration. Lampalizumab is an antigen-binding fragment of a humanized monoclonal antibody to complement factor D (CFD). CFD has been implicated in the pathogenesis of age-related macular degeneration via its role in the alternative complement pathway. Inhibition of CFD may slow or stop the progression of geographic atrophy. This study will last about 2 years and plans to recruit about 1000 patients beginning in September, Patients should be > 50 years old, with vision of 20/100 or better, and have a well-circumscribed area of geographic atrophy between 1 and 7 disc diameters in size. Patients cannot have prior or active wet AMD in the either eye or have had certain ocular surgeries in the study eye. 3

4 Retina Group of Florida Physicians Barry S. Taney, MD Boynton Beach Boca Raton Lawrence S. Halperin, MD Boynton Beach Boca Raton W. Scott Thompson, MD Boca Raton Plantation Patrick Rubsamen, MD Boynton Beach Boca Raton Scott R. Anagnoste, MD Plantation Krista D. Rosenberg, MD West Palm Beach Boynton Beach Boca Raton Mandeep Singh Dhalla, MD Plantation Kevin Kelly, MD Stuart Wellington Mario Del Cid, MD Plantation Darin R. Goldman, MD Wellington Boynton Beach Boca Raton 4

5 Retina Group of Florida Locations Imperial Point Medical Arts Pavilion 6333 North Federal Hwy, Suite 300, FL p: f: Directions: I-95 to Cypress Creek Road. Exit East to Federal Hwy. Turn left (north) onto Federal Hwy and then left again into Broward Health Imperial Point Medical Center. Building is on the left. Boca Raton Glades Tower I 950 Glades Road Suite 1-C Boca Raton, FL p: f: Directions: I-95 to Glades Road. Exit east to NW 10th Avenue. Go right then a quick left into the parking lot. Boynton Beach The 8190 Building 8190 Jog Road Suite 250 Boynton Beach, FL p: f: Directions: I-95 to Gateway Blvd. Exit west to Jog Road. Turn right onto Jog, then right onto Le Chalet. Building is yellow, marked 8190, 2nd on the right. Plantation Bank of America Building 1776 N. Pine Island Rd. Suite 312 Plantation, FL p: f: Directions: I-95 to Sunrise Blvd. West to Pine Island Road. Southeast corner of Pine Island Road and Sunrise Blvd. Presidential Circle 4000 Blvd. Suite 190-N, FL p: f: Directions: I-95 to Blvd. Exit west and approx. 1 mile to Presidential Circle, 1/4 around circle. Building on left, office is in the the north wing. Wellington Bldg 1397/Med Arts Pavilion III 1397 Medical Park Blvd Suite 240 Wellington, FL p: f: Directions: I-95 to Forest Hills Blvd. Exit west to SR7/441. Go right, then a quick left into Wellington Region Medical Campus. Last bldg. on NW corner. West Palm Beach BB&T Building 2000 Palm Bch. Lakes Blvd. Suite 400 West Palm Beach, FL p: f: Directions: I-95 to Palm Beach Lakes Blvd. 2 blocks west of I-95. SW corner of Robins Drive and Palm Beach Lakes Blvd. Stuart Eye Care and Surgery 1441 E Ocean Blvd. Stuart, FL p: f: Directions: I-95 to SR-76 (exit 101). Follow all the way down to Traffic circle and take first right which will be Ocean Blvd. Eye Care Center will be on left after about one mile. 5

6 To Peel or Not to Peel? That is the Question.. Pars plana vitrectomy remains the goldstandard for treating full-thickness macular holes (FTMHs), but ancillary internal limiting membrane (ILM) peeling has remained under debate. A meta-analysis of randomized controlled trials examined if ILM peeling improves anatomic and functional outcomes of FTMH surgery. Four trials were included in the meta-analysis and there was clear evidence for a higher primary macular hole closure rate in the ILM peel group. ILM peeling was found to be highly cost effective, principally because repeat surgery to close the macular hole was not necessary if the peeling was performed. ILM peeling during macular hole surgery improves hole closure rates, resulting in better initial visual acuity outcomes. Repeat surgery is required more often if the ILM was not initially peeled, but does allow similar final vision outcomes. Retina Group of Florida surgeons were early adopters of this advanced technique for macular hole repair, and have provided expert surgical care to South Florida for over thirty years. [published online December 4, 2013]. Spiteri Cornish K, Lois N, Scott NW, et al. Ophthalmol. 2014;121(3): doi: /j.ophtha Imperial Point Medical Arts Pavilion 6333 North Federal Hwy, Suite 300, FL