COMMENTARY

New Treatments for Diabetic Retinopathy: AAO 2010

David M. Brown, MD

Disclosures

October 28, 2010

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Hello. I'm David Brown. I'm with the Department of Ophthalmology at The Methodist Hospital in Houston, Texas. I direct clinical research at Greater Houston Retina Research at Retina Consultants of Houston. Today, I am at the American Academy of Ophthalmology (AAO) meeting in Chicago. We are going to discuss some of the developments, both here and around this meeting, in diabetic retinopathy.

In the 1990s, both macular degeneration and diabetic retinopathy were treated with ablative therapy. In 2005, we had a major paradigm shift in macular degeneration. We converted from ablative therapy to pharmacotherapy, and we realized that anti-VEGF [vascular endothelial growth factor] injections given continuously improve the visual acuity rapidly and sustain visual acuity gains in macular degeneration with pharmacotherapy. This same paradigm shift is happening in diabetic retinopathy, but at a much slower pace.

In 2007, the Diabetic Retinopathy Clinical Research Network (the DRCR Network) showed that bevacizumab injections into the eye improved the anatomy for about 3 weeks.[1] Although this seems trivial, those injections given every 6 weeks seemed to improve the visual acuity at 12 weeks.

On this basis, Quan Nguyen and the investigators at John Hopkins did the READ [Ranibizumab for Edema of the mAcula in Diabetes] studies, in which they investigated ranibizumab given continuously and showed that, at the end of a year, ranibizumab injections were associated with very large improvements in visual acuity that were sustained.[2]

So where are we today? The RISE and RIDE [Ranibizumab Injection in Subjects With Clinically Significant Macular Edema With Center Involvement Secondary to Diabetes Mellitus], the pivotal phase 3 ranibizumab studies, are testing head-to-head intravitreal injections of ranibizumab monthly vs our previous ablative laser therapy. These data will be out in the first quarter of 2010. [Editor's note: The data will be out in the first quarter to second quarter of 2011.] We anticipate that release of these data will change us to a proven pharmacotherapy treatment for diabetic retinopathy.

Will there still be a role for laser? Probably. In diabetes, VEGF production is continuous, and if pharmacotherapy is the only thing we have, this will mean sustained injections for the rest of the patient's life. So, I think there is going to be a role for combination therapy, and the Diabetic Retinopathy Clinical Research Network is going to look at some of these combinations.

Are injections into the eye every month going to be our end game? Maybe not. There are fluocinolone implants of a steroid derivative that are injected only every 18-24 months. They show improvements of visual acuity with a small risk for glaucoma and cataract; these implants may compete with sustained anti-VEGF monthly therapy.

The next few quarters of data releases, including this meeting, will be pivotal in this change from ablative therapies to pharmacotherapy. Stay tuned. It's going to be exciting. This is David Brown for Medscape.

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