Dr. Rishi Singh, MD, with the Cleveland Clinic discusses the unmet need in the treatment of Age-related Macular Degeneration (AMD) and a white paper on Retinal Rejuvenation Therapy (2RT®) by Ellex, a first of its kind therapy for the treatment of early and intermediate AMD.
Dr. Rishi P. Singh MD is a staff surgeon at the Cole Eye Institute, Cleveland Clinic and Associate Professor of Ophthalmology at the Lerner College of Medicine in Cleveland Ohio. He also currently serves as the medical director of informatics at the Cleveland Clinic. He received his bachelors and medical degrees from Boston University and completed his residency at the Massachusetts Eye and Infirmary Harvard Combined Program in Boston, Massachusetts. Dr. Singh then completed a medical and surgical fellowship at the Cole Eye Institute in Cleveland, Ohio.
He specializes in the treatment of medical and surgical retinal disease such as diabetic retinopathy, retinal detachment, and age-related macular degeneration. Dr. Singh has authored more than 100 peer reviewed publications, books, and book chapters and serves as the principal investigator of numerous national clinical trials advancing the treatment of retinal disease. Dr. Singh is the current president on the Retina World Congress and is on the board of the American Society of Retina Specialists. Dr. Singh’s current work focuses on the electronic medical records implementation, lean process improvement, and decision support modules for clinical practice. He operates the Cleveland Clinic Electronic Health Record Consulting program. Dr Singh has been honored with several research recognitions such as the Alpha Omega Alpha Research Award and American Society of Retina Specialists Senior Honor Award.
Neal Howard: Hello and welcome to the program, thank you for joining us here on Health Professional Radio. I’m your host Neal Howard and I’m glad that you are here. Our guest is Dr. Rishi Singh, he’s with the Cleveland Clinic and he’s joining us here on the program to talk about an unmet need, the unmet need in the treatment of age-related macular degeneration. EWe’ll also talk briefly about a new therapy for retinal rejuvenation therapy by Ellex. Welcome to the program Dr. Singh, thank you for taking the time.
Dr. Rishi Singh: Hi, thank you for having me.
Neal: Well I did mention that you’re with the Cleveland Clinic, what type of doctor are you? What’s your specialty and are you practicing in any place else other than Cleveland?
Dr Singh: Yeah, I’m a practicing retina specialist here. I’ve been here on staff now for 12 years and my focus is our age-related macular degeneration, diabetic retinopathy and surgical retinal diseases and I’ve published extensively in the field.
Neal: Now age-related macular degeneration, what is macular degeneration and what’s the difference between MD and AMD?
Dr Singh: AMD is a leading cause of blindness in the United States. It happens in most patients above the age of 65, it causes a loss of the central vision. There are two flavors of this – wet forms and dry forms of the disease. The wet form of the disease is something that is aggressive and is treated with these injection medications we have now. The dry form of the disease is something we don’t have much treatment for right now and it’s … causing this will compromise in patients. Sometimes patients are complaining of difficulty seeing their plates, recognizing the objects in front of them that are in the central part of their vision – those are all common complaints of patients with this sort of condition.
Neal: So it’s you’re looking at your plate, you can’t see it because it’s directly in front of you but you still maintain peripheral vision?
Dr Singh: Correct. The peripheral vision that’s part of that is important to keep and that happens with AMD but central vision is lost and that’s a big detriment to people’s ability to act and function independently.
Neal: Now you mentioned that we don’t have a treatment currently for as you say the dry form of macular degeneration and this is something that is pretty much going to happen around 65, 60, 70 years old. Are there forms of this disease that affect and present much earlier in life?
Dr Singh: Yeah. Actually what one of the big issues is that this can happen even at earlier phases of life. Sixty five is sort of a time where we start to screen patients with macular degeneration but we find lots of patients present even earlier than that and they don’t even realize they have the disease because in the early forms of the disease state, patients can be really quite silent. They might not manifest some sort of symptoms initially and while they might have a strong family history or poor dietary intake of essential nutrients or a smoking history, they don’t get evaluated and so it’s a real detriment to making sure that we’re able to screen them and evaluate them at a certain age. So you’re probably correct, they probably come in much earlier than we think before below the age of 65 but we haven’t had much to do with them up to this point. Typically it revolves around smoking cessation, diets full of green leafy vegetables, a dose of fish once a week – those are the typical recommendations for patients who had continued or some form of macular degeneration at least initially.
Neal: So the person that doesn’t smoke, lives a healthy lifestyle, eating right, exercising – are they much less likely to develop MD or just as likely as anyone else based on the nature of the disease?
Dr Singh: It’s a hot combination of factors, I couldn’t say one or the other at this point. It’s a combination of dietary, lifestyle modification. Genetics play a huge role in this condition, more so than many other conditions. You might have heard of like breast cancer or even cardiovascular disease, really we think that genetics play a huge role in this. So it’s a conglomeration of all those together, I can’t really say that one is particularly more important than the other one.
Neal: Now is this a condition that gets progressively worse until absolute blindness takes place or is it something where you can’t see your plate because it’s directly in front of you and that’s the way it’s going to be until treatment is successful?
Dr Singh: That’s actually a sign that either the disease has advanced to the wet form of the disease or that you have advanced dry disease and what we’re really trying to do in this condition is prevent people early in the form of the disease, in the stages where they might be silent and don’t realize there’s a problem and those are the patients we need to screen and evaluate and potentially treat. And up into this point, we really haven’t had a lot of treatments in that sort of area up until this point of this recent study we’ve had looking at sort of the treatment for the management of these patients earlier in that disease stage.
Neal: You mentioned patients being silent in the early stages of the disease. Is this because there are certain symptoms that seem like maybe a little bit of dry eye or something like that or maybe they’ve experienced a trauma and they associate these symptoms with that trauma? Is that part of the unmet need and if so, how much of the responsibility to fill this unmet need falls on the patient and how much falls on the caregiver?
Dr Singh: I think that’s a great point. I think the other thing about this is that people really feel like at some level that their disease as they get older, as you become an older adult, that you should have vision loss and changes in your vision over time and that’s actually an interesting I think phenomenon. I think people have this sort of almost a psychology that when they get older, they’re not supposed to have a good vision as other people might and that’s simply not true. Patients in the late form of their lifetime should have as good of a vision as anyone for their state and in fact could have 20-25 or even 20-20 vision but I think the prevailing mentality has been that there probably is some patients who believe that there is definitely a loss or detriment of vision over time. And for that I think it’s just not right for them to necessarily have that sort of mindset because there is a lot we can do for them in their disease state.
Neal: You mentioned earlier that AMD is the number one cause of blindness, now that’s here in the United States. Is it true in other industrialized nations because of I guess the processed foods? You mentioned diet, because of smoking and some of these other things. Of eleven million folks or more have some form of AMD, I’m understanding and that number is expected to be a double by about 2050 or so. Would you say that environment plays a huge part or at least some part in it aside from the diet and the smoking cessation.
Dr Singh: You’re actually hitting on a really great point which is that we’ve done studies looking at this and we find that patients in for example in Western Europe are at much more higher rates of macular degeneration than Eastern Europeans would be. So just the difference in just the European countries, even though the genetics might be sort of similar in nature, the lineage … the big difference in just the locational factors that are involved. We also know that sun exposure is one of the really, really leading causes of the issues that are surrounding patients with AMD and so those certainly with increased sun exposure have been thought to have higher rates of macular degeneration so a person like me who unfortunately lives in Cleveland, Ohio, might not get as much sun as somebody who lives in California or in Mexico or Southern Country and so those patients might have a higher risk of developing macular degeneration…
Neal: Now you’re familiar with Ellex I understand and they’ve developed a treatment for AMD.
Dr Singh: I think it’s a really great breakthrough as far as understanding more about this disease state. I would say that I think the data is very preliminary, it’s very supportive of the idea that there might be a benefit in treating patients with laser for this condition but what the study really showed, it was a proportion of patients who were in the study who actually benefited who did not go on to developing the later forms of macular degeneration and by that, I mean they didn’t go on to developing the vision … for the disease and a less percentage than those did not get the laser at all. Actually with a 77 percent reduction in patients who are going on to late forms a disease and it’s sort of a breakthrough right now in science because what we’re learning about this treatment is that it can be applied to patients even before they develop the actual condition. The condition I talked to you about before which is that they could develop really late stages of the disease where they lose vision over time, if we could get them potentially earlier and treat them earlier if we were seeing them and having them evaluated with this sort of laser technology. The data is preliminary right now, it’s an early trial but I think there’ll be more trials coming. Some of the more interesting data from this trial has really been about how patients can potentially benefit by not developing that later condition and what sort of phenotypes or sort of clinical … has a maximum possible gain. So what I can say about that is that it’s really about patient selection and determining who would benefit from later. It’s not for everyone but certainly going to an eye care specialist and talking about it is the first step in determining whether you’re even eligible for this sort of treatment.
Neal: Where can our listeners go and get some more information online about this 2RT® therapy developed by Ellex and also about your practice there in Cleveland, the Cole Eye Institute Cleveland Clinic?
Dr Singh: Alright. So for my practice please go onto clevelandclinic.org and if you just could just search the 2RT® Lead Study, you’ll see a lot of great data and a supplement we just recently wrote for one of the … journals for retina today where we really talked about this sort of treatment and what it could allow our patients to do. I think the data is very compelling, we have to have more studies to show us the benefit of this on the long-term and … better way certainly.
Neal: Well some great information, thank you for joining us on the program Dr. Singh. It’s been a pleasure.
Dr Singh: Thank you again for having me.
Neal: You’ve been listening to Health Professional Radio, I’m your host Neal Howard transcripts and audio of this program are available at hpr.fm and healthprofessionalradio.com.au.You can also subscribe to this podcast on iTunes, listen in and download at SoundCloud and be sure and visit our Affiliate Page at hpr.fm and healthprofessionalradio.com.au