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The Basics of Pigment Epithelial Detachment and the Latest in nAMD Therapies

By: Amy S. Babiuch, MD; Caroline Baumal, MD; David Eichenbaum, MD; Roger A. Goldberg, MD, MBA and Nancy M. Holekamp, MD

Webinar Credits: .5

Retinal disorders, including age-related macular degeneration, diabetic eye disease, and retinal vein occlusion can result in vision loss if not treated early and continuously. Prevent Blindness America has found the total health care costs of vision problems in the United States in people older than 40 years to reach almost $139 billion annually. Retina specialists must be continuously educated on the latest advances relating to the management of these diseases to allow for the best possible care for their patients.

This certified CME activity is designed for retina specialists and eye care professionals involved in the medical management of patients with retina disorders.

Expiration Date: Monday, May 31, 2021
Release Date: May 2020

Learning Objectives

  • Describe the existing barriers to treatment and ways to overcome them.
  • Describe the relationship between drugs, treatment frequency, visual, and anatomic outcomes.
  • Identify the newer compounds in development that may reduce treatment burden while maintaining efficacy.

Accreditation and Designation Statement

Accreditation Statement

Evolve Medical Education LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation Statement

Evolve Medical Education LLC designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 

This educational activity is provided by Evolve Medical Education.

 

Participation Method

Please proceed through the program, complete the post-test, evaluation and submit for credit.

 

Faculty and Disclosures

It is the policy of Evolve that faculty and other individuals who are in the position to control the content of this activity disclose any real or apparent conflict of interests relating to the topics of this educational activity. Evolve has full policies in place that will identify and resolve all conflicts of interest prior to this educational activity.

The following faculty members have the following financial relationships with commercial interests:

Amy S. Babiuch, MD, has had a financial agreement or affiliation during the past year with the following commercial interests in the form of Consultant: Genentech; Grant/Research: Regeneron.
Caroline Baumal, MD, has had a financial agreement or affiliation during the past year with the following commercial interests in the form of Consultant:  Genentech, and Ocular Therapeutics; Speaker: Genentech, Novartis, and Carl Zeiss.
David Eichenbaum, MD, has had a financial agreement or affiliation during the past year with the following commercial interests in the form of Consultant: Alimera Sciences, Allergan, Allegro, Clearside Biomedical, Eyepoint Pharmaceuticals, Genentech, Orbit Biomedical, Notal Vision, Novartis, Opthotech, and Regeneron Pharmaceuticals, Inc.; Grant/Research Support: Alimera, Allergan, Chegdu, Clearside Biomedical, Genentech, Mylan, Novartis, Opthea, and Ophthotech; Speaker: Allergan, Genentech, and Novartis; Stock/Shareholder: Boston Image Reading Center, Humera, and US Retina.
Roger A. Goldberg, MD, MBA, has had a financial agreement or affiliation during the past year with the following commercial interests in the form of Consultant:  Carl Zeiss, Genentech, and Regeneron; Grant/Research Support: Aerie, Carl Zeiss, Genentech, Graybug, Novartis, and Santen; Speaker: Allergan, Genentech, and Novartis.
Nancy M. Holekamp, MD, has had a financial agreement or affiliation during the past year with the following commercial interests in the form of Consultant:  Allergan, Genentech, Lineage, Gemini, Novartis, Regeneron, and Viewpoint Therapeutics. Grant/Research Support: Genentech, Gemini, Gyroscope, and Notal Vision; Speaker: Allergan, Genentech, Novartis, Regeneron, and Spark; Stock/Shareholder: Katalyst.

Editorial Support Disclosures:

The staff and planners involved in this activity have no financial relationships with commercial interests. Nisha Mukherjee, MD, peer reviewer, have no financial relationships with commercial interests.

 

 

Disclaimer

OFF-LABEL STATEMENT
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The opinions expressed in the educational activity are those of the faculty. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
DISCLAIMER
The views and opinions expressed in this educational activity are those of the faculty and do not necessarily represent the views of Evolve, or Genentech.

Pretest

  • 1 Not at all confident23 Neutral45 Very Confident
  • 1. Never2.3. Sometimes4.5. Always

Introduction

This program will focus on the basics of pigment epithelial detachment and treatment options as well as the latest in available neovascular age-related macular degeneration therapies and select investigative agents in the pipeline nearing FDA approval.

Pigment Epithelial Detachment (PED)

The natural history of PED is that they will lead to progressive vision loss, with 50% of affected patients losing greater than 3 lines of visual acuity (VA) after 1 year without treatment. In addition, patients with PED also are a higher risk for ocular comorbidities such as vision loss, disciform scars, and retinal pigment epithelium (RPE) tears.1-3

Multiple retrospective studies demonstrate a reduction in size of PEDs after intravitreal anti-VEGF treatment.2-5

Figure

PEDs that demonstrate suboptimal response to anti-VEGF therapy present a unique challenge in the management of nAMD.6-10 Prospective and post-hoc analysis have demonstrated that both ranibizumab and aflibercept are effective in treating PEDs secondary to nAMD.11

Options include switching anti-VEGF therapy or increasing the dose or frequency of anti-VEGF therapy employed.10 HARBOR showed that PED resolved more frequently in the 2.0-mg group but this did not correlate with VA gains, which were not significant between the 0.5-mg IVL and 2.0-mg IVL groups.11 Multiple retrospective studies evaluated switching agents, and no pattern of visual improvement can be attributed to switching anti-VEGF agents, despite anatomical improvements.6-10

PEDs have been shown to decrease in volume over time with continued anti-VEGF therapy, and there is no correlation between reduction in PED height and VA improvements. Complete flattening of PEDs may yield an unfavorable outcome due to the development of macular atrophy with resolution.12,13

Volumetric analysis of OCT demonstrates a decrease in PED volume and height with an increase in basal diameter. This suggests that PEDs flatten and widen with minimal changes in volume overtime, and that they may be protective against RPE tear.12,13

PED and RPE Tears

PEDs with a height greater than 400 to 600 microns suggest an increase in the risk for RPE tear development,14,11 and evidence suggests a trend in RPE tears occurring in the first 3-months of anti-VEGF therapy.15,16

However, more frequent injections during the 12- to 24-month period following an RPE tear can result in continued VA gains.11

Figure

Case Discussion: RPE Tear

These images show an 82-year-old man with nAMD in his right eye who was treated with five injections of bevacizumab. At first presentation, his VA 20/70 OD and 20/30 OS.

He developed RPE tear after one bevacizumab injection and his VA declined to 20/300 in his right eye. He continued monthly anti-VEGF therapy and his VA improved to 20/150 OD.

Figure

AMD and the Heavy Treatment Burden

Current treatment options for nAMD requires regular anti-VEGF injections. However, patient adherence to follow-up over 5 years is poor for various reasons.17 A study by Boulanger-Scemama and colleagues to analyze adherence to follow-up over 5 years among patients treated in a tertiary health care center with intravitreal ranibizumab for exudative AMD found that three factors were associated with failure to follow up: high age at baseline (82.2 vs. 76.5 years, P < .001), poor best-corrected visual acuity (BCVA) at baseline (42.5 vs. 51.0 letters, P= .020), and long distance from home to hospital (132 vs. 17.1km, P< .001).

A total of 201 patients were included, and the rate of loss to follow-up during the 5-year period was 57% (115/201). Fifty-eight patients lost to follow-up completed the questionnaire. The main reasons reported by patients for follow-up discontinuation were long distance from home to hospital (51.7%, 30/58), subjective dissatisfaction with the benefits of intravitreal injections (34.5%, 20/58), and the excessive burden of periodic follow-up visits (24.1%, 14/58).

Figure

CATT: 5-Year Outcomes

A study by Maguire et al described outcomes 5 years after initiation of treatment with bevacizumab or ranibizumab for nAMD among patients enrolled in CATT.

This graph shows the distribution of VA over time for 647 patients. The authors concluded that vision gains during the first 2 years of the trial were not maintained at 5 years. However, 50% of eyes had VA 20/40 or better, confirming anti-VEGF therapy as a major long-term therapeutic advance for nAMD.

VA was obtained for 647 (71%) of 914 living patients with average follow-up time 5.5 years. The mean number of examinations for AMD care after the clinical trial ended was 25.3, and the mean number of treatments in the study eye was 15.4. Most (60%) patients were treated ≥1 times with a drug other than their randomly assigned drug. At the 5-year visit, 50% of study eyes had VA 20/40 or better and 20% had VA 20/200 or worse. Mean change in VA was −3 letters from baseline and −11 letters from 2 years. Among 467 eyes with fluorescein angiography, mean total lesion area was 12.9 mm2, a mean of 4.8 mm2 larger than at 2 years. GA was present in 213 (41%) of 515 gradable eyes and was subfoveal in 85 (17%). Among 555 eyes with spectral domain OCT, 83% had fluid (61% intraretinal, 38% subretinal, and 36% sub-retinal pigment epithelium). Mean foveal total thickness was 278 μm; a decrease of 182 μm from baseline and 20 μm from 2 years. An abnormally thin retina at the foveal center (<120 μm) was present in 36%. Between 2 and 5 years, the group originally assigned to ranibizumab for 2 years lost more VA than the bevacizumab group (−4 letters; P= .008). Otherwise, there were no statistically significant differences in VA or morphological outcomes between drug or regimen groups.18

Figure

Comparison of Current and Emerging Anti-VEGF Agents

New treatments may help alleviate the nAMD treatment burden. This image shows the current and emerging anti-VEGF agents, their format, molecular structure, molecular weight, and clinical dose used for treating wet AMD.19-27

Note the large size of bevacizumab and aflibercept. It was once hypothesized that large molecules, if delivered intravitreally, would not be able to penetrate the retina to treat choroidal neovascularization (CNV). Clearly that theory has been disproven and both bevacizumab and aflibercept are effective agents in treating wet AMD.21,23,26,27 Also, note, the small molecular weight of brolucizumab.24,25 This allows a high dose to be delivered. Finally, abicipar is a DARPin platform that is distinct from the other agents. DARPin molecules are a novel class of binding proteins with the potential to overcome some limitations of antibody-based therapeutics. DARPin molecules are small, highly stable proteins that contain engineered ankyrin repeat domain(s) and can be selected to bind any given target protein with high specificity and affinity.20

Figure

HAWK / HARRIER: 48 Weeks

Brolucizumab, an anti-VEGF for the treatment of nAMD, was approved by the FDA in October 2019. The recommended dose for brolucizumab is 6 mg monthly (approximately every 25-31 days) for the first three doses, followed by one dose of 6 mg every 8 to 12 weeks.28

HAWK and HARRIER, two phase 3, double-masked, multicenter, active-controlled, randomized trials, compared brolucizumab with aflibercept to treat nAMD that included 1,817 patients with untreated, active choroidal neovascularization due to AMD in the study eye. Patients were randomized to intravitreal brolucizumab 3 mg (HAWK only) or 6 mg or aflibercept 2 mg. After loading with 3 monthly injections, brolucizumab-treated eyes received an injection every 12 weeks (q12w) and were interval adjusted to every 8 weeks (q8w) if disease activity was present; aflibercept-treated eyes received q8w dosing.28

At week 48, each brolucizumab arm demonstrated noninferiority to aflibercept in BCVA change from baseline (least squares [LS] mean, +6.6 [6 mg] and +6.1 [3 mg] letters with brolucizumab vs. +6.8 letters with aflibercept [HAWK]; +6.9 [brolucizumab 6 mg] vs. +7.6 [aflibercept] letters [HARRIER]; P< .001 for each comparison).

Greater central subfield thickness reductions from baseline to week 48 were observed with brolucizumab 6 mg versus aflibercept in HAWK (LS mean 172.8 mm vs. 143.7 mm; P= .001) and HARRIER (LS mean 193.8 mm vs. 143.9 mm; P< .001).

The authors concluded that brolucizumab was noninferior to aflibercept in visual function at week 48, and more than 50% of brolucizumab 6 mg treated eyes were maintained on q12w dosing interval through week 48. Anatomic outcomes favored brolucizumab over aflibercept.

Figure

HAWK / HARRIER: 96 Weeks

The BCVA achieved by brolucizumab at week 48 (primary endpoint) was maintained at Week 96.29

In addition, 82% and 75% of those patients who reached week 48 on a q12w 6 mg brolucizumab interval remained on q12w dosing through week 96. Though not reported directly, since 56% of eyes in HAWK and 51% in HARRIER reached 48 weeks at q12w dosing, this would imply that of the total cohort 46% of eyes in HAWK and 38% of eyes in HARRIER maintained q12w dosing.30

Figure

CEDAR / SEQUOIA Studies

Abicipar, which is currently under investigation for treatment of nAMD, was tested in two global pivotal phase 3 trials, CEDAR and SEQUOIA, against the standard of care (ranibizumab given every 4 weeks [q4w]) in the following two ways: three monthly loading doses and then q8w or two monthly loading doses followed by a bimonthly dose and then q12w. Of note, the primary outcome for this study was not mean change in BCVA but rather the percent of eyes maintaining VA.31,32

Figure

In both the SEQUOIA and CEDAR studies, abicipar met the prespecified primary endpoint of the proportion of patients with stable vision at week 52 and demonstrated statistical noninferiority to q4w ranibizumab for both the 12- and 8-week dosing regimens. Noninferiority was demonstrated for abicipar despite substantially fewer injections required for q12w and q8w abicipar vs q4w ranibizumab with six, eight, and 13 injections required, respectively. In each trial, more than 91% of patients had stable vision on the q12w dosing regimen.

Figure

Figure

Port Delivery System

The Port Delivery System (PDS) for extended release of ranibizumab was well-tolerated and improved BCVA versus monthly injections in a phase 1 trial. The device received fast-track designation from FDA and is being studied in an FDA phase 3 clinical trial.33-35

The nonbiodegradable refillable port is placed beneath the conjunctiva, and the reservoir is refilled via subconjunctival opening using a custom refill needle. The device is designed to provide constant levels of ranibizumab.33,34

The current design of the device requires it be surgically implanted in an ambulatory surgery center or hospital operating room at the present time. Refills are performed in the office.

Figure

LADDER Study

The figure shows the LADDER study, an FDA phase 2 clinical trial of the PDS to evaluate the efficacy, safety and pharmacokinetics of three different formulations of ranibizumab delivered via PDS implant compared with monthly intravitreal injection of ranibizumab in participants with subfoveal nAMD.36,37

Figure

The results of the LADDER study show that the median time to refill for the 100 mg/mL dose of ranibizumab was 15.0 months, and 80% of patients went at least 6 months without requiring a refill. The results for the other two doses of ranibizumab used in the PDS show that this occurs in a dose-dependent fashion.37

Only the 100 mg/mL dose of ranibizumab will be used in the phase 3 clinical trial, ARCHWAY.38

Figure

When looking at mean change in BCVA, it is important to remember that all eyes included in the LADDER clinical trial had already received at least three anti-VEGF injections, so the PDS with ranibizumab can be described as a maintenance strategy.39

Figure

Looking at mean change in Central Foveal Thickness (CFT), once again it is evident that the PDS is a maintenance strategy.39

Figure

ARCHWAY

ARCHWAY is the clinical trial designed for the 100 mg/mL dose of ranibizumab in the PDS.  Note the mandatory refills every 6 months as well as the opportunity for rescue injections at each of the two visits prior to the 6-month time point.38 Enrollment is complete and are results pending.

Also note that all patient in the PDS arm will rollover to the PORTAL study, a phase 3, multicenter, long-term extension study of safety and efficacy.40 This is an extension of the LADDER phase 2 study which allows patients who were in the control group to receive the PDS implant. Enrollment is complete, and results are pending.

Figure

Conclusion

This activity reviewed the currently available anti-VEGF agents plus therapeutic agents under investigation, which could greatly expand the nAMD treatment options. Additionally, advances being made in sustained delivery of these agents may further help with treatment adherence.

References

  1. Pauleikhoff D, Löffert D, Spital G, et al. Pigment epithelial detachment in the elderly. Graefes Arch Clin Exp Ophthalmol. 2002;240(7):533-538.
  2. Cho HJ, Kim KM, Kim HS, et al. Response of pigment epithelial detachment to anti-vascular endothelial growth factor treatment in age-related macular degeneration. Am J Ophthalmol. 2016;166:112-119.
  3. Au A, Parikh VS, Singh RP, et al. Comparison of anti-VEGF therapies on fibrovascular pigment epithelial detachments in age-related macular degeneration. Br J Ophthalmol. 2017;101:970-975.
  4. Dirani A, Ambresin A, Marchionno L, et al. Factors influencing the treatment response of pigment epithelium detachment in age-related macular degeneration. Am J Ophthalmol. 2015;160(4):732-738.
  5. Inoue M, Arakawa A, Yamane S, et al. Variable response of vascularized pigment epithelial detachments to ranibizumab based on lesion subtypes, including polypoidal choroidal vasculopathy. Retina. 2013;33(5):990-99.
  6. Chan CK, Abraham P, Sarraf D. High-dose ranibizumab therapy for vascularized pigment epithelial detachment. Eye (London). 2012;26(6):882-885.
  7. Patel KH, Chow CC, Rathod R, et al. Rapid response of retinal pigment epithelial detachments to intravitreal aflibercept in neovascular age-related macular degeneration refractory to bevacizumab and ranibizumab. Eye (London).2013;27(5):663-668.
  8. De Massougnes S, Dirani A, Ambresin A, et al. Pigment epithelial detachment response to aflibercept in neovascular age-related macular degeneration refractory to ranibizumab: time course and drug effects. 2016;36(5):881-888.
  9. Broadhead GK, Hong T, Zhu M, et al. Response of pigment epithelial detachments to intravitreal aflibercept among patients with treatment-resistant neovascular age-related macular degeneration. Retina. 2015;35(5):975-981.
  10. Kanesa-Thasan A, Grewal DS, Gill MK, et al. Quantification of change in pigment epithelial detachment volume and morphology after transition to intravitreal aflibercept in eyes with recalcitrant neovascular AMD: 18-month results. Ophthalmic Surg Lasers Imaging Retina. 2015;46(6):638-641.
  11. Sarraf D, Hill L, Lu N, et al. Efficacy of ranibizumab therapy in eyes with neovascular AMD and pigment epithelial detachment (PED): a HARBOR subanalysis study. Paper presented at The ARVO 2016 Annual Meeting; May 1-5, 2016; Seattle, WA.
  12. Kanesa-Thasan A, Grewal DS, Gill MK, Lyon AT, Mirza RG. Quantification of change in pigment epithelial detachment volume and morphology after transition to intravitreal aflibercept in eyes with recalcitrant neovascular AMD: 18-month results. Ophthalmic Surg Lasers Imaging Retina.2015;46(6):638-6341.
  13. Zinkernagel MS, Wolf S, Ebneter A. Fluctuations in pigment epithelial detachment and retinal fluid using a bi-monthly treatment regimen with aflibercept and neovascular age-related macular degeneration. 2016; 235:42-48.
  14. Chan CK, Abraham P, Meyer CH, et al. Optical coherence tomography–measured pigment epithelial detachment height as a predictor for retinal pigment epithelial tears associated with intravitreal bevacizumab injections. Retina. 2010;30(2):203-211.
  15. Sarraf D, Joseph A, Rahimy E. Retinal pigment epithelial tears in the era of intravitreal pharmacotherapy: risk factors, pathogenesis, prognosis and treatment (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc. 2014;112:142-159.
  16. Cunningham ET Jr, Feiner L, Chung C, et al. Incidence of retinal pigment epithelial tears after intravitreal ranibizumab injection for neovascular age-related macular degeneration. 2011;118:2447-2452.
  17. Boulanger-Scemama E, Querques G, About F, et al. Ranibizumab for exudative age-related macular degeneration: A five-year study of adherence to follow-up in a real-life setting. J Fr Ophthalmol. 2015;38:620-627.
  18. Maguire MG, Martin DF, Ying GS, et al; Comparison of Age-related Macular Degeneration Treatments Trials (CATT) Research Group. Five-year outcomes with anti-vascular endothelial growth factor treatment of neovascular age-related macular degeneration: The comparison of age-related macular degeneration treatments trials. Ophthalmology. 2016;123(8):1751-1761.
  19. Molecular Partners. www.molecularpartners.com/our-products/abicipar/. Accessed August 19, 2019.
  20. Rodrigues GA, Mason M, Christie LA, et al. Functional characterization of abicipar-pegol, an Anti-VEGF DARPin therapeutic that potently inhibits angiogenesis and vascular permeability. Invest Ophthalmol Vis Sci. 2018 59:5836-5846.
  21. Bevacizumab [package insert]. South San Francisco, CA: Genentech, Inc. 2016.
  22. Aflibercept [package insert]. Tarrytown, NY: Regeneron Pharmaceuticals, Inc. 2017.
  23. Ranibizumab [package insert]. South San Francisco, CA: Genentech, Inc. 2017.
  24. Holz FG, Dugel PU, Weissgerber G, et al. Single-chain antibody fragment VEGF inhibitor RTH258 for neovascular age-related macular degeneration: a randomized controlled study. Ophthalmology. 2016;123(5):1080-1089.
  25. Dugel PU, Jaffe GJ, Sallstig P, et al. Brolucizumab versus aflibercept in participants with neovascular age-related macular degeneration: a randomized trial. Ophthalmology. 2017;124(9):1296-1304.
  26. CATT Research Group, et al. Ranibizumab and Bevacizumab for Neovascular Age-Related Macular Degeneration. N Engl J Med. 2011;364(20):1897-1908.
  27. IVAN Study Investigators, et al. Ranibizumab versus bevacizumab to treat neovascular age-related macular degeneration: one-year findings from the IVAN randomized trial. 2012;119(7):1399-1411.
  28. Singh RP et al. Poster presented at the Annual Meeting of the Association for Research in Vision and Ophthalmology (ARVO); April 29-May 3, 2018; Honolulu, HI.
  29. Dugel PU et al. Presented at: The Annual Meeting of the American Academy of Ophthalmology 2018; Chicago, IL; October 27-30, 2018.
  30. Yannuzzi NA, Freund KB. Brolucizumab: evidence to date in the treatment of neovascular age-related macular degeneration.Clinical Ophthalmology. 2019;13:1323-1329.
  31. gov. https://clinicaltrials.gov/ct2/show/NCT02462928. Accessed 7/24/19.
  32. gov. https://clinicaltrials.gov/ct2/show/NCT02462486. Accessed 7/24/19.
  33. Helzner J. Retinal Physician.retinalphysician.com/issues/2017/january-2017/genentech-acquires-developer-of-sustained-release. Updated January 18, 2017. Accessed January 3, 2020.
  34. Barakat MR, Dugel PU. New developments for the treatment of exudative and nonexudative AMD. Retinal Physician.  www.retinalphysician.com/issues/2015/october-2015/new-developments-for-the-treatment-of-exudative-an#ref17. Updated October 1, 2015. Accessed January 3, 2020.
  35. Pieramici DJ. The Port Delivery System With Ranibizumab: A new treatment strategy for patients with nAMDenters a phase 3 clinical trial. Retinal Physician. https://www.retinalphysician.com/issues/2019/march-2019/the-port-delivery-system-with-ranibizumab. Updated March 1, 2019. Accessed January 9, 2020.
  36. Clinical trials.gov. Study of the efficacy and safety of the ranibizumab port delivery system (RPDS) for sustained delivery of ranibizumab in participants with subfoveal neovascular age-related macular degeneration (AMD) (LADDER).  https://clinicaltrials.gov/ct2/show/NCT02510794. Updated June 10, 2019. Accessed January 13, 2020.
  37. Campochiaro PA, Marcus DM, Awh CC, et al. The port delivery system with ranibizumab for neovascular age-related macular degeneration: results from the randomized phase 2 LADDER clinical trial. Ophthalmology. 2019;126(8):1141–1154.
  38. gov. A phase III study to evaluate the port delivery system implant with ranibizumab compared with monthly ranibizumab injections in participants with wet age-related macular degeneration (ARCHWAY). https://clinicaltrials.gov/ct2/show/NCT03677934. Updated January 7, 2020. Accessed January 13, 2020.
  39. Regillo CD et al. Presented at: The Annual Meeting of the American Academy of Ophthalmology 2018; Chicago, IL; October 27-30, 2018.
  40. gov. Extension Study for the Port Delivery System With Ranibizumab. https://clinicaltrials.gov/ct2/show/NCT03683251. Updated January 7, 2020. Accessed January 13, 2020.

Next

Test

Instructions

Step 1 of 2

  • 1 Not at all confident23 Neutral45 Very Confident
  • 1. Never2.3. Sometimes4.5. Always
  • AgreeNeutralDisagree
    Identify the current treatment options available for the management of common retinal diseases (neovascular age-related macular degeneration, diabetic eye disease, retinal vein occlusion).
    Summarize how treatment paradigms have evolved over time and how they relate to current treatment options.
    Identify the relationships between disease characteristics, drug, treatment frequency, visual and anatomic outcomes.
    Implement best practices using individualized patient treatment plans to ensure optimal outcomes for patients.
    Recognize the growing importance of imaging for use in disease management.
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