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The use of VR mazes hold an intrinsic advantage compared with physical mazes in the ability to control conditions and test various patterns with reliability, participant safety, and repeatability.

Using virtual reality mobility testing as a standardized clinical end point in inherited retinal disorders

Real-world treatment outcomes from a study of patients with retinal vein occlusion

At this year's American Society of Retina Specialists (ASRS) meeting, the Eye Care Network spoke with consultant ophthalmologist Christiana Dinah, BSc, MB BS, MRes. Her presentation focused on real-world outcomes of anti-vascular endothelial growth factor (VEGF) therapies for patients with retinal vein occlusion.

Editor's note: The below transcript has been lightly edited for clarity.

 Hi my name is Christiana Dinah. I'm a consultant ophthalmologist at London North West Trust, in London, United Kingdom. It is my pleasure to present, at ASRS 2024, our work on the real-world outcomes with anti-VEGF therapy in retinal vein occlusion in the United Kingdom. We know the retinal vein occlusion is a significant cause of visual impairment, being the second most common retinal vascular disease, second only to diabetic retinopathy. We are fortunate to have anti-VEGF therapy now, with significantly beneficial results in pivotal randomised controlled trials. 

However, these results have often been difficult to translate in the real world. Additionally, there is sparse data on long-term, real-world outcomes with anti-VEGF therapy in the context of retinal vein occlusion. We extracted data from 16 geographically dispersed eye clinics in the United Kingdom. Our study included approximately 3500 patients in the [branch retinal vein occlusion] BRVO arm and a similar number in the [Central Retinal Vein Occlusion] CRVO arm, so this is quite a large sample size. However, the proportion with follow-up out to 5 years was closer to 500 eyes in each cohort. We included patients that were treatment-naive to any treat previous treatment for retinal vein occlusion, who had had at least 1 anti-VEGF therapy within the timeframe of the study, and had a minimum of 3 month follow-up and up to 60 months follow-up, and that is 5 years. 

Importantly, in the United Kingdom at the moment, the only approved anti-VEGF therapies for retinal vein occlusions are aflibercept, ranibizumab and bevacizumab. So these were the anti-VEGF therapies that we looked at, as under the umbrella of anti-VEGF. To our results, there was significant visual gain, with the average visual acuity gain of approximately 11 to 13 letters in both the branch retinal vein occlusion groups and the central retinal vein occlusion groups. And this was demonstrated quite early, within 3 months, and maintained up to around 12 to 18 months, at which point the visual acuity gains start to reduce slowly, and by the time we get to month 60, that is 5 years, the visual gains at that point is approximately 7 to 8 letters, almost half of the initial gains. We next looked at the number of injections delivered on average in the first year. In both the BRVO cohort and the CRVO cohorts a mean number of 6.4 to 6.5 injections were delivered. And this reduced over the follow-up period to approximately 2.5 injections in both cohorts in the year 5. 

We delved deeper by stratifying the cohorts into low injection receivers, medium injection receivers and high injection receivers. The low cohort received less than 4 injections in within a 12 month period, the medium 4 to 8, and the high greater than 8 injections, and we demonstrated the high cohort reported visual gains similar to what we've seen in the clinical trials that into 15 letter gains, whilst the low cohort reported approximately half of that, and this pattern was evident right out to month 60. Additionally, eyes receiving intravitreal steroids and macular laser increased gradually from year 1 through to year 5, suggesting efforts to achieve or maintain disease control right out to year 5. 

Our study strengths include a large heterogeneous population in a geographically dispersed population across United Kingdom, but limitations include the lack of anatomical data, in addition to a loss to follow-up, whereby the proportion of eyes at the start is approximately 3500 in the BRVO, and in the CRVO, separately whilst at year 5, we have approximately 500 eyes in each arm. The take home message is anti-VEGF therapy does work in retinal vein occlusion and translates into the real-world. However, there are factors limiting our ability to deliver the same volume of injections, as in the randomised control trials. Therefore, there's an unmet need for sustained durable treatments for retinal vein occlusions and long-term monitoring to ensure disease control. Thank you.

Consultant ophthalmologist Christiana Dinah, BSc, MB BS, MRes, presented research findings on retinal vein occlusion in the United Kingdom

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ASRS 2024: Real-world treatment outcomes from a study of patients with retinal vein occlusion

ASRS 2024: Intraoperative fluorescein angiography reduces the rate of postoperative vitreous hemorrhage

Alan Franklin, MD, PhD, FASRS, spoke about his presentation, "Intraoperative Fluorescein Angiography Reduces the Rate of Postoperative Vitreous Hemorrhage" at this year's American Society of Retina Specialists (ASRS) meeting in Stockholm, Sweden. 

Hi I'm Alan Franklin, MD, PhD. FASRS, I practice at Diagnostic and Medical Clinic in Mobile, Alabama, [and I] had the opportunity to present intraoperative fluorescein angiography, how that's improving our outcomes in diabetic vitrectomy at this great venue in Stockholm, Sweden. intraoperative fluorescein angiography, was initially described by Steve Charles 20 to 30 years ago, with the advent of digital visualization, it's gotten more traction as our visualization is better. The images and the video on the operating room are quite compelling, but the question begs is even though the video is great, and shows us reproducible biomarkers that we see in clinic, will it help her outcomes.

So we did a study where we looked at our diabetic patients and looked at rate of vitreous hemorrhage after vitrectomy with or without fluorescein angiography guidance intraoperativly of laser and other surgical maneuvers. Indeed, we found that fluorescein angiography reduced our post-op vitreous hemorrhage rate greatly, especially over the first 1 to 2 months with corresponding better vision reported rate with fluorescein guidance during the surgery is on the order of 10%, which is much lower than the standard reported rates after vitrectomy surgery for diabetic retinopathy and we both Dr. Abruro, our colleague and Dominican Republic, and we showed a significant reduction and rates of vitreous hemorrhage after surgery compared to those who did not receive intraoperative fluorescein angiography before surgery, it was highly significant, especially at both the 1- and the 2-month time points And that we had about 90 patients that underwent fluorescein angiography, so it's still a relatively large study. It is limited by the retrospective nature.

Hopefully it'll improve adoption. It's one thing to show pretty pictures and videos, but to show and prove surgical outcomes, hopefully will will get better adoption. We need to work on making this available for both digital visualization platforms and standard optical visualization with a surgical microscope as well.

ASRS 2024: Intraoperative fluorescein angiography improving outcomes in diabetic vitrectomy

ASRS 2024: Ixo-Vec phase 2 interim data presentation

Charles Wykoff, MD, PhD, gives an insight into first-time data from the phase 2, LUNA trial looking at Ixo-Vec at the annual ASRS meeting in Stockholm, Sweden.

Hi I'm Charles Wykoff, retina specialist from Houston, Texas, and it's great to be here ASRS 2024 in Stockholm, Sweden. So at this meeting, we presented first-time data from the LUNA trial looking at Ixo-Vec, previously known as AVDM-022. 

So ixo-Vec is an intravitreal gene therapy that leads to continuous intraocular aflibercept production, and over about 115 patients treated to date. We've seen consistent and strong efficacy at controlling exudative disease activity, and we've also seen notable levels of intraocular inflammation. So into that context, LUNA was designed as a trial, a phase 2 trial, to look at 2 main things: 1 was lower doses of Ixo-Vec, so lower doses of the of the virus that's being given as a gene therapy, and secondly, to look at enhanced steroid prophylactic regimens. 

So 60 patients with wet AMD were randomized to 1 or 4 steroid prophylactic arms, and also a single injection of Ixo-Vec either 6E10 or 2E11, and then followed for what will ultimately be a 1-year primary endpoint, but at this meeting, we're presenting the completed 26 week pre-specified data. So enrolled patients were were heavily pre-treated patients with wet AMD on average 3 years since AMD original diagnosis and 10 mean annualized anti-VEGF injections at baseline vision was about 20/40, CST 350 microns. Let's talk about efficacy, and then safety giving each equal weight. So from an efficacy perspective, after Ixo-Vec dosing, we saw 76% to 83% of patients remaining injection free through week 26. We also saw stability in visual acuity through week 26, and also stability with CST through week 26. And maybe, to me, the most interesting efficacy signal that we saw was looking at the sub-population of patients that had a CST of greater than 300 microns at baseline. In that population of patients, I think, we really saw the anatomic stability achieved here through 26 weeks as those eyes with fluid at baseline actually had a reduction and CST at week 26 of minus 30 microns and CST stability through that 6-month endpoint. 

So from a safety perspective, there were no Ixo-Vec related SAEs and all related adverse events were mild or moderate, the most common being dose-dependent, anterior chamber cellular inflammation as well as anterior pigmentary changes with 91% of patients in the local steroid regimen arms, having no or minimal inflammation at every visit through week 26. You know, again, of the key objectives of the trial was to evaluate these different enhanced steroid prophylactic regimens. 

And so the key learnings from that were twofold. One, the dexamethasone-alone implant did not provide adequate prophylaxis, and therefore early in the trial, there was a protocol amendment that was incorporated to add difluprednate eyedrops to the OZURDEX alone arm. And once we made that change, we saw meaningful reduction in the IOI rates. And the second important finding, I think it's quite relevant to intravitreal gene therapy at large, was that the use of oral steroids, a meaningful relatively-high dose of prednisone over many weeks, did not provide additional benefit beyond local corticosteroid prophylaxis alone. Both of these things were findings that we did not know before the trial. This trial was designed to look at those 2 arms in particular, and both of them now we have much more clarity about what is useful for prophylaxis in this setting. Looking specifically at at the development of anterior chamber cellular activity or anterior chamber pigmentary changes. 

When you look at the data from the patients with the prophylactic regimens that are being considered for future trials, we saw that most patients at most visits did not have cellular activity. There were 4 patients and both the difluprednate-alone, and the difluprednate plus dexamethasone populations that did have cellular inflammation and at least 1 visit, and there was also potential increase in anterior pigmentary cellular activity toward the end of the 26 week period. And then the last point about safety focusing in on the difluprednate-alone population. We saw in that group a dose-dependent dozens of anterior chamber cellular activity and anterior pigmentary changes through week 26. So in particular, in the lower dose, the 6E10 population, there was one patient at 26 weeks that had a very minimal amount of anterior cellular activity, and then 4 patients with anterior pigmentary changes, 3 of them being mild, 1 moderate. 

So that was the summary of LUNA for ASRS 2024 It says 26 week completed data and a pre-specified endpoint and ultimately this will be a 1 year trial. Thank you.

ASRS 2024: Ixo-Vec phase 2 LUNA study interim data presentation

ASRS 2024: Long-term results of macular hole surgery with long-acting gas tamponade

John T. Thompson, MD, spoke about his presentation, "Long-Term Results of Macular Hole Surgery With Long-Acting Gas Tamponade and Internal Limiting Membrane Peeling" at the annual ASRS meeting in Stockholm, Sweden.

Hi. I'm John Thompson, I'm a retina specialist in Baltimore. And my topic here is the long-term results of using ICG [indocyanine green] to peel ILM [internal lining membrane], and use of a long-acting gas bubble in the treatment of macular holes. And specifically, I was looking at the long-term results in patients who were followed at least 5 years. And the study was from a larger study of 250 consecutive eyes that had primary macular holes, so these were all first surgery macular holes. And patients in this study, in the 250 patient study, there were a total of 83 patients, almost exactly a third of patients, were followed 5 or more years. And the goal was to look at the long-term results of macular holes, both in terms of anatomic and functional success.

What I found is that initially, in this group of 83 eyes, all of the holes were closed at 3 months primarily. However, there were two eyes that developed late reopening of the macular hole between 6 and 7 years, kind of unusual, but it did happen. So the overall one-surgery success rate for the eyes followed 5 or more years was 98%. Now you might think that only the good eyes were followed for 5 or more years, but actually of the 250 eyes, the success rate was also 98% for closing with one surgery. The visual results were also very favorable. 52% of eyes had a visual acuity of 20/40 or better at the final exam. And if you look at 20/63 at the final exam, that also was up, 82% of eyes were 20/63 or better.

To look at it a different way: The average visual acuity improved from 2100 preoperatively to 2050 at the final exam. The results were similar at the 1 and 2-years exams. So these visual acuity improvements are maintained. And unlike macular degeneration and some of the other conditions we treat, the long term results for these eyes are excellent. There were a few complications, a few tears, and a few peripheral detachments, none of which involve the macula. But overall, we seem to be very successful in treating macular holes. These eyes were all treated with ICG removal of the ILM and patients had to remain prone 1 to 2 weeks. And part of the main message of this is that doing simple things like that, a peeling ILM, and long term gas tamponade with prone positioning, results in a very high success rate. And that obviates the need to do these rescue techniques such as autologous retinal transplant or embryonic membrane transplant in these eyes

ASRS 2024: Long-term results of using indocyanine green to peel internal lining membrane

ASRS 2024: Novel approach to myopic traction maculopathy

Nikoloz Labauri, MD, FVRS, founder of DAVINCI Eye Clinic in Tbilisi, Georgia, discusses his presentation, "Suspensory Macular Buckling for Myopic Traction Maculopathy" at this year's American Society of Retina Specialists (ASRS) meeting in Stockholm, Sweden

Hi, I'm Dr Nikoloz Labauri from Tbilisi, Georgia and founder of DAVINCI Eye Clinic. Today I have spoken about the special technique for myopic traction maculopathy. So as we know, this is a disease, which comprises a large spectrum of complications, which certainly goes to the posterior pole of the eye. So this specific method is made specially to indent the posterior pole of the sclera. Today, we spoke about the six patients we have operated on plus 1 year, and the results were quite promising because, as the retinal detachments and macular holes since retinoschisis, which we had in our patients, all of them have vanished and all the holes were closed, and detached retinas were attached.

Compared to the traditional buckling devices, which we had before, this new technique actually suggests us much better results in terms of distorted vision and metamorphosia. The beauty of this buckling is that it indents a wider range, the wide surface of sclera. Instead of a dome shape indentation, it provides the flat shaped indentation. Another advantage is that it's just assembled before the implantation by the surgeon, so it doesn't need any specific custom makings and specific orders, so every surgeon has it in his or her OR. I have plenty of cases where ordering the traditional other types of [buckles] during this time period, this pathology, which is retinal detachment in high myopes, was progressing...until the devices were approaching the operating theatre.

Let's talk about the drawbacks and the dark side. The dark side of this technique is that it's a two-point fixation buckling, that it requires much much larger incisions. Instead of tugging teo muscles, we have to open the conjunctiva 360 and tuck all six muscles to slide the a buckle under the muscles, all the muscles except same medial rectus. In other words, we call it a wristwatch buckling, because indenting part is still placed exactly under the fovea, and around which covers, as I already mentioned, 7 millimeters of surface. It has a learning curve. It's the main disadvantage of this technique, and also it needs a larger incision.

Otherwise it offers a much higher satisfaction of our patients in terms of metamorphosia and distorted vision. Our results were very encouraging. However, we need larger numbers of study subjects and longer follow-up period. So I hope [to] come back with longer follow-up results by the next meeting. Thanks for having me.

Nikoloz Labauri, MD, FVRS, founder of DAVINCI Eye Clinic in Tbilisi, Georgia, discusses his presentation, "Suspensory Macular Buckling for Myopic Traction Maculopathy" at this year's American Society of Retina Specialists (ASRS) meeting in Stockholm, Sweden.

ASRS 2024: Safety and durability of voretigene neparvovec-rzyl for biallelic RPE65

Stephen Russell, MD, discussed his presentation on safety and durability of voretigene neparvovec-rzyl for biallelic RPE65 at the annual ASRS meeting in Stockholm, Sweden.

Hi, I'm Steve Russell from the University of Iowa. I am one of the principal investigators on the phase 3 trial of voretigene neparvovec-rzyl, otherwise known as Luxturna. I'm here at the ASRS presenting the 8 and 9 year follow-up results of the trial, which are quite interesting. Unfortunately, we lost quite a few patients to follow-up during COVID. In the data that we presented, we realigned the data a bit. Let me explain about that. So the trial, as you may recall, involved randomizing the patients 2 to 1 to immediate treatment versus delayed intervention, which was allowed 1 year after the primary endpoint was determined. 

The primary endpoint was met all of the patients who participated in the trial that were in the control group, the delayed intervention group, then we're allowed to get the voretigene neparvovec-rzyl. So to look at how patients are responding over a longer period of time, as we begin to lose patients from the trial because of COVID and other drop out, we realigned to the intervention points of the delayed intervention with the original intervention group, so that we would have the same duration from the intervention to look at how they were doing following intervention. 

As you recall, the original intervention group did quite well improved approximately 2 light levels on the mobility test, the multi-luminance mobility test, FST, visual field ,and so on. The delayed intervention group did similarly, and over the longer term in 8 to 9, and the reason it's 8 to 9 year follow up is because it's 8 year follow-up for the delayed intervention and 9 year follow up for the original intervention because they were in, they had been treated for an additional year at our follow-up time points. 

The bottom line of the study is that for a majority of measurements, especially the mobility tests, the MLMT primary endpoint, there did not appear to be any drop off in terms of the effectiveness of the therapy at 9 and 10 years, there was a little bit more variability in the visual field out results, which suggested that there may be, there's some patients that are having some loss, or that there may be just a generalized loss, but we didn't look at that these were all averages of the outcomes. There were a couple of safety things that should be mentioned. The first is that we did find 3 cases of chorioretinal atrophy in phase 3 trial, which is significant, since we had not identified those previously. There was also 1 case of acute myelogenous leukemia in 1 patient who died at year 7. There was no evidence, however, that that was associated with the use of voretigene neparvovec-rzyl or gene therapy. 

One of the reasons that we're following patients for so long on this particular trial is that this was the first approved gene therapy for any inherited disease, and because of that, the FDA stipulated that we had to have a 15 year follow-up, we have actually collected already the 10 year information, we just didn't have it available for this meeting. And that will be in the forthcoming publication. We hope to have out soon. But there's additional 5 more years of collection for safety reasons, I think that there are, you know, a whole bunch of exciting areas that are sort of in development and competitively vying for the next breakthrough, inherited retinal diseases, there have been a number of non-gene therapy kinds of approaches using things like RNA oligonucleotide therapy, which is, can be very effective in certain conditions, but has some other kinds of side effects. We don't have time to talk about all of those. There is hope that the more generalized gene therapy of CRISPR Cas-9 might be able to be applied to inherited retinal diseases. It was an attempt to do it on a gene CEP290, which unfortunately didn't reach his primary endpoint. There's reason to think that there may be a way of increasing something called the the cut rate, which is the ability of the CRISPR Cas-9 to be able to cut the DNA in the appropriate location using a primer, which is called prime editing. That looks very exciting. So there are some newer technologies out there, it may be a combination of things. 

There are also a lot of interesting technologies now looking at potentially a broader approach to inherited retinal disease where you may be able to treat more generally with a stabilizing agent, I guess for lack of a better term, for cones, and so there may be some alternative therapies that may be really exciting coming up.

George Magrath, MD

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