Dr. Torres gives great information on age related macular degeneration. This is a great update not only on the disease but on emerging treatments for this devastating problem.

1. Age Related Macular Degeneration
Emerging Technologies
Waldemar Torres, MD, FACS

2.  VITREO-RETINAL SURGEON
 NATIVE FROM PUERTO RICO
 TRAINED IN THE UNIVERSITY OF PUERTO RICO AND PONCE SCHOOL OF
MEDICINE, P.R.
 INTERSHIP IN STATE UNIVERSITY OF NEW YORK, BINGHAMTON, N.Y.
 OPHTHALMOLOGY TRAINING AT THE ALBERT EINSTEIN COLLEGE OF
MEDICINE / YESHIVA UNIVERSITY, BRONX, NY
 SUB-SPECIALTY TRAINING AT SOUTH TEXAS RETINA
CONSULTANTS, CORPUS CHRISTI, T.X.
 MEDICAL PRIVILEGES AT:





SARASOTA MEMORIAL HOSPITAL
VENICE REGIONAL HOSPITAL
DOCTORS HOSPITAL
LAKEWOOD RANCH HOSPITAL
ST. ANDREWS OUTPATIENT SURGERY CENTER

3.  FELLOW OF THE AMERICAN COLLEGE OF SURGEONS
 FELLOW OF THE AMERICAN ACADEMY OF OPHTHALMOLOGY
 DIPLOMATE OF THE AMERICAN BOARD OF OPHTHALMOLOGY
 MEMBER OF THE PAN AMERICAN ASSOCIATION OF
OPHTHALMOLOGY
 MEMBER OF THE SARASOTA MEDICAL SOCIETY
 MEMBER OF THE AMERICAN MEDICAL ASSOCIATION
 MEMBER OF THE FLORIDA OPHTHALMOLOGY ASSOCIATION
 MEMBER OF THE HILLSBOROUGH COUNTY OPHTHALMOLOGY
SOCIETY

4. Age-Related Macular Degeneration
 Known as macular degeneration, AMD, ARMD
 Approximately 15 million people in the USA have AMD
 Described more than 80 years ago by Holloway
TB, Verhoeff, Trans Am Opth Soc 1928
 AMD is a chronic, progressive disease of the macula (central
portion of retina) that destroys central vision required for
reading, driving, cooking, facial recognition and other common
tasks

5. Leading Cause of Vision Loss
 AMD is the leading cause of severe vision loss &
blindness in adults over age 50 in the western
world
[1]
 It is a global public health problem
 The general consensus is that as the population
grows and ages, the incidence will increase as well
 The main cause of vision loss in AMD is the
development of choroidal neovascularization or
abnormal blood vessel growth, also known as wet
AMD
[1] Early Detection & Treatment of Neovascular AMD, Bressler, JABFP 2002

6. AMD Types
Dry AMD
(non-neovascular)
Wet AMD
(neovascular)

7. Dry AMD
 Accounts for the majority of AMD cases
 Early stage can be very mild at first
 Progressive degeneration of the RPE ( retinal pigment
epithelium) and the photoreceptor loss (the light
sensitive cells) and subsequent vision loss
 When the patient loses most of the central vision, this
central spot or degeneration is called geographic atrophy
( GA) or the end stage of it,
 The progression varies between individuals, with vision
loss occurring more quickly in some than in others as the
tissue in the macula degenerates

8. Wet AMD: A Rapid Descent
Early
Intermediate
Advanced
(dry)
(dry)
(wet)
There are no good
predictors for who will
develop Wet AMD or
when
No Vision Loss
Today: many are
diagnosed after
vision loss
Wet AMD
Severe Vision Loss
Blindness
TIME

9. Wet AMD is a debilitating
disease that can result in
rapid deterioration of your
central vision

10. Wet AMD
 Imbalance of:
 pro-angiogenic factors that induce new blood vessels
formation
 angiogenic inhibitory factors that inhibit new blood
vessels formation
 Excess production of VEGF (vascular endothelial
growth factor)
 Growth of “ abnormal blood vessels” or a choroidal
neovascular membrane leading to scar formation

11. Wet AMD
 New blood vessels grow
beneath the retina
 Leak blood & fluid
 Damage photoreceptors
( the light sensitive cells
at the back of the eye)
causing permanent vision
loss

13. Risk of Conversion to Wet AMD
 43% of patients who already have wet AMD in one eye will
develop wet AMD in their other eye within 5 years [1]
 26.4% of patients with intermediate (dry) AMD in both eyes
will develop wet AMD within 5 years [1]
 6.3% of patients with intermediate (dry) AMD in one eye
will develop wet AMD within 5 years [1]
[1] AREDS Report No. 11, Arch Ophthalmol, 2003

14. Treatment for advanced
dry AMD (GA)
 AMD is a complex disease with various pathologic
mechanisms
 Current strategies pursued by researchers are:
 New drugs that aim to prevent damage to the retina or to
slow the progression of dry AMD
 Anti-inflammatory drugs
 Complement inhibition ( inhibition of a immune system
pathway)
 Alleviation of oxidative stress ( anti oxidants use)
 Reduction of accumulation of retinal toxins
 Enhancement of choroidal blood perfusion ( improving
circulation of retinal circulation)

15.  Sirolimus ( Rapamycin): anti fungal and immunosupressant agent
 Various phase1/2 clinical trials sponsored by National
Eye Institute has been completed
 Subconjunctival injection every 2 months for dry AMD
 Patients with geographic atrophy
 Another study is using an oral dose along with other
agents for wet AMD
 Results will be available shortly

16.  Fluocilonolone Acetonide Intra-vitreal implant
 Synthetic hydrocortisone derivative implant inside the
eye
 Sustained release for up to 36 months
 Ongoing Phase 2 trial is enrolling patients with
bilateral GA
 Will assess the rate of GA progression in a 2-year span.
 This is a medicine secreting implant to protect dying
retinal cells

17.  POT-4
 Designed to inhibit the complement activation system (
an immune system pathway)
 Intra-vitreal gel sustained release system
 Neutralize early AMD inflammatory component
 A phase 1 study was completed and a phase 2 study is
being pursued

18.  ARC1905 ( C5 inhibitor aptamer)
 Prevents C5a production
 Eyes with dry AMD stains for C5a in histopathological
studies
 Possible benefit in blocking this agent
 A phase 1 study was recently completed
 Intra-vitreal injection
 Results not yet available

19.  Eculizumab
 An antibody against C5
 Currently FDA approved for paroxysmal nocturnal hemoglobinuria
 Phase 2 study
 NT501
 Genetically modified RPE intra-vitreal implant
 Overexpresses ciliary neurotrophic factor, a growth factor capable of
retarding cellular and functional losses in RPE and photoreceptors in
neurodegenerative diseases
 A phase 2 study reported visual stabilization in 96.3% of treated eyes
vs. 75% of control eyes
 Improvement in retinal thickness was observed as early as 4 months
 It received a FDA fast track designation for the treatment of visual loss
associated with GA

20.  AL-8309A
 Has shown capacity to decrease oxidative damage in
animal studies of light-induced damage
 Similar changes has been found in patients with dry
AMD
 Potential candidate
 Phase 2 study
 Topical solution for possible prevention of GA
progression as well as visual acuity changes 0ver 2-year
span

21. Reduction of retinal toxins
 Studies have shown that there is an accumulation of
lipofuscin, a waste product at the leading edge of the lesion in
dry AMD
 It precedes the spreading of the lesion and death of retinal
tissue
 To slow or stop progression of GA
 ACU-4429 and Fenretinide were developed to prevent the
accumulation of lipofuscin
 Oral doses
 Phase 1 and 2 studies ongoing
 Accutane is a possible candidate

22. Choroidal blood perfusion
enhancers
 Reduction in choroidal blood flow is more pronounced in
patients with AMD
 Alprostadil
 Intra-venous injection to try to improve macular blood flow
 The drug failed to reach the primary outcome
 MC-1101
 Topical drug that has been shown to increase mean
choroidal blood flow
 Compelling results from a Phase 1 study have led to a fast
track FDA designation for further development of the drug

23. Other AMD Risk Factors
 Age
 Genetics
 Ethnicity
 Gender
 Diet - modifiable
 Smoking - modifiable

24. AREDS 2 study
 The original AREDS study established that antioxidants, zinc supplements or a combination of both can
result in a reduction in risk for AMD progression in
patients at high risk
 Omega 3 fatty acids in this study population given as a 1gram dose do not appear to have any beneficial effect on
preventing progression to wet AMD
 Lutein and zeaxanthine , although showing no statistically
significant advantage for preventing AMD
progression, are reasonable substitutes for beta carotene
due the increased risk of lung cancer associated with beta
carotene

25. AREDS 2
supplement
Vitamin C 500 mg
Vitamin E 400 IU
Copper 2 mg
Zinc 80 mg
Lutein 10 mg
Zeaxanthine 2 mg

26. If you are taking several medications
you should consult with your
physician
The idea that “ more is better”
should be avoided

27. AREDS 2
 18 % reduction in the progression to advanced AMD
 22% reduction in the risk of progression to neovascular ( wet) AMD
 30% reduction in any cataract progression

28.  Major breakthroughs have been made in the last
decade in treating the wet form of AMD
 The change in near-term prognosis with 90% chance
of stabilizing or increasing vision
 Significant price tag of monthly intra-vitreal
injections
 Injection-related adverse events/ risks
 Uncertainty of how long the treatment will last or
when it can be stopped without risk of recurrence

29. Importance of Early Detection
On Treatment for Wet AMD
Now there are treatments for wet
AMD which have proven to be
effective in halting the
progression of wet AMD in most
cases.
These treatments consist of
injections in the eye.
Clinical studies have shown that
these new treatments are
generally more effective the
earlier they begin, when the
patient still has good visual acuity
and the lesion is still small.

31. Intra-vitreal injection
 It is performed in the office
 Using topical anesthesia (eyedrops and gel) or a
subconjunctival anesthesia (injection under the
capillaries of the eye)
 Under aseptic/ sterile conditions
 Very low risk of infection, bleeding inside/outside the
eye, cataract, retinal detachment or corneal scratch
after the injection
 Usually is very comfortable

32. Treatments for advanced
wet AMD
In wet AMD, too much VEGF ( Vascular endothelial growth factor) is
produced in the eye
 This causes the growth of unwanted, unhealthy blood vessels
 Anti-VEGF drugs block the production of VEGF and stop the
development of the blood vessels
 Ranibizumab ( Lucentis) Genentech, Novartis.
 Approved by FDA in 2006
 Antibody fragment that is injected inside the eye ( intra-vitreal
injection)
 Has proven its benefits in several clinical trials by stabilizing or
improving the visual acuity in 95% of patients
 Reduces the retinal thickness and promotes sub retinal fluid resorption
 A monthly intra-vitreal dose , approximately $ 2000

33.  Bevacizumab (Avastin, Genentech)
 Possibly the anti-angiogenic agent most widely used
worldwide
 Full length antibody against VEGF
 Approved by the FDA for the treatment of metastatic
colorectal cancer, metastatic breast cancer and nonsmall cell lung cancer.
 Monthly dose ( 1.25 mg)
 Approximately $ 17-50 month
 Recent infection outbreak in USA ( 2011) was linked to
a single compounding pharmacy

34. CATT trial
 1,208 patients were randomized
 injections of Lucentis vs Avastin
 Monthly vs as needed injections with monthly
evaluations
 They were found to be equivalent on a monthly
injection regimen

35.  Aflibercept ( Eylea), Regeneron, Bayer
 Fusion protein of VEGFR1, VEGFR2 and IgG1 Fc
fragment
 Every month X 3 then every 2 months
 Trials suggest that it is effective for longer periods of
time

36. Combination therapy
 Targets formation of new blood vessels, inflammation and prevention of
scar formation
 Goal is to increase the overall efficacy and reduce the need of monthly
injections and side effects by allowing the use of lower doses
 Radiotherapy





Selectively targets new blood vessels
Attenuates the inflammatory response
Decreases scar formation
Initial data by different studies was encouraging decreasing the number of
current injections
CABERNET study( 457 eyes)



Failed to demonstrate a visual acuity benefit
The future of this treatment modality is uncertain
ORAYA therapy is a combination of anti VEGF plus a single, small dose of
radiotherapy, less than 20 minutes total procedure

It significantly reduced the need of multiple anti-VEGF

37. Photodynamic therapy and
steroids
 In the year 2000, PDT became the first FDA approved
treatment for wet AMD, by being the first treatment to
effectively prevent vision loss
 Intravenous injection of verteporfin ( light sensitive dye) that
travels to the eye
 Followed by a laser activation within the lesion
 It causes a photochemical reaction, leading to platelet
aggregation and local thrombosis ( shutting down the
abnormal blood vessels)
 Studies showed better visual acuity, stabilization of lesions and
less retreatment studies ( PDT with Ranibizumab)

39.  Dexamethasone and triamcinolone
 High rate of cataract and high ocular pressure
 Anti scar formation, anti inflammatory and anti new blood
vessels formation
 Sunitib, FDA approved for the treatment of renal and
gastrointestinal tumors
 Oral dose that has shown to reduce laser-induced
formation of new blood vessels in mice
 Topical (eyedrops) effective decreasing formation of new
blood vessels in rabbit corneas
 Ongoing studies using intra-vitreal injections

40.  CentraSight lens
 Implanted into one eye
 Magnifies
images, projecting the
bigger image onto a
healthier part of the retina
 Strict screening is
necessary

41.  Second Sight
 An implant that attaches to the outside surface of the
eye and connects to an electrode placed in the retina
 A camera mounted on a pair of glasses communicates
with the implant
 Is in clinical trials in the USA and is already in use in
Europe

44. Acupunture
 The theory is that needles placed at certain points
release energy to the liver
 In traditional Chinese medicine, the liver and
gallbladder are thought to control the eyes
 The energy supposedly improves the function of the
liver and thereby increases the blood supply to the
retina
 Rigorous controlled testing on a large number of
patients is needed

46. Rheopheresis
Still not a proven therapy for dry
AMD
In clinical trials it was shown to be
safe but the visual results were not
conclusive
It is similar to kidney dialysis, the
patient’s blood is filtered
It removes substances that
accumulate in the blood as LDL
cholesterol, fibrinogen and
lipoprotein A to promote an
improvement in blood flow and
vascular function in the retina and
elsewhere

47. Microelectrical stimulation
 Is being promoted as a therapy for early stages of AMD
 TENS ( Transcutaneous Electrical Nerve Stimulation)
 Routinely used for alleviation of pain
 A low voltage current is delivered through electrodes in
contact with the skin overlying key nerves around the eye
 The theory is that it improves macular function and aids
the removal of potentially harmful waste products
 One study reported improvements of vision in patients
with AMD but the study did not use controls, making the
results inconclusive

49. Genetic testing
 There are different laboratory developed genetic
tests to evaluate the risk of a patient with early or
intermediate AMD progressing to advanced wet
AMD within certain period of time
 The idea is to be able to customize an approach to
monitor and treat each individual based on their
reported risk scores for disease progression
 This allows for a more effective monitoring of
patients

50. Gene therapy
 The idea is to replace or remove a defective gene to stimulate the
cell not to die and function properly again
 Different abnormal genes related to AMD have been identified
 The new gene is introduced into the retina via a virus (vector)
, which deliver the genetic information for the rest of the patient’s
life
 Gene replacement therapy
 Studies using animal models are now underway
 Several companies are at the forefront of research into the use of
gene therapy for wet AMD. These include Genzyme; Avalanche
Biotechnologies, working with the Lions Eye Institute of
Perth, Australia; and Oxford BioMedica, in partnership with Sanofi.

52. Macular degeneration and
stem cells
 On January 3, 2011, Advanced Cell Technology received a FDA
approval to treat advanced dry AMD using retinal pigment cells
(RPE) from human embryonic stem cells
 Uses a proprietary technique to extract a single cell from a
young embryo allowing the rest to remain intact and develop
normally
 Phase1/2 study to determine the safety of RPE sub retinal
implantation
 UCLA, Wills Eye and Ear infirmary, Bascom Palmer Eye Institute
and Massachusetts Eye and Ear.
 July 9, 2012, FDA approved an increase of stem cell dosage to
100,000 RPE cells derived from human embryonic stem cells

53.  June, 2012, a total of 16 patients started transplantation with Human
Central nervous system stem cells ( non embryonic)
 Study criteria:




50 years old or older
Have no prior or current choroidal neovascularization
Specific degree and extend of geographic atrophy
No Diabetic retinopathy, cancer, glaucoma or autoimmune disease
 Allogenic cells ( another source other than the patient) and will receive
immunosuppressive drugs X 3 months
 4 patients have been transplanted with a single dose of 200,000 HuCNSSC
 Retina Foundation of the Southwest, Dallas, TX and Byers Eyes
Inst., Stanford, Palo Alto, CA

54.  January 2013 update:
 “No significant safety issues with human embryonic
stem cells in any of the 18 patients”
 “ 2 patients that has been treated showed some signs
of visual improvement and those gains in visual acuity
have persisted for 18 months”
 “ no signs of tumorigenicity, apparent
rejection, ectopic tissue formation”
 August 8, 2013 - The RIKEN Institute in Japan has started a
clinical study for a wet AMD treatment derived from induced
pluripotent stem cells (iPSC) — mature cells that have been
genetically reprogrammed to a stem cell-like state

56. Importance of Early Detection
Unfortunately, many wet AMD patients suffer irreversible
vision loss by the time they are diagnosed.(3)
Because wet AMD progresses rapidly, at a rate of 18-20 µ per
day (4), frequent monitoring is critical.
It is impractical for patients to visit their eye doctor as
frequently as needed for earliest detection.
The most effective solution for early detection is home-based
monitoring in addition to routine eye exams.
(3) Olsen, Ophthalmology 2004
(4) Vander, Ophthalmology 1989

57. Amsler grid
To test each eye individually to determine if there are
any squiggly lines or distortions in the grid

58. Early Detection of AMD
Our brain will correct the signals received if assumes incomplete or inaccurate, making it extremely
difficult for AMD patients to notice that something has gone wrong in their retina until damage is
Normal Fundus
Fluidprofound
and Lipid
Hemorrhage
20/25
20/30
20/100
Therapeutic
window
By the time you notice symptoms or Amsler Grid changes
irreversible vision loss often has already occurred

59. •
•
•
•
The first FDA cleared home based telemonitoring system for AMD
Personalized patient monitoring, between physician exams
Designed for early detection, before noticeable symptoms & vision loss
Preferential Hyperacuity Perimetry
• Demonstrated sensitivity, specificity
• Robust normative database
• Quantifies changes in metamorphopsia

60. The ForeseeHome
was designed
specifically for easy
operation by AMD
patients. It has
received numerous
awards for product
design and its user
friendly interface.

61. So what do we have to do?
Do not smoke
Control your blood pressure
Get regular physical activity such walking 30 minutes daily
Eat a variety of colors of fruits and vegetables
Consider natural sources of omega-3 fatty acids such tuna and wild salmon
Take AREDS 2 supplements
Protect you eyes with 100 % UV protection sun glasses
Use a visor or a hat to block out more of the sun’s rays

62. www.geteyesmart.org