Part I: The Current Therapeutic Paradigm

Carmen A. Puliafito, MD, MBA

A recent study of 27 retina practices including more than 300 retinal specialists in the United States found that more than half of all visits to retina practices (52%) were for macular degeneration or retinal vascular disease (A. Moshfeghi, MD). This represents the continuing and increasing dominance of medical retinal disease in the practice of retinal specialists in the industrialized world. In this study, wet macular degeneration represented 13% of all visits. Most of these patients are undergoing anti-VEGF therapy. The anti-VEGF revolution which began in 2004 with the introduction of pegaptanib (MACUGEN – Bausch + Lomb) and continued with the introduction of bevacizumab (Avastin) in 2005 and the approval of ranibizumab (LUCENTIS^® – Genentech) in 2006 has preserved vision in millions of patients. The sustainability of these vision gains over a decade have been challenged in many eyes by the development of fibrovascular disease or geographic atrophy. The treatment burden associated with the anti-VEGF revolution has been remarkable. It is estimated that in 2019, more than 24 million anti-VEGF injections were performed worldwide, with more than 7 million injections in the United States alone. Current anti-VEGF agents are used or approved for treatment of intervals of 4 to 8 weeks or prn. These -VEGF agents are typically used in a treat and extend paradigm in which eyes are show no evidence of neovascular activity are monitored with increasingly long treatment intervals. Nonetheless, a number of studies have concluded that many patients are undertreated, and the more injections eyes receive the better the long-term visual results. The treatment paradigm is poised for a dramatic shift in 2020 and beyond, and subsequent parts of this series will detail the changes in retinal pharmacotherapy that are poised to drive this shift.

Dr. Carmen A. Puliafito can be reached via e-mail – capuliafito@gmail.com