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Medical Retina > Treatment of AMD > Flashcards

Treatment of AMD Flashcards

1
Q

what has been proven about the modification of the AREDS 2 formula

A

did not further reduce risk (adding lutein, zeaxanthin, DHA or EPA)

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2
Q

what is the risk of High dose Vit A

A

may increase risk of lung cancer in smokers/ex-smokers

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3
Q

what is the risk of High dose Vit E

name 3

A

may be associated with increased mortality rate, heart failure and prostate cancer

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4
Q

what is the risk of High dose zinc

name 2

A

may be associated with neurotoxicity and prostate cancer

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5
Q

name an anti VEGF that is not licensed for the use of AMD tx and give a trade name example

A

Bevacizumab - avastin

e.g. Pegabtanib

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6
Q

give a trade name of Ranibizumab

A

Lucentis

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7
Q

give a trade name of Aflibercept

A

Eyelea

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8
Q

what was the first ever agent to tx wet AMD called and what problems did it cause, what was this then replaced by

A

Macugen

intraocular inflammation

replaced by Ranibizumab

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9
Q

what type of structure does Eylea have

what size is it

what 3 things does it target

what is the systemic half life

what is the intravitreal half life

A

Recombinant fusion protein

115 KDa

VEGF- A, VEGF- B and PIGF

systemic: 5-6 days
intravitreal: 4 days (rabbit)

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10
Q

what type of structure does Avastin have

what size is it

what does it target

what is the systemic half life

what is the intravitreal half life

A

Recombinant humanized monoclonal antibody

48 KDa

VEGF

systemic: 19 days
intravitreal: 4 days (rabbit) 5 days (human)

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11
Q

what type of structure does Lucentis have

what size is it

what does it target

what is the systemic half life

what is the intravitreal half life

A

Antibody fragment

150 KDa

VEGF-A

systemic: 2 hours
intravitreal: 3 days (rabbit) 9 days (human)

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12
Q

how is the agent Ranibizumab initially given for tx and how is it given thereafter

A

0.5mg given monthly until maximum gain achieved (loading)

Treat as deemed necessary thereafter

  • Monthly monitoring
  • T+E (treat and extend): increase intervals by maximum of 2 weeks
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13
Q

how is the agent Aflibercept initially given to tx AMD and how is it given thereafter

A

3 monthly doses = 1x a month (loading), then bimonthly up until end of first year

Can extend by 2- to 4- weeks depending on response, but not more frequent than bi-monthly during first year

No monitoring between injections necessary

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14
Q

what is necessary when treating a px with Ranibizumab compared to treating with Aflibercept

A

monitoring between injections not necessary with Aflibercept/Eylea

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15
Q

name and explain 2 different types of regime for treating AMD with anti VEGF

A

PRN
– 3 consecutive monthly injections (loading)
– As needed when there’s signs of deterioration

T&E
– Consecutive monthly injections until maximal improvement
– Increase interval between injections if no progression

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16
Q

which tx regime works out better when treating wet AMD with anti VEGF and why

A

Treat and Extend

PRN not always treated in a timely manner, therefore potentially worse long-term outcomes

17
Q

what did studies prove about the T&E programme compared to monthly injections

A

T&E gained comparable vision with fewer injections needed

18
Q

what did a RCT study about Ranibizumab vs Aflibercept in the 1st year show

A

Ranibizumab outperformed by gaining more letters with the same amount of injections

19
Q

what did a RCT study show about Ranibizumab vs Aflibercept after 3 years of T&E regime

A

both drug effects end up being similar hence no advantage in using one drug over the other

20
Q

list the 9 steps of the Intravitreal injection procedure in order

A

Identify correct patient and eye

Consent

Anaesthetise eye topically

Povidone-Iodine - to prevent post op endopthalmitis

Prepare injection

Speculum/Invitria

Inject

Irrigate

?Post-injection antibiotic (stat) - limited evidence not necessary

21
Q

what is the risk of getting Endophthalmitis post anti VEGF in %

list 4 ways to prevent this

list 2 things that are not necessary to prevent Endophthalmitis

A

0.019-1.6%

Treat eyelid conditions e.g. blepharitis, ectropian

5% Povidone-Iodine in fornices (min 30s) prior to injection

Sterile equipment to be used

Face mask to reduce air-droplet contamination

Topical antibiotics not required pre- or post- injection

Theatre not necessary (air-flow)

22
Q

what is the risk of getting inflammation post anti VEGF tx

name to signs that differentiates inflammation to endopthalmitis

A

1.4-2.9%

Inflammation
Onset of symptoms
<24 hours

A/C activity
Mild-moderate

Endophthalmitis
Onset of symptoms
>24 hours

A/C activity
At least one of:
KPs, hypopyon, fibrin, anterior synechiae

23
Q

what is the risk of getting a RRD in % post anti VEGF tx and how can it be caused and how can this be prevented

A

0-0.67%

Usually associated by induction of PVD or incorrect injection technique

Use small needle, tunnelled insertion, 3.5-4mm posterior to limbus

24
Q

how is IOP elevation a risk factor post anti VEGF injection

A

Usually temporary

Pre-existing glaucoma risk factor

?low grade trabeculitis, blockage of TM by agent e.g. larger molecule such as avastin

?IOP spike after injection - repeatedly if a person has multiple injections longterm these people have ^ IOPs

25
Q

what 3 types of Haemorrhage can you risk getting after anti VEGF tx and what is not necessary if this occurs

A

Subconjunctival ~10%
Subretinal
Choroidal

No need to stop anti-coagulant therapy

26
Q

list the 5 post tx risk factors after anti VEGF injection

A 
Endophthalmitis
Inflammation
RRD
IOP elevation
Haemorrhage
27
Q

which anti VEGF drug has no systemic adverse effects attributable to VEGF inhibition

A

Macugen

28
Q

what 4 types of systemic risks is associated with Avastin

A

Increased risk of non-ocular haemorrhages
CVA, MI in 0.5%
Death in 0.4%

29
Q

what systemic risk is associated with Lucentis

and what is not a risk which is with Avastin

A

increased risk of non-ocular haemorrhages; echhymosis, GI, etc

No increased risk of death, MI, CVA

30
Q

Improve chances of stabilising/improving

_ injections needed to gain __ letters
_ injections required to maintain

A

8 injections needed to gain 15 letters

5 injections required to maintain

Medical Retina (17 decks)

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