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 Table of Contents  
LETTER TO EDITOR
Year : 2016  |  Volume : 28  |  Issue : 1  |  Page : 80-81

Author's reply


Vitreoretinal Services, Chaithanya Eye Hospital and Research Institute, Trivandrum, Kerala, India

Date of Web Publication11-Nov-2016

Correspondence Address:
S Manoj
Vitreoretinal Services, Chaithanya Eye Hospital and Research Institute, Trivandrum, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-6677.193873

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How to cite this article:
Manoj S. Author's reply. Kerala J Ophthalmol 2016;28:80-1

How to cite this URL:
Manoj S. Author's reply. Kerala J Ophthalmol [serial online] 2016 [cited 2019 Sep 21];28:80-1. Available from: http://www.kjophthal.com/text.asp?2016/28/1/80/193873



Dear Dr. Ashok Nataraj,

The authors would like to thank you for the interest shown in our article titled “Real world dosing of Anti-VEGF therapy in ARMD – Patient compliance, Efficacy and Complications” and pointing out relevant facts.

As regards to the criteria for switching over from ranibizumab to bevacizumab, it was purely on financial grounds. Considering our economic situation, this is to be expected and is not surprising. Use of anti-VEGF agents in the Indian scenario present some unique challenges including poor penetrance of health insurance and limited affordability of the citizens of a developing economy, as also discussed by Shanmugham et al.[1] 52.1% of eyes that received intravitreal ranibizumab in our series switched over to bevacizumab mostly after the three loading doses. There was no instance of poor responders or tachphylaxis, which was the reason for the switch in this series though this could be another reason for anti-VEGF switch.[2] There are no published studies from India on the impact of anti-VEGF dosing patterns but the retina practice trends (RPT) study revealed that many vitreoretinal specialists switch bevacizumab over ranibizumab for ARMD and start off with 3 loading doses followed by PRN dosing (www.retina-practice-trends.com). Biswas et al.[3] had reported that, in Indian eyes too, intravitreal bevacizumab fared as good as ranibizumab akin to CATT and IVAN trial reports in the west. Though it is well-known that monthly anti-VEGF monotherapy offers the best anatomical and visual results, economics of scale do not allow the same in the Indian scenario, resulting in modified protocol often involving loose PRN dosing and bevacizumab switch, as noted in our study. However, the fact that even this loose PRN schedule is good enough is proven in this study because the mean pretreatment vision improved from 0.91 to 0.76 log units posttreatment, and 216 out of 240 eyes showed stable/improved vision.

As you have rightly pointed out, it is very essential that we discuss the importance of multiple injections and long-term follow up in patients with ARMD as this is vital for achieving good visual results and stability of the disease. In addition, there should be a discussion on the problems with multiple withdrawals that occur with intravitreal bevacizumab and the “off label status” of this agent, especially in the light of recent reports of sterile and infectious endophthalmitis. Velpandian et al. documenting the safety of preparing aliquots of bevacizumab in one study, noted the low incidence of endophthalmitis if aliquots were prepared under controlled conditions and strict protocol.[4] However, Indian vitreoretinal specialists have reported endophthalmitis with all methods of fractionation, however, in the absence of a controlled randomized study, it is improper to draw conclusions that this could the only reason for the infectious outbreaks (http://groups.yahoo.com/group. RetNetIndia).

We would like to thank Dr. Ashok Natarajan once again for his valuable comments.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Shanmugham MP. Changing Paradigm of Anti VEGF in the Indian scenario. Indian J Ophthalmol 2014;62:88-92.  Back to cited text no. 1
    
2.
Ehlken C, Jungmann S, Böhringer D, Agostini HT, Junker B, Pielen A. Switch of Anti VEGF is an option for nonresponders in the treatment of ARMD. Eye 2014;28:538-45.  Back to cited text no. 2
    
3.
Velpandian T, Sharma C, Garg SP, Mandal S, Ghose S. Safety and cost-effectiveness of single dose dispensing of bevacizumab for various retinal pathologies in developing countries. Indian J Ophthalmol 2007;55:488-90.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.
Biswas P, Sengupta S, Choudhary R, Home S, Paul A, Sinha S. Comparing ranibizumab with bevacizumab. Ophthalmology 2011;118:600.  Back to cited text no. 4
    




 

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