cataract surgery and age related macular degeneration, recent advances, gp and optometist update...

7/30/2019 Cataract Surgery and Age Related Macular Degeneration, Recent Advances, GP and Optometist Update 2010

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RecentRecent

a arac surgery ana arac surgery an

DegeDege

Vau han

ReadingReading

Consultant Oph

Dunedin HospitalDunedin Hospital

www.tanwww.tan

dvances :dvances :

ge re a e acu arge re a e acu ar

erationeration

Tanner

WindsorWindsor

halmic Surgeon

Princess Margaret HospitalPrincess Margaret Hospital

erer--eyes.co.ukeyes.co.uk


2/73

A eA e--relarelaNuclear sclerosis

Cortic

ed cataracted cataract

l lens opacity

Posterior sub-capsular


3/73

Small incision phacoerevolutionised catarac

1.8 mm Micro-incis

Less astigmatism

Day case

Local anaesthetic

ulsification hassurgery

ion


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Topical ATopical A

Topical anaesthesia - my preProxymetacaine and amethoca

o n ec on

No orbital bruising

Faster visual recovery

General anaesthetic if very

Sub-tenons anaesthesia if b

naestheticnaesthetic

ferred techniqueine

ervous / young

inker


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Asti matismAsti matism

m a re ax ng nc s ons


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Limbal RelaLimbal RelaPartial thickness incisions i

of tissue and decrease in asAim make cornea closer t

are u no o overcorrec

in Incisionsin Incisionsthe cornea result in relaxation

igmatisma perfect sphere

550 um


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Acrysof NaturaAcrysof Natura

Recently released Currentl use hi h risk

May start using as rout

e es with si ns of ARMD

ne in all eyes if continued


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Modern CataracModern Catarac

Predictable lens power

Day case oc e g t

Blocked harmful blue

Decreased astigmatis

Surgery so far :Surgery so far :

ight


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near and reverse pres

with standard distant

yopia ?

ocus lens implants


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Try and use different partsto focus for near and dista

Introduce optical problem

Compromise both near an

But lenses improving

of lensce

distant


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Alcon RestorAlcon Restor -- MultifMultif calcal


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AccommoAccommo ating IOLating IOL


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anterioranterior ovementovement


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AccommodatingAccommodating

Post op fibrosisPost op fibrosis

Posterior CapsulePosterior Capsule

IOLIOL

pacitypacity


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A e Related MaA e Related Ma

AMD is the major cause of bl

ular De enerationular De eneration

ndness in western world


18/73

Age and AMDAge and AMD

1/3 ARMD to some degre

1/3 of them will have wetsevere visual loss

% of people

25

30

10

15

Wet AMDDry AMD

0

60-64 65-69 70-74 75-80

Age

form assoc. with


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Impact of AMImpact of AM on the Patienton the Patient:

Reading

DrivingSevere visual loss


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on rme

-- AMD in one eye- Nutrition- Smoking

n er nves ga on

-- Cardiovascular disease

- Race-


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Anatom of theAnatom of theand retinaand retina

P

Chor

e ee eRetina

ChoroidSclera

Macula(fovea)

Lens

Iris

hotoreceptors

Cilliary body

RPE

oid

ruc s em rane


22/73

Ageing RetiAgeing Reti

Small well-defined spots

aa -- DrusenDrusen

Larger, ill-defined spots

Ma enlar e and coalesce

Increased risk of AMD


23/73

Main formsMain forms DRY - NonNon--neovascularneovascular

Drusen and atrophy of RDrusen and atrophy of R

UntreatableUntreatable

WETWET -- Neovascular AMNeovascular AM

New vessel from the chorNew vessel from the chor Rapid and severe drop inRapid and severe drop in

TreatableTreatable

of AMDof AMDMDMD

EE

idal layeridal layervisionvision


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Dry or AtrDry or Atr

Initially drusen and non-

Late RPE (geogra

phic AMDphic AMD

pecific RPE changes

hic) atrophy


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WET or Choroidal neWET or Choroidal ne

Metamorpho

Man lesions

Pinkish-yellow subretinal lesionwith fluid

vascularization (CNV)vascularization (CNV)

sia is initial symptom

re not visible clinicall

Subretinal blood or lipid


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s ss s

Patient presentation

sua acu y es s

- Distortion = urgent referral

Fundoscopy


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Norma

Photoreceptors

RPE

Choroid

Retina

Copyright protected


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Formation of

New abnormal blooand penetrate Br

New Vessels

vessels proliferate

y

uchs membrane


29/73

Fa

VEGFVEGF

tor

VEGFVEGF

VEGFVEGF


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New vessels enetrateNew vessels enetrateBruchs membraneBruchs membrane

Disciform scarDisciform scar


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Possible subsequePossible subsequent course of CNVnt course of CNV


32/73

Bri ht area offluorescence fromabnormal leaking


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ass c orass c or ccuccu


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O ticalO tical CoherenceCoherence

OCT of stage 4 macular hole

(vision 6/60)

omo ra h OCTomo ra h OCTOCT of normal macula

PhotoreceptorsFovea

RPE / Choroid 100um

OCT of Wet ARMD


35/73

Current tCurrent t

for Afor A

I

reatmentsreatments

RMDRMD

etary upp ements

hotodynamic therapyteroid Injection

nti Growth Factor

ect ons


36/73

Dietary SDietary S

Large study USA (AREDLarge study USA (ARED 5000 atients 5 r follow5000 atients 5 r follow

High dose antioxidants anHigh dose antioxidants an

VitVit E,E, VitVit CC Selenium, Zinc,Selenium, Zinc,bb CaroteCarote

Current trialsCurrent trials

luteinlutein and ome a 3and ome a 3

pplementspplements

)) -- published 2001published 2001

d vitamin supplementationd vitamin supplementation

ee


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Vitamin C 500

Beta Carotene 15

Smokers version No beta

Increasin evidence for Lut

mg

g

arotene

inwww.tanner-eyes.co.uk


38/73

Risk of visual los

patients with high

s from ARMD in

isk characteristics


39/73

supplementsupplement

Visual loss from ARM

Bilateral soft drusen In these high risk grou

Not all those with early

in one eye

s 25% reduction in

ARMD


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supplementsupplement

Cost 10 per month

Skin tint - mild Gastric upset

B Carotene and smokin

g


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Laser beam aimed

at CNV

Damage caused to RPE and

photoreceptors


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PhotodynaPhotodyna

ic therapyic therapy


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PhotodynaPhotodyna

Step 2

ic Therapyic Therapy


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Surgical removalSurgical removal

Wet ARMDWet ARMD

of subof sub--foveal CNVfoveal CNV

Type 2Type 2 -- ChorioretinitisChorioretinitis


45/73

RemovalRemoval f SRNVMf SRNVM

Lucentis (ranibizuma ) Antibody Therapy


46/73

Lucentis (ranibizuma

- Lucentis bindi

) Antibody Therapy

g to VEGF-A

Wet RMD


47/73

Wet

oro a neo

Inflammator mediators

Oxidative stress

and angiogenic cytokines

nappropr a e vesse grow

RMD

ascu ar sa on

Inhibit rowth of abnormal

oc e neovascu ar s mu us

blood vessels


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-dimeric VE

VEGFR

binding

site

F receptors

VEGFRbinding

site

VEGF A: Ke

mediator of


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VEGF-A: Ke

angio

VEGF-A

ProliferatiSurvival

P

P

Endothelial cellactivation

VASCULAR

PERMEABILITY

mediator of

enesis

Binding and activation of

VEGF receptor

n Migration

P

P

Ferrara et al, Nat Med 2003; 9: 669

R ibi b


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Ranibi

Ranibizumab binds all

isoforms including 110, a

plasmin-cleaved form of

1

165 121189206 145 110

umab

VEGF

165121 189 206145110

1Chen et al, J Mol Biol 1999; 293: 86

Dvora et a , Am J Patho 1995; 146: 102

Das et al, Prog Retinal Eye Res 2003; 22: 72

Ferrara et al, Biochem Biophys Res Commu1989; 161: 85


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-of A

Oxidative stress

n amma ory me a ors

and angiogenic cytokines

nappropr a e vesse

growth

xu a on an emorr age

Discoid scar formation

MD

oc e neovascu ar s mu us

Eliminate edema and

n grow o a norma

blood vessels

hemorrhage

Repair retinal scarring


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SecondarMean change in

Mean change fro

ANCHOR

4

8

-8

-4

01 3 4 5 6 7 8 9 10 11 122

-12

Ranibizumab 0.3 mg

Ranibizumab 0.5 mg

End oint:A from baseline

baseline (VA)

MARINA

4

8

2 3 4 5 6 7 8 9 10 11 121

-8

-4

0

-12

Sham (n=238)

PDT (n=143)


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IntraIntra--vitrevitre l injectionl injection


54/73

Lucentis treaLucentis trea

All sub types wet

Some useful vision be

n ect ons one mont

Then review VA and O

inject

ment regimement regime

ter than 3/60

part

T if further leak re-


55/73

76 yr old male76 yr old male ViVision Count Fingerssion Count Fingers


56/73

Post 3 Lucentis InjPost 3 Lucentis Inj ctionsctions Vision 6/12Vision 6/12


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About 40% si nificant im

If catch early and treat urge

I tend to do six and then re

Rest very variable but may

eye

ovement rest stabilise

tly = save vision

iew

equire prolonged treatment


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LucentiLucenti

Major problem econoon- oin risk

Radiation treatment off

Delivered via vitrectom

JunkiesJunkies

ics, patient convenience,

rs exit strategy

procedure

Epimacular Brac ytherapy for the


59/73

p

rea men o

EPI

y py

ovascu ar

AD


60/73

Radiation Dose to24.0 Gy

Center of Lesion

2.Op

6 Gy at edges of5.4mm lesion

Tissue Effect

Lens Cataract

Reference: Finger PT, Berson A, Ng T, Szechter A. Ophthalmic plaque radiotherapy for age-rneovascularization.Am J Ophthalmol. 1999 Feb;127(2):170-7. Adapted from Bardenstein, Ch

e na a a on e nopa y

Optic Nerve Optic Neuropathy

Ocular Structures

Gy attic Nerve

0.6 mGyDelivered to Lens

Dose for Clinically

Observable Damageby NeoVista Strontium 90

Device

2 Gy .00056 Gy

elated macular degeneration associated with subretinalr and Rosenblatt

- y y

>55 Gy 2.4 Gy

h B

R i i


61/73

h BIonizing Radiation Targeted

Inhibitory Effects

AMD

-(inhibits blood vesselgrowth)

Anti-inflammatory(inhibits

Anti-fibrotic (inhibits

R i i nRadiation Rapid Energy

Lesion

Less Exposure

lesion site, but littlepenetration to other

Whole-body exposure

that received from aroutine chest x-ray

Proport

on of Patients


62/73

Proport

Losin

100%

85%

fSubjects

Percento

Month 3

N=34

Month 6

N=34

Mo

N

on of Patients

15 Letters

93%

th 9

31

Month 12

N=34

Month 18

N=30

Proport

ion of Patients


63/73

Proport

Gaini

f

Subjects

53%

47%

3

Percento

Month 3

N=34

Month 6

N=34

Mo

N

ion of Patients

g 15 Letters

% 38% 37%

th 9

31

Month 12

N=34

Month 18

N=30

EPIRAD potenti l to dramatically


64/73

p

decrease num

18 Months 73% of patients did not re

Mean gain of +6.6 ETDR

37% of patients gained 3-l

* Additional tx was administered per investigator discretion based upon evidence of lesion acti

y

er of lucentis

uire additional tx*

letters

nes or more

vity


65/73

IOL VIP


66/73


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LMI implant


70/73

retainedretained eripheraleripheral

Gene TGene T erapyerapy


71/73

Lebers ongeLebers onge tal Amauros stal Amauros s


72/73


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