Avastin vs. Lucentis
Nothing has stimulated more controversy in the history of retina (and possibly ophthalmology) than that of Lucentis versus Avastin. Both of these medications have achieved unparalleled success in the treatment of wet AMD. Outside of the obvious cost differences, there are no current head-to-head studies comparing the two medications. Most clinicians feel that the medications are equally efficacious.
The most stunning part of this controversy relates to the widely accepted use of Avastin and the attempts by Genentech to curtail this usage. This has created a somewhat adversarial relationship between physicians and the company that supplies both medications. Genentech will limited the supply of medication to compounding pharmacies starting in 2008. They have also utilized a direct-to-patient marketing campaign that has included a advertisements and a patient letter regarding the use of off-label Avastin. These efforts have served to alienate many physicians who use these medications on a daily basis.
A randomized clinical trial (the CATT study) is set to begin in 2008 and should answer any questions about efficacy and safety. This study alone has set several precedents in the design and implementation of a study of its nature.
Buckle vs. Vitrectomy
The debate of scleral buckling or primary vitrectomy for the repair of rhegmatogenous retinal detachments began with the advent of more effective vitrectomy instrumentation. Adding “fire” to this controversy has been increased patient (and referring physician) expectations. Refinements in IOL technology (multifocal IOLs, improved biometry) have lead to increased patient expectations. Current training programs often emphasize vitrectomy over buckling. Finally, higher reimbursement for vitrectomy-based repair may prompt some to choose to abandon the silicone band for the vitrectomy probe. The truth in this controversy is that each retinal detachment requires its own custom approach. The best part of vitreoretinal surgery is that it is not a “one-size fits all” specialty. Some patients will do best with scleral buckling and others with vitrectomy; still others will benefit from a combined approach. The best surgeons have good fundamentals in each technique. More importantly, they know who does best with each approach.
ICG Toxicity
This controversy became somewhat moot in 2007 as ICG availability was limited for most of they year. Many surgeons became facile with using triamcinalone to assist with membrane peeling. The controversy is sure to return with the availability of ICG. It seems as though most papers show a slightly increased rate of hole closure, but a slightly decreased rate of visual improvement with ICG. Reports of toxicity are prominent throughout the literature but the mechanism of such in vivo toxicity may be related to other factors (light toxicity, infusion-related toxicity, etc).
Combination Therapy vs. Monotherapy
In most years, this may be the the most controversial subject in retina. The entire subject has taken a “backseat” to the controversy surrounding Avastin. Studies have not shown any benefit in visual acuity with combination therapy. The advantage of using of PDT in combination with Avastin or Lucentis is centered around the desire to decrease the frequency of intravitreal injections. PDT has a distinct disadvantage in the risk of severe vision loss (up to 4%) and this risk prevents many from using it as a primary therapy in patients with good visual acuity. Efficacy questions should be answered by both the DENALI and MONT BLANC studies.
Routine Dosing vs. PRN Dosing
The excellent results of the ANCHOR and MARINA studies combined with the disappointing percentage of 3-line gainers in the PEIR study emphasize the importance of monthly therapy with Lucentis. Fortunately, the PrONTO study has shown that OCT-guided therapy can yield results that are comparable with ANCHOR and MARINA while reducing the number of treatments by half. Most retinal physicians have adopted some variation in this approach in their practice.
OCT vs. Angiography
The advent of anti-VEGF therapy and its widespread efficacy in regards to all lesion types has reduced the number of angiograms used to detect and monitor therapy for AMD. There are many physicians that feel that progressive hyperfluorescence can be seen with angiography and not detected with OCT. Most physicians have abandoned angiography for OCT in determining whether retreatment is warranted in patients with AMD.
Spectral Domain OCT
The big controversy is not in whether their are advantages to spectral domain OCT, but whether these advantages are worth the cost. The viewing software associated with the newer machines does not appear to match the technology of many of these machines. This can lead to frustration with the device and overall disappointment. It is certain that this technology will improve the care of the AMD patient by allowing higher sensitivity in detecting the recurrence of subretinal fluid.
SF6 vs. C3F8
SF6 has gained popularity among vitreoretinal surgeons in the management of macular hole surgery and the repair of retinal detachments. The transition to SF6 comes with improved surgical techniques and in an effort to provide more rapid visual rehabilitation to patients. Vitreoretinal surgeons are certainly learning from our refractive colleagues in this manner.
Does anti-VEGF therapy increase the risk of stroke?
Interim (8 month) results of the phase IIIb SAILOR study which showed a higher rate of stroke in patients receiving the higher dose of Lucentis (0.3% in the 0.3 mg dose versus 1.2% in the 0.5 mg dose) has raised concerns with physicians and patients. It should be noted that both of these rates are lower than the rate of CVA in the Medicare patient population.
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