US, international physicians mostly in agreement over treatment practices

CHICAGO – In its 20th year, the ASRS Preferences and Trends (PAT) survey is designed to track treatment trends of retinal specialists around the world. This year in addition to the ASRS, 41 retina societies around the world also participated in the Global Trends in Retina Survey (see the following article). Respondents to the PAT survey included members in the U.S., Canada, Mexico/central America/South America; Africa/Middle East; Europe; Japan/Asia-Pacific; and “other.” More than 87% of all respondents were medical/surgical retina specialists, with the remaining identifying as either a medical or surgical specialist. In both groups, the majority have been in practice (after fellowship) from 8-15 years.

Interestingly, 69% of international respondents and 76.4% of U.S. respondents have not used intraoperative optical coherence tomography (OCT), and 68.9% of U.S. respondents and 51.7% of international respondents have not used 3-D heads-up visualization systems in the OR.

Macular Disease

Members were generally in agreement in this area, noting that if cost were not an issue, 77% of U.S. respondents and 74% of international respondents would initiate intravitreal aflibercept in a patient with new-onset wet age-related macular degeneration (AMD). In that same treatment-naïve patient, both groups would start with at least 3 monthly injections before considering treat-and-extend (TAE). However, almost four times as many international respondents (21.8%) would give the 3 dose-loading injections before initiating PRN as compared to their U.S. counterparts (5.7%), whereas 22.7% of U.S. respondents would move to TAE as soon as the retina is dry or stable compared to only 10.7% of international respondents.

More international respondents (62.2%) believe patients are being undertreated than U.S. respondents (53.7%), but more U.S. respondents (27.3%) than international (18.8%) believe it is inaccurate to extrapolate clinical trial data and expect the same outcomes.

In general, fluid on optical coherence tomography (OCT) drives the decision to retreat, with little difference among the type of fluid (subretinal or intraretinal).

If a patient presents with a recent heart attack or stroke, about 22% of international respondents would stop anti-vascular endothelial growth factor (VEGF), observe, or consider alternatives; 56% of U.S. respondents and 38.2% of international respondents would not alter management strategies.

Looking into the future, if a 6-month, continuous-release anti-VEGF implant device were available, 15% of U.S. respondents and 25.3% of international respondents would initially target all wet AMD patients. Slightly more than one-quarter of U.S. respondents would initially target wet AMD patients who have recalcitrant choroidal neovascularization despite maximal frequency dosing. Should these patients receive the implant, most respondents would recommend exams every 2-3 months.

Respondents were generally unaware of the phase 2 data on faricimab, will use brolucizumab (presuming approval and insurance coverage) on incomplete responders to other anti-VEGFs or try it on a few and expand use if they see a benefit. Almost half the respondents remain unsure if complement inhibition is important to the progression/development of AMD. In this group of specialists, social media plays a minimal - if any - role in the practice. About one-quarter of the respondents overall are involved in clinical trials.

Vascular Disease

When it comes to patients with retinal vascular disease or diabetic macular edema (DME), the responses were more varied in terms of treatment. In a 30-year-old, type 1 diabetic patient with high-risk proliferative diabetic retinopathy (PDR), but good vision (20/20) and no DME, anti-VEGF and complete panretinal photocoagulation (PRP) in ≥2 sessions was as likely a treatment preference as complete PRP treatment in ≥2 sessions. PRP became the leading treatment choice in that same patient who now had only mild PDR.

A smaller percentage (<20%) of respondents in both groups use anti-VEGF therapy in cases of non-PDR without DME.

Although almost 90% of respondents are aware of PANORAMA, it will have little effect on how clinicians manage non-PDR without DME. Initial treatment of phakic patients with DME is overwhelmingly bevacizumab in the U.S. (65%), but aflibercept outside the U.S. (41%). Intravitreal steroids are still reserved for suboptimal responders. Treating fovea-involving clinically significant DME before a patient undergoes cataract surgery is overwhelmingly the preferred treatment strategy.

The results of the SCORE2 study has not altered management strategy among clinicians in the treatment of retinal vein occlusion (RVO). In asymptomatic patients without macular edema, observation is a common treatment strategy in central RVO.

Pharmacology

Clinicians will switch anti-VEGFs if vision does not improve or worsens, or if there is insufficient fluid retention. In the U.S., clinicians are likely to switch to a different anti-VEGF, but more international respondents (33%) would consider switching to a steroid than their U.S. counterparts (8.2%).

Prefilled syringes have not made much of a difference in which anti-VEGF clinicians prefer to use.
Half the U.S. respondents have found more insurers are mandating step therapy, or increased requirements for prior authorization.

Although voretigene neparvovec received approval in 2018, 21% of international respondents are unaware of the gene therapy (approved for inherited retinal dystrophies). More importantly, however, is that for the most part, clinicians do not have patients who could benefit from the treatment.