eSight...a Canadian invention!

interview with Dr. Devenyi

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Argus II Podcast November 2017 (iTunes required to listen)

https://itunes.apple.com/ca/podcast/the-retina-channel-podcast/id1299937225?mt=2#episodeGuid=b45e083061cc7184b12c1f1205b3f538

The Donald K. Johnson Eye Institute

Seeking sight for more eyes

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Kathryn Boothby, Special to National Post | September 24, 2016 | Last Updated: Sep 24 12:01 AM ET
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SuppliedDonald K. Johnson, business leader and philanthropist

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Vision loss is reaching a crisis level in Canada. In 2007, more than four million Canadians were living with blinding ocular disease, according to the National Coalition for Vision Health. That number is expected to double by 2020. 

The social-economic impacts are enormous: social isolation, high unemployment and emotional distress for the individual; $15.8 billion in annual costs for the health-care system in 2007 alone; and annual economic costs expected to reach $30.3 billion by 2032.

SuppliedDr. Robert Devenyi, Co-Director of the Donald K. Johnsons Eye Institute

An aging population is but one of the factors influencing the rise in the demand for subspecialty ophthalmology services, says Dr. Robert Devenyi. “The demand for our services is exploding far beyond what the predictable demographic rise in the aging population would dictate,” he says. “This is because not only is the number of elderly people increasing at an exponential rate, but we can now treat many conditions which a few years ago we could not.” Devenyi is ophthalmologist-in-chief at University Health Network and co-director with the Donald K. Johnson Eye Institute in Toronto. Based at the Toronto Western Hospital, the Institute combines groundbreaking research with world-class clinical care. Over 55,000 outpatients are served and more than 4,000 surgeries performed at the facility each year.

The most common conditions treated at the Institute are adult macular degeneration (AMD), glaucoma, diabetic retinopathy, and diseases of the cornea.  Often, individuals with the most complex conditions come from across the province to receive treatment. Advances in treatments and surgical techniques over the past decade such as injectable drugs and more precise instruments have helped mitigate the effects of eye disease and reduced patient recovery time, says Devenyi.

SuppliedPatient, Robert Pryce and Dr. Michael Brent - Director, Medical Retina Program at the Donald K. Johnson Eye Institute.

For Robert Pryce, early detection and treatment at the Institute were key in halting the progression of his vision loss due to diabetes. “There is no doubt in my mind that without treatment I would have suffered significant vision loss, which would have affected me for the rest of my life,” says Pryce. “The care provided by highly trained, experienced professionals at the Institute is second to none.”

Clinical practitioners, led by Devenyi, are working with Dr. Valerie Wallace — co-director of the Institute and head of the vision science research program — and her team to help find new methods to prevent, mitigate or repair vision loss.

SuppliedDr. Valerie Wallace, Co-Director of the Donald K. Johnson Eye Institute

“Collaboration is key,” says Wallace, whose research is focused on the use of stem cells to rebuild damaged retinas. “From clinicians, researchers learn about the realities faced by patients. From researchers, clinicians gain a better understanding of what is feasible. Interaction that crosses these two perspectives helps bring forward new ideas and solutions to challenges faced by patients every day.”

Funding is critical if research and care is to move forward, but pre-clinical work, toxicological studies, safety protocols and clinical trials are extremely expensive. As the transformative nature of new discoveries and treatments brings new patients to existing populations, more infrastructure, human resources, laboratories, operating rooms and physicians are required.

Those increasing needs mean philanthropists like Donald K. Johnson are becoming indispensable, says Devenyi. “His and his wife Anna’s generosity allowed us to open this Institute and bring unimaginable benefits to our patients,” he says. “Donations allow not only frontier-breaking research to happen, they also help provide the resources with which to hire the world’s best in the field and to purchase state-of-the-art equipment for surgery and diagnosis.”

Johnson has contributed over $15 million to the Institute that bears his name. His myopia, glaucoma, cataracts and early AMD stimulated his interest in the prevention and treatment of eye disease, and enhanced a firm belief in the responsibility to put that interest into action.

“It is very gratifying to give back to organizations that have touched our lives, and to see the benefits to those they serve,” he says. “While government funding enables these organizations to be good, private sector donations and philanthropists provide the catalyst that allows them to be great.”

At 81, Johnson is still very active. He works in the financial sector five days a week and serves on six boards — four of which are for not-for-profit organizations.

Johnson says he has been very fortunate over his lifetime. He encourages others to follow his philanthropic lead and help provide the capital necessary to make incredible things happen. “It’s better to give it away with a warm hand than a cold hand,” Johnson says. “I hope to continue to do so for many years — I’m only 81 and the best is yet to come.”

The same can be said for the Institute that bears his name.

an Argus II story...

an episode of "The Surgeons"

First two Argus II Artificial Retinal Implants performed in Canada!

On June 5, 2014 and on September 5, 2014, Dr. Robert Devenyi and his colleagues performed Canada's first two Argus II artificial retinal chip implant procedures at the Donald K. Johnson Eye Center, The University Health Network at The University of Toronto. These procedures mark a new era in Ophthalmology, offering hope for patients who are completely blind from outer retinal degenerations. The generous support of the Foundation Fighting Blindness is gratefully acknowledged. CTV news

What is Ocriplasmin?

Ociplasmin (marketed by Alcon under the name "Jetrea") is a new drug, which was approved by the FDA in the US in October 2012.  It is an enzyme (a "recombinant protease with activity against fibronectin and laminase") which helps separate the back of the vitreous gel from the retina.  In certain conditions...when there is a strong attachment of the vitreous gel to the retina...and when the vitreous collapses forward in the eye...the retina can be lifted up like a "tent" (as seen in the OCT picture above),  Such an elevation results in visual loss.  Until the availability of this drug...the only solution was vitrectomy surgery...in which the vitreous gel is removed surgically...relieving the traction on the retina...resulting in visual improvement.
The availability of this drug allows some patients to be cured without surgery.  The drug needs to be injected directly into the vitreous cavity of the eye.  The success rate is much lower than with surgery (approximately 30% vs 100%).
A small percentage of macular holes can also be treated with this drug...and also avoid the need for vitrectomy surgery (ONLY in those cases of macular holes where there is traction from the vitreous in an "anteroposterior" or front-to-back direction)
Ocriplasmin is anticipated to receive Health Canada approval later in 2013

Is it true that an "artificial retina" has been developed?

On February 14, 2013...the FDA approved the "Argus II Retinal Prosthesis System".  This ingenious device was developed by "Second Sight" in California.  It consists of an intraocular portion and an extraocular portion.
The intraocular portion consists of a pattern of electrodes which are implanted onto the surface of the retina...as well as a receiving and transmitting coil...implanted onto the surface of the eye...these transmitters are connected by a wire to the electrodes inside of the eye.
The extraocular portion consists of a pair of glasses, onto which is mounted a camera.
The camera then sends images wirelessly...to the receiving coils...which then sends the images to the transmitting coils...and then to the electrodes on the retinal surface.  Impulses are then transmitted to the retinal nerve finer layer...then to the optic nerve...and then to the brain.
As of this writing...30 patients have had this device surgically implanted, as part of an FDA study.  The results have been quite remarkable.  Only patients with no light perception vision or bare light perception vision were eligible...and only patients who had a previous history of "form vision" in the past.  Patients have shown variable abilities to see large objects, navigate obstacles, reach for items on a table and even read large letters!
It is important to note that this device is now FDA approved ONLY for patients with an inherited retinal disease called RETINITIS PIGMENTOSA.
We anticipate commencing studies with the Argus II system in Toronto in late 2013.

Watch an actual intravitreal Lucentis injection (patient consent obtained)

How frequently does Lucentis need to be injected for wet ARMD?

There is no absolute answer. Lucentis...blocks a chemical called "VEGF" (vascular endothelial growth factor) which is secreted in excess by the body in wet macular degeneration. VEGF causes abnormal blood vessels to grow and bleed...while Lucentis is in the eye...it blocks VEGF...and stops bleeding...once Lucentis is absorbed...the blood vessels tend to grow and bleed.

Different people however absorb Lucentis at different rates...so Lucentis stays inside the eye for different periods of time in different people. On average...Lucentis stays for approximately 28 days...so when Lucentis was first evaluated...it was re-injected every 28 days...we now however know...not surprisingly...that different people differ in how quickly or slowly they absorb Lucentis...and therefore...people differ in how frequently they need to be retreated with Lucentis.

The best approach if for the retinal specialist to follow each patient as an individual...by clinical examination and, as required...OCT and angiography...to individualize the treatment program best suited for each patient.

The iPad as a "low vision" tool.

Apple's new iPad might prove to be the most brilliant, portable and cost-effective low vision tool ever!

The iPad is extremely easy to use, portable (1.5 lbs) and relatively inexpensive (starting at $499)...when compared to very large, cumbersome and much more expensive CCD devices currently available to low vision patients.

As opposed to conventional low vision aids...which require the user to place the reading material underneath the device in order for the printed material to be magnified...the iPad not only allows the fast and easy downloading of all printed material (books, magazines, etc)...but also allows access to everything on the internet! The user can then, with simple hand gestures on the touchscreen...enlarge the image to as large as is required! A new use for an already very brilliant device.

I seem to be resistant to Lucentis...am I unusual?

Lucentis is not a cure...it must be considered a maintenance therapy. A person with "wet" macular degeneration really needs the Lucentis to be present in their eye "24 hours per day...FOREVER". While Lucentis is present in the eye...blood vessel growth and leakage is retarded...but as the Lucentis gets absorbed (by 4 weeks)...blood vessel growth and leakage resumes...in most people...usually quickly.

One should therefore not feel that they are resistant to the Lucentis...it is unfortunately the nature of the drug. Lucentis is a terrific drug...but the nature of the disease and the duration of the drug in the eye requires injections approximately every four weeks...in most people. Every patient is however different in their response...your retinal specialist needs to monitor you very frequently...both via examination...and with imaging such as OCT and sometimes angiography...to determine whether additional treatment is required.

Do i have to pay for my own Lucentis if I go South for the winter?

If a resident of Ontario goes South for the winter...we can arrange with the Pharmacy supplying Lucentis to supply the drug while you are away...arrangements must be made with a retinal specialist at your destination to receive the drug and to administer the drug. Great care must be taken in the transportation process to ensure that the drug is maintained at the temperatures recommended by the manufacturer. As an Ontario resident...you are just as entitled to have an ODB covered drug such as Lucentis while you are away as you are entitled to have a drug that is taken orally.

What is OCT and why is it necessary?

OCT stands for "Ocular Coherence Tomography". It is a brilliant new technology which allows for a very precise, non-invasive evaluation of the macula (central retina). Exquisite details of retinal structures can not only be seen...but measured very precisely...and monitored for change (improvement or worsening) over time.

The most common use of OCT is for the evaluation of macular degeneration. Very subtle collections of fluid or blood can be detected...the OCT is key to the determination of whether additional treatment is or is not required.

Many other problems...such as macular holes, vitreomacular traction, epiretinal membranes and macular edema...are also best evaluated with OCT.

In Ontario...OCT is now covered by OHIP.

How soon after retinal surgery can I swim?

In general...it is recommended that one doesn't swim for at least a month after retinal surgery. The main concern is the risk of infection from the water. What would otherwise be a trivial case of "pink eye" can become a serious infection if a surgical wound has not completely healed.

Is general anaesthesia required for retinal surgery?

Most people do not require general anaesthesia.  The eye can be very well frozen with an injection behind the eye.  In addition...the anaesthesia team gives patients intravenous sedation...so patients typically drift in and out of being awake.  If however a patient insists that they do not want to be aware of anything during the surgery...general anaesthesia can be used.

Are there any new drugs on the horizon for wet macular degeneration?

The short answer is NO.

The results with Lucentis have been so great...that many other manufacturers have abandoned development of drugs that they had been exploring...due to the huge costs involved. Any new drug will have to be shown to be better than Lucentis.

Currently...a drug called VEGF-Trap is in Phase 3 FDA trials...results are expected perhaps in 2011. VEGF-Trap will have to be shown to have better visual acuity improvement and/or less frequent dosing to have potential.

Very sophisticated new laser systems are also being explored (Opttx Medical)...perhaps to be used together with Lucentis...to decrease the number of injections required.

How many Lucentis injections will I need?

It is impossible to predict the number of injections a person will need for "wet" macular degeneration. It is important to recognize that Lucentis is not a "cure" but rather a maintenance therapy for macular degeneration. The body stimulates the growth of abnormal blood vessels in wet ARMD...for reasons that are not entirely understood. The body produces a chemical called VEGF...which stimulates the growth and leakage of these abnormal blood vessels. Lucentis...specifcally blocks VEGF...however Lucentis stays inside the eye only for about four weeks...and is then absorbed by the body...therefore...almost always...when the Lucentis gets absorbed...the blood vessels start to grow and to leak again...and more Lucentis is then required.

Most retinal specialists treat patients in a schedule similar to the following...an initial course of three Lucentis injections every four weeks...then careful monthly follow-up...with repeat injection at the earliest sign of recurrence or persistence of blood vessel growth and leakage.

What are the risks of an injection into the eye?

Retinal specialists inject an ever increasing number of medicines into patient's eyes (Amphoterecin, Kenalog, Macugen, Avastin, Lucentis, etc). These various medications have been extremely helpful in the management of many diseases such as macular degeneration, diabetes, infections and retinal vein occlusions. Techniques and anaesthetic agents have improved dramatically over the years...making the procedure much less uncomfortable than most patients fear.

There however still do exist some risks...from the injection itself. The main risks are that of infection ("endophthalmitis"), bleeding into the vitreous cavity, retinal tears, retinal detachment, cataract or corneal abrasion. The vast majority of patients however experience only minimal discomfort at the time of the procedure...and mild swelling and redness for a day or two post-injection.