Advances needed to alleviate burden of retinal disease treatment
We now have our fourth anti-VEGF drug, Beovu from Novartis. Each of the available drugs — Avastin, Lucentis, Eylea and Beovu — typically requires three monthly injections to initiate therapy. After three monthly injections are given, many patients can be converted to less frequent injections, depending on which drug is used, using a treat-and-extend approach. Patients who do not respond to one drug may respond to another. Those of us who comanage these patients with our retina colleagues need to be especially mindful of the postoperative side effects, including uveitis, both anterior and posterior, elevated IOP, secondary cataract in phakic patients and the dreaded occasional endophthalmitis.
For those of us who practiced before anti-VEGF treatment was available to treat vision loss associated with wet age-related macular degeneration, diabetic macular edema, diabetic retinopathy and retinal vein occlusion, the impact these drugs have had on the course of these potentially blinding conditions is nothing short of amazing. Some find the cost to be high, but in a well-done survey, many patients rated blindness as a greater fear than cancer or even death. Using the most expensive drug and performing an injection every month, which today is rare, the total cost per year is less than $30,000, including the professional fees. To me, for a treatment that can reverse a blinding disease and allow patients to regain enough vision to function and contribute to their communities and families, this in relative terms when compared with other treatments is a reasonable cost. There are far more expensive therapies for cancer abatement that do not improve quality of life and in many cases only extend survival a few months.
While anti-VEGF therapy is expensive and in the spotlight because so many of these patients are Medicare age or covered by Medicaid, blindness is personally devastating and also expensive to society. The financial burden is significant, but so is the burden on ophthalmologists who are trying to meet the growing demand for treatment. There is also a great burden placed on the patient and their family. It is hard for patients and a family member to spend a half day or more traveling to a doctor’s office to be examined and potentially treated every month.
We need innovation in drug delivery methods, but also in how care is delivered to the patient in need. Many extended-release drug delivery approaches are in development, and they will help by reducing the frequency of injections. Yet, it remains an extraordinary burden for many patients and a family member to travel from rural America to a retina specialist who is usually located in an urban area. I believe some form of telehealth delivery will be of great help here. Retinal cameras and OCT are being developed that are much smaller and costs are coming down, allowing local eye care providers to own the equipment needed to screen and follow these patients before and between injections. I can even imagine visual acuity/retinal photography/OCT kiosks located in local drug stores becoming available. A fairly complete eye examination can today be performed at home using one or more portable phone apps. Home screening devices such as the ForeseeHome (Notal Vision) AMD monitoring system using preferential hyperacuity perimetry to pick up early macular changes are now approved and reimbursed by many insurers.
In the future, most patients will be able to complete an examination to determine if treatment is needed, either at home or at a minimum close to home. This will be helpful in reducing the patient and family travel and time burden and may well enhance the quality of care and increase compliance. The diagnostic innovations needed are available or in development, as are several innovative extended drug release approaches that promise to reduce injection frequency to only once every 3 to 6 months.
In the more distant future, we can look forward to effective oral and perhaps even topical therapies. That will be a boon to our overburdened patients and their families and the ophthalmologists who treat them. Do not worry, the ophthalmologists who treat retinal disease will have plenty to do in future years. Intravitreal drug injection for dry AMD is in development, and the most promising approaches also require monthly injections. Not only that, there are 10 times as many patients with dry AMD as wet AMD. How we ophthalmologists, our patients and our third-party payers will manage the dry AMD treatment burden when one of these drugs is proven safe and effective, achieves FDA approval and comes to market remains to be seen. But manage we must because living with blindness is not an option in a country like America if an effective treatment is available.
Disclosure: Lindstrom reports relevant financial disclosures for Allegro, Notal Vision, ForeSight Laboratories, Ocular Therapeutix, Novartis and Zeiss.