New Genetic Test

New Genetic Test Helps Determine Risk of Macular Degeneration

Residents with a family history of macular degeneration may want to consider a new genetic test that can help determine risk for developing the disease, the leading cause of vision loss and blindness among people age 50 and older.

12237_main_image_1The new genetic test involves a saliva sample which is sent to a lab for analysis with results returning within a few weeks. The test is not yet covered by most insurance plans but may be funded through a health savings program.

Dr. Couvillion is optimistic about this testing,

“If a patient is at increased risk for developing age-related macular degeneration (AMD), they can make immediate lifestyle changes which could impact the occurrence or spread of the disease, including taking vitamins, reducing weight and most important, to quit smoking.” He continues, “Early detection has the potential of reducing the development of visual complications of AMD.”

California Retina Consultants has become a clinical site for the genetic test, called Macula Risk®, which has been developed by Toronto-based ArcticDX with some leading U.S. research laboratories involved. This is the first test to look at multiple genes that predispose someone to the disease. Seventy-five to eighty percent of all AMD has been traced to genes inherited from family members. Couvillion notes, “Macular degeneration has a very high inheritance pattern and this analysis is successful in testing for most of the genes, however there may be other, untested genes that play a part.” In the future, treatments for AMD may be patient specific depending on the genetic defect that they manifest.

Over 15 million people in North America are currently affected by AMD and experts estimate that as the population ages the number of those afflicted will double in the next ten years.

AMD is a progressive disease associated with aging that causes damage to the macula-the light-sensitive cells at the center of the retina at the back of the eye. The macula is responsible for our ability to see with enough detail to read, drive, watch television and perform other activities that require focused, straight-ahead vision, as well as providing information that allows us to perceive colors. Once significant vision is lost, it cannot be restored and, if untreated, AMD can ultimately lead to blindness. The most effective treatment strategy will be to reduce the onset of the late visual threatening complications.

New Associate Chief Medical Editor of RETINA TODAY

RETINA TODAY Announces Dr. Avery as Associate Chief Medical Editor

12234_main_image_1Robert Avery, MD has been selected to be the Associate Chief Medical Editor of Retina Today, effective with the January 2008 issue. Dr. Avery currently serves as an editorial board member of Retina Today.

“I am very excited to have Bob work closely with me in shaping the editorial development and direction of Retina Today. As we look for ways to build on this already highly respected publication, his insight and expertise from an academically-oriented private practice setting will be invaluable. “

– Allen C. Ho, MD Chief Medical Editor Retina Today.

Dr. Avery received his medical degree from Johns Hopkins University and received his ophthalmology training at the Wilmer Eye Institute. He completed a vitreoretinal fellowship at Duke University working with Drs. Robert Machemer, Brooks McCuen, and Eugene de Juan. Dr. Avery returned to Johns Hopkins as Assistant Chief of Service and head of the trauma unit. He subsequently moved to Santa Barbara and founded California Retina Consultants and Research Foundation, a six man private practice and a research facility participating in numerous clinical trials investigating new treatments for age-related macular degeneration, diabetic retinopathy, and vein occlusion, as well as evaluating new drug delivery devices.

He has received numerous honors and awards, including the Ronald G. Michels Fellowship for his contribution to vitreous surgery, the Heed Fellowship, the American Academy of Ophthalmology’s Achievement Award, and the Honor Award of the American Society of Retina Specialists. He has been named to “Best Doctors in America,” and to “Who’s Who in America.” In addition to his clinical research, he has a basic science interest in angiogenesis and drug delivery where he holds numerous patents.

“By virtue of his experience ranging from research to practice management, he will help bring vision and further value to Retina Today.”

-Allen C. Ho, MD
Chief Medical Editor
Retina Today.

International Fellows

CRC Hosts International Fellows In Vitreoretinal Surgery

California Retina Consultants is proud to tutored visiting doctors as part of its ongoing fellowship program. “The fellowship program is a wonderful addition to our practice as it allows us to teach advanced techniques to doctors on a global level” states Dr. Dante Pieramici, surgical training director. He adds, “There is no doubt that we learn as much from these visitors as we teach.” This past year the practice welcomed Dr. Juan Pablo Davila from Mexico City and Dr. Narcisa Ianopol from Iasi, Romania.

JuanPabloDavilaDr. Davila received his medical degree from Universidad Anahuac in Mexico City, Mexico. After completing his clinical clerkship with a medical retina group in Mexico City, Dr. Davila was awarded the clinical fellowship position at CRC. During his three month visit, Dr. Davila participated in clinical research projects and observed a variety of medical and surgical cases, including retinal detachments, Baerveltd glaucoma implantation and trauma. “I had the opportunity to observe patients and procedures in Bakersfield, Oxnard and Santa Maria and I was amazed by the differences in pathology and in the severity of diseases from one office to the next,” says Dr. Davila, adding, “This was an incredibly valuable learning opportunity for me and I am so fortunate to
have these well trained doctors as my teachers.”

NarcisaDr. Narcisa Ianopol has nearly twenty years of experience as a surgeon in both Romania and Germany, so in addition to receiving training locally, she also brought new ideas to the California Retina Consultants’ offices when she visited this year. Dr. Ianopol followed the doctors on patient rounds and observed in the operating room. She commented, “I was impressed by the number of patients that these doctors and staff care for each day and by their high level of professionalism.” She continues, “I
learned the art of being patient and talking with compassion, but at the same time making the best medical or surgical decisions for all ophthalmological pathologies, without any limitations.”

dr_nkangaPassed international fellows: Dr. Dennis Nkanga from Nigeria and Dr. Enkhbold from Mongolia. Dr. Nkanga spent time in the clinics and the Cottage Eye Center operating theaters learning to care for patients with diabetic related eye disease.

Nigeria is a country of over 130 million people and like the U.S. has a high incidence of diabetes and diabetic related eye blindness. Unlike the U.S. in which lasers and laser treatments are readily available, Dr. Nkanga tells us that in his country there is only one single laser to treat all the diabetic patients. Without this treatment most patients go onto blindness, often within months. This is very preventable with proper treatment. The main purpose of Dr. Nkanga’s visit was to learn to diagnose and treat diabetic eye diseases and to acquire a laser to take with him back to Nigeria.

Through the efforts of the California Retina Research Foundation and SEE International, these goals were obtained. The generosity of individuals supporting the CRRF makes these international collaborations possible. Dr. Nkanga has now established a diabetic clinic and is busy preventing blindness for countless individuals.

Around the World

World Ophthalmology Congress, Hong Kong, China

12235_main_image_1 This past summer, the World Ophthalmology Congress (WOC) held its biannual meeting in Hong Kong and Drs. Pieramici and Castellarin were among the 1,000 invited speakers who represented more than 110 countries. Over 10,000 delegates attended the meeting which featured world leaders in ophthalmology sharing the latest research and surgical techniques. It was quite fitting that China, site of the 2008 Summer Olympics and Paralympic games, hosted the premier international ophthalmology congress. This year’s meeting featured over 330 scientific sessions including a vitreoretinal subspecialty day.
The topics were timely and cutting edge, including the talks on ocular injuries and trauma by Drs. Pieramici and Castellarin

Advances in Wet AMD


The need to keep abreast of current therapies, particularly those used to treat the neovascular or wet form of Age-Related Macular Degeneration (AMD), is crucial because the incidence of AMD related visual loss is reaching epidemic proportions. Thankfully, the fruits of years of research into new treatments for the advanced stages of AMD have now ripened.

California Retina Consultant physicians and researchers have been privileged to play a role in this emerging research that provides unprecedented success in treating patients with neovascular (Wet or Bleeding) AMD. Although neovascular AMD occurs in only 10% of all AMD cases , it accounts for 90% of cases in which there is severe vision loss. In the United States, there are an estimated 150,000 – 200,000 new cases of neovascular AMD each year, with numbers increasing as the population ages. In addition, there are currently millions of patients with earlier stages of AMD that are at risk for developing neovascular AMD.

The treatment for neovascular AMD has advanced considerably since the 1980s, when laser photocoagulation was first used, and remained the only treatment option for over a decade. Numerous other therapies were tried since the mid- 1990s, yielding unsatisfactory results. These included submacular surgery, radiation therapy, and drug therapies such as Interferon.

In 1994 Robert Avery, founder of California Retina Consultants and co-founder of California Retina Research Foundation, implemented clinical trials in Santa Barbara and in collaboration with Lloyd Aiello of The Joslin Diabetes Center, published their results in the New England Journal of Medicine. Their research demonstrated the role of vascular endothelial growth factor (VEGF) in contributing to a variety of eye diseases. VEGF is one growth factor that likely stimulates the development and progression of neovascular AMD. Once the link was identified, doctors began developing and testing various treatments using anti-VEGF therapies and these showed considerable improvement over previously used modalities.

In June 2005 the doctors of California Retina Consultants commenced the off-label use of Bevacizumab (Avastin, Genentech,Inc.). They were encouraged by results of intravitreal Ranibizumab (Lucentis) in patients enrolled in ongoing clinical trials, thereby inspiring the consideration of Avastin, a molecule similar in design and function to Lucentis, but one that was more readily available since it had been previously approved by the FDA for use in cancer patients. The use of Avastin had first been reported by Dr. Philip Rosenfeld at The Bascom Palmer Eye Institute in Miami. Dr. Rosenfeld’s group suggested that Avastin yielded promising results when used systemically and intravitreally in patients with Neovascular AMD. California Retina Consultant doctors were the first ophthalmic group in the nation, following Bascom Palmer, to use the drug in this fashion. Over 500 patients participated in local trials, providing our doctors with some
of the most comprehensive research on the subject. We thank these patiets for their willingness and courage to participate in this work at a time when the outcomes were uncertain. As a result of their efforts, the vision of tens of thousands of patients worldwide may have been saved.

The success with Avastin for treating AMD inspired the California Retina Research doctors to implement trials of Avastin in patients experiencing visual complications resulting from a variety of eye diseases in which VEGF was thought to play a role, such as diabetic retinopathy and retinal vein occlusions.

The physicians at the California Retina Research Foundation have collaborated on this work with physicians around the world and locally with researchers at the University of California Santa Barbara Neuroscience Research Institute. In the last two years, the California Retina Consultants have shared their knowledge of anti-VEGF therapy at scientific meetings in six different continents including meetings in Cannes, Capetown, San Juan, Bahamas, Rome, Miami, Boston, Portugal, Israel, Las Vegas, Ft. Lauderdale, Aspen, Vail, Salt Lake City, Vancouver and Hawaii. Meetings in Sydney, Tokyo and London are scheduled for later this year. In addition to presenting their findings, CRC was the first to publish a comprehensive series of articles demonstrating the efficacy of Avastin in patients with AMD and Diabetic Retinopathy. In fact, Medicare required these articles and a toxicology study, of which we were also a part, before it would cover the use of Avastin.

National media, including Forbes, the Wall Street Journal and the Miami Herald have cited California Retina’s contributions and presented some of our very own local cases.

Both Lucentis and Avastin were designed and manufactured by Genentech, a San Francisco Bay Area Company. Lucentis was designed for intraocular use while Avastin was originally designed for systemic use in the treatment of cancer. Lucentis is FDA approved for intraocular use in AMD and the safety and efficacy of this drug has been demonstrated in phase III multi-center clinical trials (the gold standard in clinical research). Avastin, on the other hand, has not undergone such testing, but it has been the clinical impression of many retinal specialists and researchers that the two drugs work similarly in AMD patients. These drugs are not a one-time-use miracle drug and are not a cure for the disease. In fact, some patients may require monthly injections for years.

The use of Avastin and Lucentis in Neovascular AMD is revolutionary, ushering in a paradigm shift in the treatment of patients afflicted with severe proliferative retinal diseases. Whereas just two years ago we were happy to slow down the vision loss in patients with neovascular AMD, we now expect to halt the progression, and in about half of the cases we anticipate visual improvement. Neovascular AMD is estimated to develop in almost 1 million Americans older than the age of 55 years by 2009, and as the population of older persons in the United States continues to increase, the potential of these therapies to prevent vision loss is extremely significant.

The most obvious difference in these medications is the cost. Lucentis costs over $2000 per injection, whereas Avastin costs between $50 to $100 per injection. While Medicare covers 80% of the cost of these treatments, some patients must pay the rest themselves. Those with less health coverage may find it unaffordable, although Genentech does provide free or reduced cost drugs for certain eligible patients.

The Lucentis vs. Avastin showdown has stood the pharmaceutical world on end, but now the federal government hopes to settle the dispute by funding a head-to-head comparison of the two biotechnology drugs, the first such trial by the National Institutes of Health. California Retina Consultants are currently planning to participate in the CATT trial comparing Avastin and Lucentis.

Research does not stop here. Current investigations focus on improvements in the drug’s efficacy and enhancement in dosing and delivery. We have certainly cleared one major hurdle, but the race is far from over.