Global trends show similar patterns worldwide

CHICAGO - Benchmarking treatment and practice patterns among your geographic peers is one thing, but the ASRS International Affairs Committee tracks trends around the world. This year, 41 societies accepted the invitation to participate (and 1010 members of these societies responded; 670 U.S.-based ASRS members answered the same 15 clinical questions as part of the 2019 PAT Survey. International societies were classified by region: Africa/Middle East (n=147), Asia/Pacific (n=264), Central and South America (n=211), and Europe (n=274).

ASRS International Affairs Committee Chair Rishi P. Singh, MD, Cleveland Clinic Cole Eye Institute, presented some of the highlights of the 6th annual Global Trends in Retina Survey. (Of note, not all respondents answered all questions; in some cases the total responses did not equal 100%.) Here are some of the highlights:

Treatment patterns for wet AMD

Treatment-naïve neovascular age-related macular degeneration (AMD) are predominantly treated with at least 3 loading doses; in the majority of regions, once the loading doses are complete treatment moves to treat-and-extend. The notable exception to this is in the Africa/Middle East region, where clinicians prefer to move to PRN dosing. In the U.S. only, clinicians prefer to move immediately to treat-and-extend as soon as a dry or stable retina allows rather than move patients to a PRN dosing schedule.

Treatment patterns for diabetic macular edema

In both the U.S. and Africa/Middle East, clinicians consider a steroid when treating patients with diabetic macular edema (DME) if those patients have had a suboptimal response to 6 anti-vascular endothelial growth factor (VEGF) agents. The remaining regions of the world are a little less conservative, and would consider a steroid after suboptimal responses to 3 anti-VEGF injections. In both options, the preferred timing to change treatment was about 2:1 over the other option.

When clinicians were specifically asked how to manage a 30-year-old, type 1 diabetic with high-risk proliferative diabetic retinopathy (PDR), but who also has excellent vision (20/20) and no DME, respondents in Africa/Middle East, Asia/Pacific, and Europe prefer complete panretinal photocoagulation (PRP) in 2 or more sessions over combining anti-VEGF with complete PRP in 2 or more sessions. Respondents in Central and South America favored the combination treatment just slightly over PRP alone (42.7% to 40.4%, respectively), while respondents in the U.S. clearly preferred the combination treatment over PRP alone (37.7% to 29.3%, respectively).

Overall anti-VEGF use

If there is an absence of adequate response to a first-line anti-VEGF, every region overwhelmingly opts to switch to a different anti-VEGF agent. Running a distant second preference in Africa/Middle East, Central and South America, and Europe is to switch to a steroid alone. In Asia-Pacific and the U.S., respondents also opt to use a steroid in combination with anti-VEGF agents. For the purposes of this survey, “adequate response” was not defined, which may account for the varied secondary responses.
Bevacizumab use

Based upon results from the Diabetic Retinopathy Clinical Research Network (DRCR.net) Protocol T 2-year study, initial treatment for a phakic patient with DME is overwhelmingly Avastin (bevacizumab, Genentech) in both Africa/Middle East and the U.S. The remaining regions of the world use either bevacizumab or Eylea (aflibercept, Regeneron) as their first-line treatment choice.

Optical coherence tomography angiography

In every region of the world except the U.S., clinicians overwhelmingly said they had access to optical coherence tomography angiography and find it useful in clinical practice. In the U.S., however, 53% of respondents do not have access to technology.
In each region of the world, there are some who have access, but do not find it useful: 23.8% in Africa/Middle East, 16.7% in Asia/Pacific, 16.5% in Central and South America, 13.1% in Europe, and 18.9% in the U.S.

Anesthesia use

Before giving intravitreal injections, every respondent opts to use anesthesia, but the type varies across geographic regions. In Africa/Middle East, respondents preferred anesthetic drops slightly more than topical anesthetic applied with a pledget (46.9% to 40.8%, respectively). In Asia-Pacific, Central and South America, only anesthetic drops were chosen (by 83.7%, 79.8% and 91.6% of respondents, respectively).
In the U.S., however, responses were fairly even between anesthetic eyedrops (22.8%), topical anesthetic gel (23.9%), an an injected agent (33.6%). Of potential interest is that no other region of the world opts for either topical anesthetic gels or injected agents.

Pseudophakic patients

Respondents were also asked about their preferences for treatment if they needed a secondary intraocular lens (IOL) without capsular support. In Asia/Pacific and Central and South America, the preference is to use an IOL sutured to the sclera (49.6% and 47.9%, respectively). In Asia/Pacific, respondents also opt to use a sutureless IOL fixated to the sclera (23%) and an anterior chamber IOL (13.9%); in Central and South America, 30% opt to use a sutureless IOL fixated to the sclera and 9.4% opt for an anterior chamber IOL.

Using a sutureless IOL fixated to the sclera is the overwhelming preference for those in Africa/Middle East (60.3%), followed by an IOL sutured to the sclera (20.6%) and an anterior-chamber IOL (8.3%).
Europeans also prefer a sutureless IOL fixated to the sclera (32.3%), but are then equally split in choosing something else or an IOL sutured to the iris (17.3% each).

In the U.S., anterior chamber IOLs are most often preferred (34.7%), followed by a sutureless IOL fixated to the sclera (27.5%) and an IOL sutured to the sclera (27.1%).