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Neovascular Age-Related Macular Degeneration: Approaches for Improving Visual Acuity and Reducing the Burden of Care
CME Section
Neovascular Age-Related Macular Degeneration: Approaches for Improving Visual Acuity and Reducing the Burden of Care Accreditation Statement The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Credit Designation Statement The Johns Hopkins University School of Medicine designates this enduring material for a maximum of 2 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity. Release date: May 1, 2013 Expiration date: May 1, 2015 Instructions After reading this supplement, participants may receive credit by going to www.JHASIO.com, completing the CME test, evaluation, and receiving a score of 70% or higher. Certificates can be printed immediately online. Post-assessment 1. All of the following pathways are currently being explored to treat exudative age-related macular degeneration (AMD) EXCEPT: a. Blocking platelet-derived growth factor b. Upregulating mammalian target of rapamycin c. Blocking alpha 5 beta 3 integrin d. Complement inhibition 2. Which of the following statements regarding the CATT (Comparison of AMD Treatments Trials) study is TRUE? a. The CATT study demonstrated that bevacizumab given as needed is equivalent to bevacizumab given every 4 weeks. b. In the CATT study, spectral domain optical coherence tomography was used to assess for choroidal neovascularization activity. c. In the CATT study, presence of subfoveal choroidal neovascularization on fluorescein angiography was an inclusion criterion. d. In the CATT study, subjects randomized to bevacizumab had a higher rate of serious systemic adverse events compared with subjects randomized to ranibizumab. 3. In a patient with neovascular AMD who is not responding fully to anti-vascular endothelial growth factor (VEGF) therapy, as evidenced by improved but persistent intraretinal or subretinal fluid and/or less than average (compared with what is observed in pivotal phase III clinical trials) gain in visual acuity, one can consider all of these options EXCEPT: a. Inject a double dose of ranibizumab and/or shorten the duration between injections b. Combine with photodynamic therapy c. Add an anti–platelet-derived growth factor agent d. Switch the patient to a different anti-VEGF therapy (i.e., from ranibizumab to bevacizumab or vice versa) 4. Which of the following statements about anti-VEGF treatments is FALSE? a. In the CATT study, ranibizumab dosed on an as-needed basis was similar in efficacy as ranibizumab dosed monthly. b. Aflibercept has a shorter half-life than ranibizumab. c. In the VIEW 1 and VIEW 2 (VEGF Trap: Investigation of Efficacy and Safety in Wet AMD) studies, aflibercept administered every 4 or 8 weeks showed similar efficacy at 1 year in reducing retinal thickness and improving visual acuity in patients with neovascular AMD compared to ranibizumab given every 4 weeks. d. In addition to VEGF, aflibercept also acts on placental growth factor.
S26 Published by Elsevier Inc.
ISSN 0161-6420/13/$–see front matter http://dx.doi.org/10.1016/j.ophtha.2013.02.008
CME Section 5. T.G. is an 89-year-old Caucasian woman who presents with a large subfoveal choroidal neovascular membrane. You have treated her with 2 monthly doses of bevacizumab but see no improvement. What is the LEAST appropriate next step in therapy for T.G.? a. Continue treating for 3 more months; it may take longer to see a benefit. b. Switch her to ranibizumab. c. Switch to intravitreal triamcinolone. d. Switch her to aflibercept. 6. Which of the following statements regarding the SAILOR (Safety Assessment of Intravitreal Lucentis for AMD) trial is FALSE? a. All participants came from the MARINA (Minimally Classic/Occult Trial of the Anti-VEGF Antibody Ranibizumab in the Treatment of Neovascular AMD) and ANCHOR (Anti-VEGF Antibody for the Treatment of Predominantly Classic Choroidal Neovascularization in AMD) trials. b. Patients were randomized to ranibizumab every 2 months after 3 monthly injections. c. Retreatment depended upon optical coherence tomography, visual acuity criteria, or physician determination. d. Visual acuity improved in both treatment-naïve and previously treated patients. 7. Although CATT provided some important data regarding the benefits of ranibizumab versus bevacizumab, several unanswered questions regarding anti-VEGF therapy remain. They include all of the following EXCEPT: a. The benefit of a 3-month loading dose b. The place of the newly approved aflibercept in the therapy regimen c. The best time frame for extending visits in the treat-and-extend protocol d. Whether patients will do better treated monthly or as needed with ranibizumab 8. In which situation is photodynamic therapy and anti-VEGF injections MOST appropriate? a. Presence of polypoidal choroidal vasculopathy b. Non-response to bevacizumab or ranibizumab c. Classic lesion d. Type 2 lesion 9. Which of the following statements about the HARBOR (Ranibizumab Administered Monthly or on an As-Needed Basis in Patients with Subfoveal Neovascular AMD) trial is TRUE? a. The trial compared the standard 0.5-mg dose of ranibizumab to a 1.5-mg dose given monthly or as-needed. b. Monthly ranibizumab was superior to a loading dose of ranibizumab followed by as-needed use. c. As-needed ranibizumab was superior to monthly ranibizumab. d. The results were inconclusive for all arms. 10. The PrONTO (Prospective Optical Coherence Tomography Imaging of Patients with Neovascular AMD Treated with Intraocular Ranibizumab) trial evaluating traditional as-needed dosing with ranibizumab demonstrated that: a. As-needed dosing with ranibizumab was superior to monthly dosing b. Monthly dosing with ranibizumab was superior to as-needed dosing c. As-needed dosing based on visual acuity changes with evidence of subretinal fluid or macular fluid was effective d. As-needed dosing based on clinician opinion was effective
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Neovascular Age-Related Macular Degeneration: Approaches for Improving Visual Acuity and Reducing the Burden of Care Accreditation Statement The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Credit Designation Statement The Johns Hopkins University School of Medicine designates this enduring material for a maximum of 2 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity. Release date: May 1, 2013 Expiration date: May 1, 2015 Instructions After reading this supplement, participants may receive credit by going to www.JHASIO.com, completing the CME test, evaluation, and receiving a score of 70% or higher. Certificates can be printed immediately online. Post-assessment 1. All of the following pathways are currently being explored to treat exudative age-related macular degeneration (AMD) EXCEPT: a. Blocking platelet-derived growth factor b. Upregulating mammalian target of rapamycin c. Blocking alpha 5 beta 3 integrin d. Complement inhibition 2. Which of the following statements regarding the CATT (Comparison of AMD Treatments Trials) study is TRUE? a. The CATT study demonstrated that bevacizumab given as needed is equivalent to bevacizumab given every 4 weeks. b. In the CATT study, spectral domain optical coherence tomography was used to assess for choroidal neovascularization activity. c. In the CATT study, presence of subfoveal choroidal neovascularization on fluorescein angiography was an inclusion criterion. d. In the CATT study, subjects randomized to bevacizumab had a higher rate of serious systemic adverse events compared with subjects randomized to ranibizumab. 3. In a patient with neovascular AMD who is not responding fully to anti-vascular endothelial growth factor (VEGF) therapy, as evidenced by improved but persistent intraretinal or subretinal fluid and/or less than average (compared with what is observed in pivotal phase III clinical trials) gain in visual acuity, one can consider all of these options EXCEPT: a. Inject a double dose of ranibizumab and/or shorten the duration between injections b. Combine with photodynamic therapy c. Add an anti–platelet-derived growth factor agent d. Switch the patient to a different anti-VEGF therapy (i.e., from ranibizumab to bevacizumab or vice versa) 4. Which of the following statements about anti-VEGF treatments is FALSE? a. In the CATT study, ranibizumab dosed on an as-needed basis was similar in efficacy as ranibizumab dosed monthly. b. Aflibercept has a shorter half-life than ranibizumab. c. In the VIEW 1 and VIEW 2 (VEGF Trap: Investigation of Efficacy and Safety in Wet AMD) studies, aflibercept administered every 4 or 8 weeks showed similar efficacy at 1 year in reducing retinal thickness and improving visual acuity in patients with neovascular AMD compared to ranibizumab given every 4 weeks. d. In addition to VEGF, aflibercept also acts on placental growth factor.
S26 Published by Elsevier Inc.
ISSN 0161-6420/13/$–see front matter http://dx.doi.org/10.1016/j.ophtha.2013.02.008
CME Section 5. T.G. is an 89-year-old Caucasian woman who presents with a large subfoveal choroidal neovascular membrane. You have treated her with 2 monthly doses of bevacizumab but see no improvement. What is the LEAST appropriate next step in therapy for T.G.? a. Continue treating for 3 more months; it may take longer to see a benefit. b. Switch her to ranibizumab. c. Switch to intravitreal triamcinolone. d. Switch her to aflibercept. 6. Which of the following statements regarding the SAILOR (Safety Assessment of Intravitreal Lucentis for AMD) trial is FALSE? a. All participants came from the MARINA (Minimally Classic/Occult Trial of the Anti-VEGF Antibody Ranibizumab in the Treatment of Neovascular AMD) and ANCHOR (Anti-VEGF Antibody for the Treatment of Predominantly Classic Choroidal Neovascularization in AMD) trials. b. Patients were randomized to ranibizumab every 2 months after 3 monthly injections. c. Retreatment depended upon optical coherence tomography, visual acuity criteria, or physician determination. d. Visual acuity improved in both treatment-naïve and previously treated patients. 7. Although CATT provided some important data regarding the benefits of ranibizumab versus bevacizumab, several unanswered questions regarding anti-VEGF therapy remain. They include all of the following EXCEPT: a. The benefit of a 3-month loading dose b. The place of the newly approved aflibercept in the therapy regimen c. The best time frame for extending visits in the treat-and-extend protocol d. Whether patients will do better treated monthly or as needed with ranibizumab 8. In which situation is photodynamic therapy and anti-VEGF injections MOST appropriate? a. Presence of polypoidal choroidal vasculopathy b. Non-response to bevacizumab or ranibizumab c. Classic lesion d. Type 2 lesion 9. Which of the following statements about the HARBOR (Ranibizumab Administered Monthly or on an As-Needed Basis in Patients with Subfoveal Neovascular AMD) trial is TRUE? a. The trial compared the standard 0.5-mg dose of ranibizumab to a 1.5-mg dose given monthly or as-needed. b. Monthly ranibizumab was superior to a loading dose of ranibizumab followed by as-needed use. c. As-needed ranibizumab was superior to monthly ranibizumab. d. The results were inconclusive for all arms. 10. The PrONTO (Prospective Optical Coherence Tomography Imaging of Patients with Neovascular AMD Treated with Intraocular Ranibizumab) trial evaluating traditional as-needed dosing with ranibizumab demonstrated that: a. As-needed dosing with ranibizumab was superior to monthly dosing b. Monthly dosing with ranibizumab was superior to as-needed dosing c. As-needed dosing based on visual acuity changes with evidence of subretinal fluid or macular fluid was effective d. As-needed dosing based on clinician opinion was effective
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