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Corneal cross-linking (CXL) is improving all the time, although all protocols retain the basic requirements for oxygen, riboflavin and UV light. Recent developments mean that CXL at the slit lamp is feasible, which will improve access to the procedure.

The pathophysiology and pathomorphology of corneal ectasia: Part 4

The epithelium adapts to compensate for changes in the cornea and these changes can be detected with high sensitivity, reducing both false positives and false negatives in the diagnosis of keratoconus.

Corneal ectasia part 3: OCT epithelial thickness measurements allow monitoring of corneal changes

The pathophysiology and pathomorphology of corneal ectasia: Multimodal imaging techniques yield vital screening and diagnostics data

Eye rubbing is an essential factor in the development of keratoconus. “No rub, no cone” is the rule: a genetic predisposition for the disease will come to nothing without excessive eye rubbing.

The pathophysiology and pathomorphology of corneal ectasia: Keratoconus will not develop without eye rubbing

Dietary macular pigments, which can now be measured directly and accurately, are hugely important in optimising visual function, especially as we age.

Dietary supplement improves measurable visual outcomes

Over the last 15 years, biosimilars have become a major feature of the health care landscape. Physicians in many disciplines, particularly oncology and immunology, have embraced biosimilars. However, access to educational resources on these powerful biologics can be inconsistent, and in turn, some ophthalmologists who could benefit from the adoption of biosimilars are left in the dark.

The real-world application of biosimilars was the focus of discussion for Martin Zinkernagel, MD, PhD, chair of the Department of Ophthalmology at the University Hospital of Bern, Switzerland, and Paolo Lanzetta, MD, professor of ophthalmology and chairman of the Department of Medicine-Ophthalmology at the University of Udine in Italy. In their discussion, the experts addressed several common questions, framed around the phase 3 clinical trial for biosimilar SB11 (BYOOVIZ) from Biogen. SB11 is approved in Europe and the United Kingdom. Like the reference product ranibizumab (Lucentis), SB11 is approved for the treatment of retinal disease including neovascular age-related macular degeneration (nAMD).

Addressing physicians’ levels of familiarity with biosimilars, Dr Lanzetta attributed much of the variation to regulatory discrepancies. “The uptake of biosimilars varies throughout Europe by country and by product,” he said. “Obviously, variation in the uptake of biosimilars [is] influenced by government involvement, reimbursement issues and tender procurement policies.” Recent survey data have revealed gaps in awareness across Europe and in the United States on the efficacy and safety of biosimilars for retinal diseases, Dr Lanzetta said, especially in terms of “real-world data.”

In a clinical application, Dr Lanzetta said, biosimilars may exhibit minor differences from the reference products, but they aren’t considered to have significant impact on the efficacy or safety profile. Typically, the biosimilar and reference medicine must have the same posology and route of administration, with few exceptions, he added.

Dr Lanzetta also said that in the last 10 years, the European Medicines Agency (EMA) has approved the highest number of biosimilars worldwide.

 “And this means, to us physicians, having both the possibility to have experience on their use in terms of safety and evaluating the efficacy after that,” he explained.

One common misconception about biosimilars is that these therapeutics are interchangeable with the idea of generic medicines. But there is a key indicator that biosimilars are unique: the cost. “While generic medicines are marketed at a significantly lower price than name brand ones, why do we not see the same level of cost savings with biosimilars?” Dr Zinkernagel asked.

Dr Lanzetta explained that biosimilars are developed via a rigorous, complex and highly regulated manufacturing process. “Generics are simple chemical medicines or agents, which is not the case for biosimilars and biologics,” he said. “Unlike generics, biologics, and therefore biosimilars as well, are very complex; they’re very difficult to copy. And the development processes are patented and proprietary to the originators.” The proprietary nature of biologic development, he added, is why biosimilars may have differences from their originators.

Prof Zinkernagel and Dr Lanzetta used data from the SB11 phase 3 trial to expand upon the capabilities of biosimilars. Prof Zinkernagel detailed the study: over 700 patients were included in the randomised, double-masked, parallel-group multicentre trial. Over 52 weeks, investigators evaluated the efficacy and the safety profile of this biosimilar SB11 in comparison with monthly ranibizumab for the treatment of nAMD.

“Patients with neovascular AMD were included, [with a] visual acuity range between 20/40 and 20/200,” Prof Zinkernagel said. “[Patients] were randomised in a 1:1 ratio to either have the originator or the biosimilar every 4 weeks from baseline up to week 48.”

Primary end-points were change from baseline in best corrected visual acuity at week 8 and change from baseline in central subfield thickness at week 4. The pre-specified secondary efficacy end-points included longer-term assessments of change from baseline in visual acuity, and the proportion of participants who lost fewer than 15 letters or who gained 15 or more letters in visual acuity from baseline at weeks 24 and 52.

“Other secondary end-points included, of course, change from baseline in central subfield thickness and central retinal lesion thickness at week 24, as well as change from baseline in choroidal neovascularisation [CNV] size and proportion of participants with active CNV leakage seen via OCT [optical coherence tomography] at week 24,” Prof Zinkernagel continued. Describing the results, he said, “When you look at the visual acuity improvements, it’s really equivalent. You have equivalence between the originator and the biosimilar, and the same holds true for a decrease in central retinal thickness. So the curves are basically the same, and also the secondary end-points.”

Prof Zinkernagel also spoke about the immunogenicity outcomes of the SB11 trial, as immunogenicity reactions have been a common problem in past assessments of anti–vascular endothelial growth factor (VEGF) agents. Along with detrimental effects to visual acuity, immunogenicity reactions can also lead to vasculitis and vitritis.

“Now, in this trial, the overall cumulative incidence of anti-drug antibodies, antibodies reacting against this specific drug up to week 52, was very low,” Prof Zinkernagel said. “For the SB11 biosimilar, it was 4.2%, and for the originator it was 5.5%. So very, very similar.”

He also noted that most antibodies were non-neutralising, which generally indicates a weak antibody response. “Furthermore, no statistical or clinically relevant differences in the incidence of anti-drug antibodies and neutralising antibodies were observed between treatment groups at any of the time points,” Prof Zinkernagel explained.

Dr Lanzetta highlighted the unique potentialities for anti-VEGF therapies as an area where physicians can consider treating patients with a biosimilar. “You can either switch a patient from the originator, obviously, or you can also consider treating with a biosimilar treatment-naive patients who may benefit…from being treated with that reference agent or originator agent,” he said. When to deploy a biosimilar will depend on many factors, including the locality where a patient is being treated. “Europe has different countries, different health care systems,” Dr Lanzetta said. “You may consider treating with the biosimilar patients who may not be strictly adherent to the cost of therapy and the frequency of treatment because of some cost issues.”

Just as education on biosimilars is vital to practitioners, awareness and education resources for patients are vital, too. “We spend a lot of time with our patients in letting them know that biologics did undergo a very rigorous approval process through studies, efficacy and safety studies,” Dr Lanzetta emphasised. This education is vital to getting patients on board with biosimilars, and it sparks enthusiasm about the potential benefits. “Once they do understand that, I think they will be very prone to receive a biosimilar; [it’s] in their interest and in the interest of the community, the whole community of patients, and in the interest of the health care system,” Dr Lanzetta said.

1. Biosimilars in the EU: information guide for healthcare professionals. European Medicines Agency. Updated December 2, 2019. Accessed October 3, 2023. 

https://www.ema.europa.eu/en/documents/leaflet/biosimilars-eu-information-guide-healthcare-professionals_en.pd

Editor’s note: A prior version of this article contained a misspelling of the product name BYOOVIZ. It has been corrected. We regret the error.

How biosimilars expand treatment options for patients with retinal disease

EYLEA’s unique MoA- What is the rationale for the higher molar dose

Hello and welcome to this video series sponsored by Bayer in which we are going to explore Eylea 8 mg for the treatment of age-related macular degeneration and diabetic macular edema. I am Professor Jean-Francois Korobelnik. I'm working in Bordeaux at the University Hospital in France. In this video I will be talking about Eylea's unique mechanism of action and the rational for the higher molar dose. Before we get started, I'd like to share my disclosures. I have been compensated by Bayer for my participation in this video. First, let's explore how Eylea targets disease pathogenesis.

To do that, let's have a look at the Eylea molecule. Eylea is a recombinant fusion protein consisting of portion of human VEGF receptors 1 and 2 domains fused to the Fc portion of human IgG1. So, it works as a decoy for multiple targets: VEGF-A, VEGF-B, placental growth factor, and galectin-1. This is a pioneer for the multi-targeted therapeutic approach.

In fact, Eylea is the only widely approved agent that blocks all VEGF receptor 1 ligands and the key VEGF receptor 2 ligands.

So, let's talk about the molar dose of Eylea 8 mg and why it is so significant. Eylea 8 mg has the highest reported potency. It demonstrates a stronger binding affinity for VGF-A and it targets a broader range of molecules including VEGF-A, VEGF-B, PLGF, and galectin-1. Additionally, Eylea 8 mg has a 34% slower ocular clearance compared to its 2 mg counterpart.

Now, let's take a look at the rational for increasing the molar dose of Eylea.

As I mentioned, 8 mg dose has a slower ocular clearance than the 2 mg dose. In fact, 8 mg is estimated to remain in the eye for 6 weeks longer, on average, than the Eylea 2 mg.

Why is this significant? Well, with its four-fold higher molar dose compared with the Eylea 2 mg, Eylea 8 mg aims to achieve sustained disease control for all eligible patient groups, potentially addressing key unmet needs in retinal care.

So what would shifting the curve mean for patients with neovascular AMD and DME who currently experience a higher treatment burden? What would this mean for clinic capacity? As you can see on this illustrative model, shifting the curve on the right could mean increasing the treatment intervals by four to eight weeks, from eight-week intervals to eight or 12-weeks intervals, thus lowering the treatment burden and reducing clinic capacity issues.

Another potential benefit of longer acting agents is that they may extend the time between injections compared to current treatment options. With Eylea 2 mg, approximately a third of the patients in ALTAIR and ARIES trials received injections every eight weeks or less at year two. On the other end, the percentage of patients receiving Eylea 8 mg that had last assigned treatment interval of 8 weeks at week 96 in PULSAR and PHOTON was between 5 and 13% only.

So now, let's return to our illustrative model and take a closer look at patients who are currently able to achieve extended treatment intervals on the right of your slide.

You can see the green line that represents the higher molar dose, so that the patients can, in fact, achieve those extended intervals as a result with lower treatment burden.

Let's now take a closer look about what longer interval means really. For Eylea 2 mg, one study found that 42 to 46% of patients were on 16-week intervals at year 2. Whereas another study found that 27 to 30% of patients were at 16-week or greater intervals at year 2. By contrast, between 78 and 88% of patients receiving Eylea 8 mg in PULSAR and PHOTON had a last treatment interval of 16-weeks or greater at week 96. So this data strongly suggests that longer acting agents may extend the time between injections compared with current treatment options.

Now, let's put together all the pieces and see what impact this could have for the patient. Based on everything we've explored in this video, Eylea 8 mg has the potential for greater and longer lasting control of disease activity through lasting vision gains, rapid and resilient fluid control, and extended treatment intervals. Additionally, Eylea 8 mg has the safety profile that is consistent with the Eylea 2 mg. With this in mind, let's take one last look at the mechanism of action of Eylea to support the rational for higher molar dose. Eylea's unique mechanism of action and molecular properties contribute to a sustained suppression of VEGF which is the master regulator of disease pathology. With its four-fold higher molar dose and 34% slower ocular clearance than Eylea 2 mg, Eylea 8 mg shifts the curve for all eligible patient groups. As a result, Eylea 8 mg has the potential for greater and longer lasting control of disease activity through sustained disease control compared to Eylea 2 mg for eligible patients groups with neovascular AMD and DME. Thank you very much for watching.

 EYLEA’s unique MoA: What is the rationale for the higher molar dose?

Panelists discuss how patients experiencing a high treatment burden with frequent anti-VEGF injections every 4-8 weeks are optimal candidates for the port delivery system, which can help reduce their number of clinic visits while maintaining therapeutic effectiveness.

Patient Selection For Port Delivery Device

Video content above is prompted by the following: 


Which patients are ideal candidates for this anti-VEGF delivery method?

Patients with frequent anti-VEGF treatment burden (4-8 weeks)

Video Series

Retinal Disease 

Panelists discuss how the port delivery system (PDS) with ranibizumab represents a paradigm shift in neovascular AMD treatment by utilizing a surgically implanted refillable device that provides continuous medication delivery for 6 months, offering patients a preferred alternative to frequent intravitreal injections while ensuring consistent therapeutic levels.

Overview and Benefits of Port Delivery Device with Ranibizumab

Can you provide an overview of the port delivery device with ranibizumab approved for treating neovascular AMD?

What are the benefits of using the port delivery device with ranibizumab?

Certainty of 6 months of continuous anti-VEGF delivery

Patients in clinical trials prefer PDS over intravitreal injections

Overview of Novel Treatments for Retinal Vascular Diseases

Could you briefly provide an overview of the new treatments available for retinal vascular diseases?

A panelist discusses novel treatments for retinal vascular diseases, including faricimab, aflibercept, and port delivery system with ranibizumab.

Considerations for Surgical Implant of the Port Delivery Device and Refill Process

Video content above is prompted by the following:

What are the key considerations for the surgical implantation of the PDS? [We will include the surgical video clips in this question]

Can you explain the refill process for the PDS and how it differs from standard intravitreal injections in terms of procedure and patient experience?

Panelists discuss how successful implementation of the port delivery system requires careful attention to surgical technique during both initial implantation and subsequent refill procedures, with specialized training and protocols that differ significantly from standard intravitreal injections in terms of procedural steps, sterility requirements, and patient preparation.

Lisa Stewart, PhD

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