2. Anti VEGF

5. Options in the management of CNV 1)Observation  occult CNV also requires close follow – up.every 3 month 2) Laser coagulation 3) Surgery 4) Triamcinolone 5) Anti angiogenic drugs (lucentice,Avastin) 6) PDT & TTT 7) Diet rich antioxidants with severe AMD).(217 cases)

6. Used for: 1)Wet Macular degeneration 2)Diabetic retinopathy 3) Rubeosis iridis 4) CRVO

7. VEGF and diabetic eye disease 1) Diabetic retinopathy remains the major cause of blindness in working – eye adults in the world.

8. 2) It appears to be different retinopathy phenotype and many eyes may remain with minimal retinopathy changes and good vision for an entire lifetime.

9. Inhibition of the enzyme PK- C (proteinkinas-c) (angiogenesis factor) with ruboxistaurin represents a particularly exciting therapeutic approach it works at the early stages of the diabetic retinal disease when the disease is still reversible.

11. (Intravitreal) Steroids Have been used with some success in advanced situations of chronic diffuse diabetic macular edema. Are effective only in the short term and are associated with complications such as cataract and glaucoma.

12. The combination of intravitreal steroid with laser therapy has been shown is another interesting alternative.

13. VEGF An increase in VEGF (vasoendothelial growth factor) has been repeatedly demonstrated in the vitreous of advanced case of diabetic retinopathy

14. VEGF INHIBITORS 1) (Avastin) Bevacizumab. 2) (Macugen) or pegaptanib sodium. 3) (lucentis) or Ranibizumab

15. Avastin costs less than 150 $ Per treatment compared with 2000$ per treatment for lucentis.

17. Anti-VEGF Freeman: Anecdotaly the Anti _ VEGF drugs have proven. Very useful in treating proliferative diabetic retinopathy.

18. Anti-VEGF It is proven that is effective in wet macular degeneration and there is a growing consensus that this will be true in diabetes and retinal vascular disease.

20. Moderate NPDR with CSME

24. Rubeosis Iridis

30. BRVO

33. Avastin or Lucentis 1) Reduce macular edema in diabetic pts. 2) Reduce or stop proliferative retinopathy

34. The big problem with these drugs is that they have to be given on an on going basis These drugs don't cure any thing. They reduce VEGF

36. Anti VEGF When the drug wears off the patients need injections every four to six weeks.

37. Challenge The challenge is to deliver these drugs in away that would suppress VEGF chronically we don't know how to do this yet.

38. Kenalog(Triamcinolone) and anti- VEGF causes actual vision improvement.

39. Laser + subtenon injection of Kenalog (steroid) stabilize the vision.

41. Stabilize the vision If you stabilize vision when patient is still at 20/30 that patient is going to do better than someone in whom the diagnosis is delayed and vision is worse.

42. Laser problem Loosing peripheral and night vision

43. Avastine injections monthly

44. Treated patients 1) Showed better visual acuity 2) Greater reductions in retinal thickness 3) Reduced need for PRP 4) Regression of Neovascularization 5) Microaneurysms and hemorrhage improvement

46. Bevacizumab (Avastin) is in clinical trial for treatment of diabetic macular edema and retinopathy at centers in IRAN, Mexico & Venezuela

47. Ruboxistaurin

48. Ruboxistaurin is a drug that is administered in tablet form and also produced promising early results. However, it is now uncertain whether Eli Lilly will continue to develop the drug, following a recent FDA decision mandatimy three years of additional clinical trials.

49. Remote diabetic retinopathy screening by: 1) Digital imaging 2) Non-mydriatic exams. 3) Internet

51. Genome-wide scan of native Americans suggests genetic loci for diabetic retinopathy

53. Macugen in addition to PDT pegaptanib sodium injection ( macugen) is proven to preserve visual acuity regardless of CNV,type, lesion size or baseline visual acuity

54. 70% of 1186 patients who had 0.3mg of macugen every 6 weeks lost fewer than 3 lines of vision on the eye chart compared with 55% of patients in the control group a 27% treatment benefit

55. Ranibizumab ( Lucentis ) is another anti VEGF compound that has recorded very positive initial results

56. Ranibizumab Approximately 95% of patients maintained or improved vision at one year compared to 62% of those in the control. Control group demonstrated substantial decrease in mean visual acuity from base line to 12 months

57. New agents under investigation 1)Avastine ( bevacizumb) 2) Squalamine lactate 3) Aminosterol ( extracted from dogfish) shark 4) Tyrosine 5) Gene therapy

58. We have increasing options for treatment of CNV but we have to bring all our clinical experience to bear in deciding what combination of approaches will work best for our patients