Transcript
Dr. Lim:
This is CME on ReachMD. I’m Jennifer Lim, and I'm joined today by Justis Ehlers. Besides fluid control, what other biomarkers are there for assessing disease control when using second-generation agents in DME and AMD, Justis?
Dr. Ehlers:
Jenny, thank you so much for having me. It's a really great question. When we look beyond fluid, what are some of the biomarkers that we can use? And one of the ones that I look for are hard exudates. And this was a case of mine. A 48-year-old female with type 2 diabetes. We see pretty extensive nonproliferative diabetic retinopathy there with retinal hemorrhages, but hard exudates throughout the posterior pole, particularly in the fovea.
When you look at the OCT, you also see some critical pieces that can be associated with hard exudates, including variable sizes of hyperreflective foci; some smaller, some larger. The larger ones we know are related to the more significant deposits of hard exudates. And when we go ahead and treat the patient, and this was a decision to move forward with anti-VEGF therapy, we actually see a pretty remarkable response with resolution of the intraretinal fluid and subretinal fluid, and we also start to see improvements of those hard exudates based on this OCT visualization.
When we continue with anti-VEGF therapy, we see continued improvements and overall better visualization of the retinal architecture and, again, stabilization of the vision. And so, for me, it is one of those biomarkers that I'm using more and more when I look at the overall disease burden and process, when I'm treating these patients.
Dr. Lim:
Yeah, I agree with you, Justis. I think it's a really important biomarker, and it's also nice to show our patients that when they're being treated, that these biomarkers are improving. And they can easily see these hyperreflective foci, these hard exudates, going away with treatment. And I'd like to share with you a case that I have as well. And this is a 71-year-old man who had, as you can see, significant diabetic macular edema and hard exudates and, if you will, hyperreflective foci. And I agree with you, we don’t really know exactly which of these hyperreflective foci are hard exudates, which are inflammatory cells, but we can be pretty sure that the bigger ones are the hard exudates. And we see that after one faricimab, you might see that there's an increase in these hard exudates. And sometimes, as we know, when we dry the retina, we get precipitation of the hard exudate deposits that eventually will go away.
And so, with time, as you see on this patient, the larger hyperreflective spots go away, and also the smaller ones.
Dr. Ehlers:
Yeah, it's a great case. And for me, one of the things that I'm always concerned about, if they have extensive hard exudates, particularly near the fovea, is are they going to end up with subfoveal concentration of those hard exudates. And it may actually be able to be used as an indicator of possibly timing of when we should intervene. It's one of the challenges in these diseases, and I like what you said about sharing it with the patients. Because I often will say, these changes took years to develop, related to the ongoing process of diabetes, and although sometimes we see rapid fluid response, the overall disease modulation that we see with these therapies can continue for months as we're continuing to be aggressive about treating their underlying disease.
Dr. Lim:
Yes, absolutely. I think these hard exudates are a very useful biomarker, perhaps of chronicity as well as treatment response, and over time are extremely useful.
So this has been a great discussion, Justis. Unfortunately, we're out of time today. Thanks so much for joining us.
Dr. Ehlers:
I really appreciate it, Jenny. Thank you.
