Ophthalmic Surgeon Report

Q4-2009 Retina Specialists’ Quarterly Survey Report: Economics of Retinal Treatment Continue to Change Due to Anti-VEGF Treatments & Micro-Incision Surgery

2010-02-19T15:34:51Z

In this edition, we report results from our survey of US retina specialists during the fourth quarter of 2009. We report on retinal procedure volume and we provide data on anti-VEGF therapy, combo therapies, laser photocoagulation procedures, vitrectomies, and retinal surgery locations.

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Market Scope has regularly surveyed ophthalmologists on a variety of topics for more than eight years, but reporting on the retinal market is a recent addition to our coverage. The attached survey report represents our third quarterly survey of retina specialists and includes data from 82 practices and 118 retina specialists. Most survey respondents offered a full range of retinal services during the quarter, with 84.1 percent performing vitrectomy surgery, 97.6 percent performing IVT injections and 91.5 percent performing laser photocoagulation.

Highlights of our survey include experiences and usage of Lucentis and Avastin and demonstrate the spread of VEGF inhibition beyond the treatment of wet AMD. Other significant findings include the growing use of micro-incisional vitreoretinal surgery and growth in the use of disposable surgical instruments.

Q4-2009 Retina Specialists’ Quarterly Survey Report: Retinal Biotech Sparks New Treatment Realities

2010-02-19T15:34:50Z

The landscape of retinal therapies has changed dramatically during the past three years as anti-VEGF IVT injections have become the treatment of choice for wet AMD. As retina specialists await word from the CATT (Comparison of Age-related Macular Degeneration Treatments Trial) study comparing Lucentis and Avastin and due in early 2011, the use of both anti-VEGFs has expanded beyond wet AMD to include other exudative conditions, most notably diabetic macular edema. In addition, improvements in surgical technique for vitrectomy—in particular, smaller incisions—and the growing use of ASCs for surgery have changed and continue to change the economics of retinal surgery.

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Market Scope surveyed US retina specialists during December 2009 to measure and analyze these changes. Responses to the Q4-2009 Market Scope retina survey indicated that the number of retinal procedures (including IVT injections, PDT procedures, laser photocoagulation procedures, and vitrectomies) during the quarter grew 6.4 percent when compared with the same quarter of 2008.

IVT injections increased 15.1 percent to 676 thousand during Q4-2009 from an estimated 587 thousand in Q4-2008. In response to the increase in IVT injections, the quarter’s photodynamic therapy procedures fell 37.6 percent to 17 thousand from 27.5 thousand in Q4-2008, while laser photocoagulation procedures declined 18.9 percent to 112 thousand from an estimated 138 thousand in 2008’s fourth quarter. By comparison, the number of vitrectomies was relatively stable, rising 2.4 percent from 71 thousand in Q4-2008 to 73 thousand in Q4-2009.

Q4-2009 Retina Specialists’ Quarterly Survey Report: Patients’ Diagnoses

2010-02-19T15:34:49Z

Survey respondents were asked about the primary diagnoses of the patients they treated during 2009’s fourth quarter.

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The most common diagnoses were diabetic retinopathy (23.7 percent of patients) and neovascular or wet AMD (22.5 percent of patients). Of the quarter’s patients,15.3 percent were diagnosed with diabetic macular edema, while 12.8 percent were diagnosed with nonexudative or dry AMD. Patients diagnosed with retinal tears, holes, and detachments constituted 7.7 percent of patients. CMV retinitis was the least common primary diagnosis at 0.8 percent.

Q4-2009 Retina Specialists’ Quarterly Survey Report: Treatments for Wet AMD

2010-02-19T15:34:48Z

We asked respondents about the percentages of their wet AMD cases in which they used various treatments.

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Anti-VEGF injections have led to dramatic improvements in the prognosis for wet AMD patients. As a result, the number of IVT injections has soared during the past few years, as has the share of wet AMD cases treated with these injections. Lucentis and compounded Avastin IVT injections have become the standard of care in treatment of wet AMD, but opinions vary on which product is more effective. Our survey respondents reported using off-label IVT Avastin in 54 percent of wet AMD cases, while Lucentis was used in 31 percent of cases during the quarter. IVT injections of the older selective anti-VEGF drug Macugen were used in a little more than 2 percent of cases and photodynamic therapy (PDT) with Visudyne was used in 1 percent of cases. Laser photocoagulation was used in 11 percent of cases.

Market share for IVT treatments with Lucentis and Avastin has been in flux due to changing reimbursement policies and differing reports on clinical results. Many retina specialists think that these closely-related drugs have equivalent efficacy, although retina specialists around the world are awaiting more definitive comparative data from a number of large clinical trials, including the NEI-sponsored CATT study. When results from these studies are made public (beginning in early 2011), reimbursement policy and market share may well shift significantly again.

Q4-2009 Retina Specialists’ Quarterly Survey Report: Vision Gains with Anti-VEGFs

2010-02-19T15:34:48Z

We asked retina specialists about the percentage of their wet AMD patients that experience a gain in visual acuity after receiving anti-VEGF therapy.

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Both Lucentis and Avastin have transformed treatment of wet AMD in great part because of the visual gains many patients achieve on these therapies—prior to their introduction staving off or slowing further decline was the common goal of therapy. Market Scope asked retina specialists about the percentage of their patients who gained lines of vision with Lucentis and Avastin during the fourth quarter of 2009. Respondents reported that 48.5 percent of Avastin patients gained lines, while 45.9 percent of Lucentis patients experienced these vision gains.

Q4-2009 Retina Specialists’ Quarterly Survey Report: Combination Therapies

2010-02-19T15:34:47Z

We asked retina specialists if they used combination therapies to treat AMD and, if they did, which combination they used.

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Combination therapies using one or more anti-VEGFs with other treatment modalities have also received much attention at ophthalmic meetings in recent years. Proponents of various combo regimens have argued the advantages of treating with several mechanisms of action and using a combo approach to reduce the frequency and burden of regular IVT anti-VEGF injections. We asked retina specialists whether or not they used combo therapies in treating wet AMD. Forty-eight percent of respondents reported using combination therapy.

We also asked retina specialists who use combo therapy for wet AMD which of the many combinations they used during the quarter. Just under 54 percent of respondents listed a combo regimen of Avastin and Visudyne PDT, while 41 percent reported using Lucentis with Visudyne PDT. A total of just 44 percent reported using triple therapy that adds a steroid to the anti-VEGF plus PDT therapy. Slightly more than 33 percent used Avastin, Visudyne PDT and a steroid, and just over 10 percent used Lucentis, Visudyne PDT, and a steroid.

When asked about which corticosteroid our respondents used in combination therapy, 25 percent reported using triamcinolone and 10 percent reported using dexamethasone. Sixty-six percent reported that they do not use steroids in combination therapy for wet AMD.

Q4-2009 Retina Specialists’ Quarterly Survey Report: IVT Injections by Diagnosis

2010-02-19T15:34:46Z

We asked retina specialists about the diseases and conditions for which they used intravitreal (IVT) injections of anti-VEGFs or corticosteroids.

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Spurred by the success VEGF inhibitors in treating wet AMD, many retina specialists are using IVT Lucentis and Avastin injections to treat other exudative retinal conditions. Corticosteroids may also be injected intravitreally when treating several retinal disorders. We asked retina specialists how the IVT injections they performed during the quarter broke down by patient diagnosis. Respondents reported that 57 percent of IVT injections were administered as part of a treatment regimen for wet AMD, while 27 percent were given to treat diabetic macular edema. Patients with proliferative diabetic retinopathy received 6 percent of IVT injections, and patients with vitreous hemorrhage were given one percent of IVT injections during the quarter.

Q4-2009 Retina Specialists’ Quarterly Survey Report: VEGF Inhibition in Other Retinal Conditions

2010-02-19T15:34:45Z

Lucentis and Avastin are currently in clinical studies for several non-AMD diseases and disorders, and their use in the treatment of diabetic macular edema (DME) has become increasingly commonplace.

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Survey respondents reported using IVT Avastin in 22.3 percent of the DME cases they treated during the fourth quarter of 2009, an increase of 25 percent over the Q3-2009 tally. IVT Lucentis, a much more costly drug, was used in 1.4 percent of DME cases. After IVT Avastin, laser plus a steroid was the second most common treatment and was used in 18.8 percent of DME cases.

Levels of vascular endothelial growth factor (VEGF) rise significantly in the vitreous of patients with proliferative diabetic retinopathy. Survey respondents also reported their use of Avastin in conjunction with a surgical and/or laser procedure in patients with PDR and vitreous hemorrhage. Eighty-two percent of respondents reported that they used Avastin in PDR patients in this manner during Q4-2009. Fifty-eight percent used the anti-VEGF pre-operatively, while just over 20 percent used it post-operatively. Nearly 63 percent reported using Avastin in patients with vitreous hemorrhage, also in conjunction with a procedure. Just under 45 percent used the drug pre-operatively, while more than 25 percent used it post-operatively.

Q4-2009 Retina Specialists’ Quarterly Survey Report: Monitoring Anti-VEGF Therapy

2010-02-19T15:34:44Z

Survey respondents were asked to rate on a scale of one to five the effectiveness of various diagnostic technologies in monitoring the progress of anti-VEGF therapy.

]]> Spectral-domain ocular coherence tomography (OCT) received the highest rating with an average rating of 4.6. Time-domain OCT and fluorescein angiography both received an average rating of 3.7. And fundus autofluorescence was given an average rating of 2.0.

Q4-2009 Retina Specialist's Quarterly Survey Report: Laser Photocoagulation

2010-02-19T15:34:43Z

Survey respondents were asked about the number and types of laser photocoagulation procedures they performed in Q4-2009.

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Laser photocoagulation procedures declined 18.9 percent when compared with estimated volume in Q4-2008. Procedure numbers are generally declining because VEGF inhibition has altered the treatment paradigm for wet AMD. Nonetheless, laser photocoagulation remains a common procedure in a variety of retinal diseases and disorders—and in cases of wet AMD, in particular when anti-VEGFs fail to stanch progression of the disease.

Based on survey responses, Market Scope estimates that slightly more than 112 thousand laser photocoagulation procedures took place in the US in the fourth quarter of 2009. Survey respondents reported a monthly average of 46.2 slit lamp photocoagulation procedures during the quarter, slightly more than in Q3-2009 and somewhat less than in Q2-2009. During the quarter, laser indirect ophthalmoscopic (LIO) photocoagulations and endophotocoagulations averaged 10.4 and 15.4, respectively, on a monthly basis. The total average monthly photocoagulation procedures (including slit lamp, LIO and endoprobes) reported for the fourth quarter was 72.

Q4-2009 Retina Specialist's Quarterly Survey Report: Photocoagulator Purchases

2010-02-19T15:34:42Z

Laser photocoagulators often remain in service for a long time. Twenty-nine percent of our survey respondents reported that their last laser photocoagulator purchase took place in 2001 or earlier. Slightly more that 16 percent reported purchasing their last coagulator in 2005. The same percentage reported their last purchase in 2009.

Twenty-five percent of survey respondents indicated that they have plans to purchase a laser photocoagulator, while 75 percent indicated no such plans. Of those respondents planning to make a purchase, 44.6 percent said they planned to purchase a multi-wavelength (green, yellow and red) laser. Another 44.6 percent, up from Q3-2009’s 37.9 percent, planned to purchase a single wavelength 532 nm laser.

Q4-2009 Retina Specialist's Quarterly Survey Report: Vitrectomies

2010-02-19T15:34:41Z

We asked survey respondents about the number of vitrectomies they performed in Q4-2009.

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Based on our survey responses, the number of vitrectomy procedures in Q4-2009 increased 2.4 percent over Q4-2008’s estimated tally. This growth in vitrectomy volume is due to a combination of increases in the elderly population segment, improved surgical techniques that have lowered complications and improved efficacy, and a significant increase in the number of diabetic retinopathy patients.

Just under 32 percent of survey respondents reported performing 10 or fewer vitrectomies during 2009’s fourth quarter, while less than 18 percent reported performing 76 procedures or more. More than 35 percent reported performing 31 to 75 vitrectomies. Retina specialists reported performing an average of 41 vitrectomies during Q4-2009.

Q4-2009 Retina Specialist's Quarterly Survey Report: Change in Vitrectomy Volume

2010-02-19T15:34:39Z

We asked survey respondents if the number of vitrectomies they performed in Q4-2009 increased, decreased, or remained about the same when compared with Q4-2008.

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A significant majority—more than 81 percent—of survey respondents reported that their vitrectomy volume had remained about the same in Q4-2009 as in Q4-2008. The same number of respondents—9.3 percent—reported either an increase or a decrease in procedure volume.

Q4-2009 Retina Specialist's Quarterly Survey Report: MIVS & Instrument Gauge

2010-02-19T15:34:37Z

We asked survey respondents about their use of vitrectomy instruments of various gauges during the fourth quarter of 2009.

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During 2009, one of the most significant trends in vitreoretinal surgery was the growth in micro-incision vitreoretinal surgery (MIVS). This surgical approach is less invasive and obviates the need for sutures to close incisions, prompting quicker healing. The increase in this surgical technique has triggered growing demand for smaller-gauge instrumentation.

According to survey respondents, 20-gauge instrumentation, the more conventional choice, was used in just over 43 percent of vitrectomy procedures, while, together, newer micro-instrumentation in 23 gauge and 25 gauge was used in just under 57 percent of vitrectomies. Nearly 39 percent of procedures were performed with 23-gauge instruments, and just over 18 percent employed 25-gauge instruments.

More than 61 percent of survey respondents reported using 23-gauge instruments during the quarter, and just over 44 percent used 25 gauge. Only 14.3 percent of respondents did not use 20-gauge instruments in Q4-2009.

Q4-2009 Retina Specialist's Quarterly Survey Report: Disposable & Reusable Instruments

2010-02-19T15:34:36Z

We asked survey respondents about thier use of scissors and forceps during Q4-2009 and how often they used disposable versions of these instruments.

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Growing demand for disposable vitrectomy instruments has been one consequence of the increased use of 23-gauge and 25-gauge instruments. Difficulty in sterilizing these more fragile micro-instruments and concomitant concerns about the danger of infection have stimulated this demand.

Survey respondents reported using forceps in more than 43 percent of procedures and scissors in nearly 20 percent. We then asked about use of reusable versus disposable versions of these instruments, nearly 43 percent of respondents reported using disposable forceps during Q4-2009, while 33 percent reported using disposable scissors.