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`Retinal Physician - Fine-Tuning Your Anti-VEGF Injection Protocols
`
`Article
`
`Fine-Tuning Your Anti-VEGF Injection Protocols
`The second article in our series recapping research and analysis presented at
`our annual meeting
`
`October 1, 2009
`
`2
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`RPS: From the Podium to the Practice
`
`Fine-Tuning Your Anti-VEGF Injection Protocols
`
`The second article in our series recapping research and analysis presented at
`our annual meeting.
`
`ANDREW E. MATHIS, PhD, MEDICAL EDITOR
`
`This issue, we will be covering four presentations from the 5th Annual Retinal Physician Symposium, which took
`place in the Bahamas from March 25 to March 28, 2009. Two of the presentations look at anti-VEGF drugs for
`AMD — particularly regarding their safety and finding an optimal dosing strategy. Keeping AMD in mind, we also
`present a lecture on lesion size and grading. Finally, we offer a discussion of practice management considerations,
`with an eye toward lowering costs and increasing revenue.
`
`DAVID BOYER ON THE SAFETY OF ANTI-VEGF DRUGS
`
`There's little question that anti-VEGF drugs are effective in treating conditions such as age-related macular
`degeneration, but what safety concerns arise? This was the topic of a presentation at the Retinal Physician
`symposium by David S. Boyer, MD, a retinal physician in private practice in Los Angeles.
`
`Dr. Boyer pointed to the case of Merck's NSAID Vioxx, which is believed to have caused roughly 100,000 heart
`attacks before it was withdrawn from the market in 2004. The potential problem with anti-VEGF drugs, Dr. Boyer
`continued, is that VEGF is a naturally occurring chemical signal that is necessary for normal function in several
`bodily systems. A drug such as ranibizumab will not only block excess levels of VEGF, but it may block VEGF
`levels to such an extent that they fall below normal levels needed for proper function. This occurs systemically and
`is not limited just to the eye. Plus, VEGF is a neuroprotectant and may have roles in treatment of Alzheimer's
`disease and epilepsy.
`
`Referring to the age of AMD patients, Dr. Boyer said, “The people that we're dealing with are a sick group of
`patients.” He cited the higher risks of stroke, hypertension and elevated cholesterol in the AMD patient group, not
`to mention the increase in rates of stroke among participants in the SAILOR trial. This may have constituted a
`safety signal, Dr. Boyer said, warranting further investigation into the safety of anti-VEGF drugs.
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`Retinal Physician - Fine-Tuning Your Anti-VEGF Injection Protocols
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`Also, Dr. Boyer pointed to another key safety consideration to be taken into account when using anti-VEGF drugs
`— progression of geographic atrophy despite a halt in the wet form of AMD. This is a cause of vision loss in
`patients despite initial improvements after treatment with anti-VEGF drugs, and may be related to the effects of
`anti-VEGF drugs on the choriocapillaris (Figure 1).
`
`Figure 1. Suppression of VEGF-A has a negative effect on photoreceptors and other ocular anatomy.
`
`The first data set Dr. Boyer looked at was the VISION trial of Macugen for wet AMD. He noted that, in this trial,
`there did not seem to be either a problem with progression of geographic atrophy or serious adverse events.
`Nevertheless, the problem of the adverse events in the ANCHOR and MARINA trials remained disconcerting.
`Genentech conducted the SAILOR trial to better determine if there were any systemic or ocular adverse events
`that would be exposed from analyzing a larger cohort of patients.
`
`Patients in the SAILOR trial were divided into two cohorts: The first were given injections of ranibizumab of either
`0.3 mg or 0.5 mg, while the second were given 0.5 mg injections only. Dr. Boyer stressed that these injections
`were not given for efficacy as that had already been demonstrated.
`
`The cohorts differed further in terms of how often injections were given. Cohort 1 received a mandatory three
`treatments and then were retreated based on changes in visual acuity or retinal thickness. Cohort 2 was on no
`fixed dosing schedule and retreatment was based on the judgment of the individual investigator.
`
`First, Dr. Boyer noted the high dropout rates in both cohorts (18% in cohort 1 and 50% in cohort 2). Dr. Boyer
`chalked up the rate to three factors: (1) The availability of bevacizumab, (2) The ability of some patients to receive
`injections covered by their own insurance policies, and (3) The unwillingness of some investigators to wait for the
`required 100-μm increase in retinal thickness before retreatment could occur.
`
`Presenting an overview slide of all nonocular serious adverse events in the SAILOR trial, Dr. Boyer showed the
`audience that the incidence of all side effects was very low. That point notwithstanding, Dr. Boyer pointed out that
`death rates, particularly for nonvascular death, were higher in patients receiving 0.5-mg doses, though this was not
`felt to be related to anti-VEGF therapy. Further, arterial thrombolic events were higher than other serious adverse
`events in patients in both cohorts.
`
`Focusing on stroke rate, the highest incidence was among former stroke patients who were in cohort 1 and
`receiving 0.5-mg injections (Figure 2). However, Dr. Boyer noted, the differences were not statistically significant
`and thus no conclusive statements could be made about stroke risk. This was further emphasized by the fact that,
`if a patient had not had a previous stroke, he or she was far less likely to experience a stroke during the study
`period. Arrhythmias were slightly more common in all groups, but incidents of congestive heart failure were not.
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`Retinal Physician - Fine-Tuning Your Anti-VEGF Injection Protocols
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`Figure 2. Key nonocular side effects.
`
`Dr. Boyer spoke frankly about the data. “I think you have to realize that, if you had about a 0.7% incidence of
`stroke in the 0.3-mg arm, then you need to show a 2.5% to 2.6% incidence in the 0.5-mg arm to show statistical
`significance. That's what a great difference you would need if you had only 1,200 patients. So we didn't have
`enough patients to really show small differences.”
`
`The next step, therefore, was to look at other randomized clinical ranibizumab studies collectively. Besides the
`MARINA, ANCHOR and SAILOR trials, the FOCUS and PIER studies were also included in a meta-analysis that
`showed higher doses of ranibizumab trended toward higher incidences of stroke. However, these results were also
`not statistically significant and again showed the leading risk factor for the development of stroke was previous
`stroke.
`
`Dr. Boyer closed with a “wait and see” approach, noting, “We're all anxiously awaiting the CATT trial looking at
`ranibizumab vs bevacizumab — 1,200 patients — to see whether there's any safety signal with bevacizumab,” he
`said.
`
`K. BAILEY FREUND ON OPTIMAL DOSING
`
`For nearly as long as retinal physicians have been giving intravitreal injections of anti-VEGF agents, notably
`Lucentis and Avastin, the question of what is the optimal dosing schedule for these drugs has lingered. In the first
`of two presentations he gave at the Retinal Physician Symposium, K. Bailey Freund, MD, crunched the data from
`several clinical trials and made some suggestions regarding dosing scheduling.
`
`Dr. Freund, from Vitreous Retina Macula Consultants of New York, began by discussing five ranibizumab trials:
`HORIZON, SAILOR, PIER, ANCHOR and MARINA. He noted that monthly treatment trials showed sustained
`improvement in visual acuity for two years; however, he cited data from the PIER and HORIZON studies in which a
`decline in visual acuity appeared to result from a reduced injection frequency. “We saw a pattern: Once we gave
`fewer injections, vision started to drop. This drop in vision was presumably explained by recurrent exudation
`resulting from undertreatment,” he said.
`
`Dr. Freund then turned to phase 2 trials of Regeneron's VEGF Trap-Eye, noting that prn dosing from the initiation
`of therapy was inferior to a loading sequence of three monthly injections. Dr. Freund said, “So you might ask, 'Well,
`with those results, why aren't we just treating all patients every month?'” He answered his own question with what
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`Retinal Physician - Fine-Tuning Your Anti-VEGF Injection Protocols
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`was learned from the PrONTO study: retreatment based on OCT could give visual acuity results comparable to
`monthly dosing. However, he cautioned, the PrONTO trial was small (37 patients) and not randomized.
`
`Nevertheless, the PrONTO study showed that three injections could dry the macula for an extended period of time.
`In Dr. Freund's view, monthly dosing may actually be overtreating some eyes. Here Dr. Freund presented his
`“scorecard,” a list of pros and cons of monthly dosing. While, on the one hand, monthly dosing will improve vision
`by keeping the macula dry and reduce risk of vision loss by reducing the risk of recurrent fluid and hemorrhage, on
`the other hand, monthly dosing entails greater risks of complications from intravitreal injections, costs more money,
`is less convenient for patients, and may incur long-term safety concerns.
`
`At this point, Dr. Freund turned briefly towards the possible beneficial effects of monthly dosing on conversion
`rates from dry to wet in the non-treated fellow eyes (Figure 3). Having looked at fellow eyes from the ANCHOR
`and MARINA trials, Dr. Freund and his colleagues concluded that there was no difference between results for
`patients receiving monthly ranibizumab versus sham injections. “It doesn't seem that monthly ranibizumab has a
`prophylactic effect on the fellow eyes with dry disease,” he said.
`
`Figure 3. OCT images of fellow eyes in patients treated with ranibizumab.
`
`Conceding further that monthly dosing is often logistically difficult with the population of patients with AMD, Dr.
`Freund gave his recommendations for which eyes he might consider dosing monthly. These eyes included: those
`in monocular patients who had lost vision in the fellow eye already due to AMD, those with preserved foveal vision
`but lesions close to fixation, those that have already demonstrated aggressive recurrent exudation, and those in
`poorly compliant patients.
`
`Dr. Freund suggested that any optimal dosing schedule will likely need to include at least three initial doses on a
`monthly basis (Figure 4). Retinal physicians then need to consider several other factors in determining a dosing
`schedule for each individual patient. An alternative to monthly dosing Dr. Freund discussed at some length was the
`PrONTO dosing schedule. He provided another “scorecard” here, this one pointing out that the pros were primarily
`an often reduced number of injections and associated drug cost with theoretically greater systemic safety. The
`cons included the necessity for monthly visits and OCTs, which are costly and difficult for patients to maintain, and
`uncertainty regarding when treatments will be administered.
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`Retinal Physician - Fine-Tuning Your Anti-VEGF Injection Protocols
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`Figure 4. Considerations for optimal dosing of anti-VEGF drugs.
`
`Dr. Freund then showed a few cases from his own practice, noting that recurrent hemorrhage seemed to be a risk
`with prn dosing. “This raises the question of whether we can completely rely on OCT as an indicator of disease
`activity,” Dr. Freund said. To demonstrate the correlation between injection frequency and macular hemorrhages,
`Dr. Freund and his colleagues compared the patients in the ANCHOR, MARINA and PIER studies, concluding that
`macular hemorrhages occurred in patients more often when dosing was quarterly rather than monthly.
`
`Dr. Freund then described his own “treat and extend” dosing regimen. Monthly injections are given until the macula
`appears dry on OCT. “And then I just do two simple one- to two-week extensions as long as the OCT, clinical exam
`and visual acuity remain stable. Patients who do not develop recurrence of exudation at two months will continue
`on a maintenance regimen with visits and injections every two months,” Dr. Freund said. “With this strategy, you
`can probably get at least 50% of patients to only six visits and six injections a year,” Dr. Freund noted. He
`presented a scorecard for treat-and-extend dosing to underscore his points, suggesting that the approach seems
`to offer a good balance in terms of the goals of maximizing visual outcomes, patient safety and convenience, and
`minimizing cost to the healthcare system and the burden on retinal physician's practices in terms of managing
`these cases.
`
`Dr. Freund presented data from a retrospective study conducted in his practice, which found that patients with type
`3 neovascularization or RAP lesions managed with the “treat and extend” regimen required, on average, 13
`injections and office visits in a period of two years. Visual results in these eyes were similar to those seen in the
`ANCHOR, MARINA, and PrONTO trials.
`
`He closed his presentation with data on bilateral same-day dosing that showed that these procedures had rates of
`ocular complications that were similar to what are seen in single-eye injections. He emphasized the notion that
`optimal dosing is best determined on a case-by-case basis and that there is no “one size fits all” strategy. He said
`“as retinal specialists we need to combine the available data and our own clinical experience regarding dosing with
`the specifics of each individual case in order to come up with an optimal dosing strategy tailored to each and every
`patient.”
`
`DR. FREUND ON LESIONS
`
`Dr. Freund's second presentation was entitled “Does Lesion Composition, Age, or Size Matter?” He began by
`going over what many consider to be the most important strategies for obtaining the best visual result in treating
`wet AMD: achieving a dry macula, preventing growth in lesion size, and trying to eliminate the CNV. His focus is
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`Retinal Physician - Fine-Tuning Your Anti-VEGF Injection Protocols
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`somewhat different. Dr. Freund said he believes that “what is most important is to preserve the RPE and
`photoreceptors at the fovea, which is not always achieved through aggressive attempts to completely dry the
`macula an eradicate the CNV” He demonstrated his approach with a slide of a patient who had sustained
`improvement in vision over three years on intravit-real ranibizumab despite having continued growth of the CNV
`lesion and persistent subretinal fluid.
`
`Next, Dr. Freund reviewed lesion terminology. He questioned whether the terms “classic/well-defined” and
`“occult/poorly defined,” which had been based on fluorescein interpretation, were still clinically relevant. Dr. Freund
`suggested that these fluorescein findings often don't match what is seen on OCT, stating further that more and
`more retinal physicians were characterizing the disease and tracking its progression with OCT. He followed by
`showing how FA and OCT findings differed in a few cases.
`
`Dr. Freund continued: “For the past several years, Tve really stopped using these older terms and go exclusively
`with an anatomical classification that is based on the best aspects of FA and OCT, looking at whether the vessels
`are in the sub-RPE space, subretinal space, or are proliferating within the neurosensory retina.” He showed the
`typology of these lesions — type 1, type 2 and type 3 (which Dr. Freund pointed out most people would call a RAP
`lesion) (Figure 5). He acknowledged the work of Donald Gass in this field.
`
`Figure 5. The three types of AMD lesions.
`
`Dr. Freund then turned to discussions of each type of AMD lesion. Starting with type 1 lesions, he said, “They often
`require more frequent injections, but they do very well visually because the RPE and the photoreceptors are more
`likely to be preserved than with the other lesion types.” Dr. Freund showed several slides of cases of type 1
`lesions.
`
`One of the more interesting type 1 cases that Dr. Freund showed involved a patient who presented in September
`2006 with type 1 CNV and geographic atrophy in one eye and geographic atrophy without neovascularization in
`the other. He described how he treated the eye with CNV for 30 months, increasing vision in that eye by one line.
`However, the eye that did not have neovascularization had a more rapid progression of geographic atrophy and
`vision loss over time. “This is something that I've observed in other cases,” Dr. Freund said. “It's suggestive that
`type 1 neovascularization may actually serve a role in protecting the RPE and the outer retina.” He cautioned that
`aggressive treatment approaches in which the goal is to eradicate the CNV, such as combining anti-VEGF therapy
`with verteporfin PDT or radiation, could theoretically accelerate atrophy over the long term.
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`Retinal Physician - Fine-Tuning Your Anti-VEGF Injection Protocols
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`Finally, he discussed a variant of type 1 lesions, polypoidal choroidal vasculopathy (PCV) (Figure 6). Dr. Freund
`said these lesions are important particularly because they sometimes do not respond well to anti-VEGF therapy.
`He detailed a case of PCV, noting that increasing lipid exudation while on anti-VEGF treatment was often an
`indicator of PCV.
`
`Figure 6. Polypoidal choroidal vasculopathy.
`
`Dr. Freund then turned to type 2 lesions. “These are aggressive lesions,” Dr. Freund said. “They're destroying
`photoreceptors quickly. It's important to treat them early.” Dr. Freund pointed out that, if treated early, some type 2
`lesions appear to revert to type 1 status, provided they have not grown too large and the surrounding RPE is still
`healthy. In general, because type 2 lesions have eroded through the RPE, there is a greater risk of subretinal
`hemorrhage and rapid photoreceptor damage when they develop recurrent exudation.
`
`Turning then to type 3 lesions, Dr. Freund presented the controversial thesis that most type 3 lesions develop
`directly from type 1, nodding again to Dr. Gass, who he believes “got this right without the benefit of OCT.” He then
`showed examples of type 3 lesions, detailing retinal choroidal anastomosis in one patient, which, Dr. Freund said,
`“typically persists unless you catch them very early.” He also showed a case with retinal choroidal anastomosis
`that, like many of these eyes had a disappointing visual result due to a wide swath of lost photoreceptors present
`at the site of the anastomosis and antecedent exudation.
`
`The last part of Dr. Freund's presentation dealt with what he called “outer retinal tubulation” (ORT), which he
`introduced as a non-neovascular lesion component. He showed OCT images of eyes with ORT in which it
`appeared that a damaged photoreceptor layer rearranged itself into tubular structures resembling either subretinal
`fluid or cystoid macular edema depending on how the OCT B-scan cut through the area of involvement. Dr. Freund
`suggested that, in cases such as these, C-scans may be superior to B scans in showing the extent of this
`pathology. “So the take-home message with ORT,” Dr. Freund concluded, “is that, if you're using a prn dosing
`regimen in which retreatment is based on the presence of fluid, then look for ORT as it does not appear to
`correlate with neovascular activity.”
`
`PRAVIN DUGEL ON ABC ANALYSIS
`
`Your practice as a retinal physician has changed dramatically over the last four or five years. But how do you know
`whether it's still as profitable? This was the subject of a talk by Pravin U. Dugel, MD, at the Retinal Physician
`symposium in March. Dr. Dugel suggested a way to assess the profitability of new techniques and procedures:
`activity-based costing, or ABC analysis.
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`Retinal Physician - Fine-Tuning Your Anti-VEGF Injection Protocols
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`ABC, he explained, is a three-step process: (1) Identify the main activities as separate profit-loss centers; (2)
`Assign time and resource value to each of these activities; and (3) Determine the total dollars per unit cost of each
`activity (Figure 7). Dr. Dugel presented data from an ABC analysis conducted at his own practice, Retinal
`Consultants of Arizona in Phoenix, where he is managing partner.
`
`Figure 7. Principles of ABC analysis.
`
`The years Dr. Dugel chose for analysis were 2005 and 2007, because they were before and during the ubiquity of
`anti-VEGF therapies, respectively. Dr. Dugel's first observation was one shared by the audience: Traditional
`services provided for decades have been replaced by nontraditional services (Figure 8). “But in the end,” Dr.
`Dugel said, “it seemed to turn out OK because my revenues had increased by 42%.” However, Dr. Dugel also
`discovered that his operating costs had increased by 64%, leaving him with a profit margin decrease of 14%.
`
`Figure 8. Distribution of physician activities in 2007.
`
`Lest anyone think that the drug cost of intravitreal injections was the key reason for this loss, Dr. Dugel reported
`that at the time of the analysis his office was using ranibizumab exclusively and, at that time, he had a 100%
`collection rate, and reimbursements were higher than they are now. It was what Dr. Dugel called “the best-case
`scenario” for potential profitability.
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`Retinal Physician - Fine-Tuning Your Anti-VEGF Injection Protocols
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`“Now realize that this has no bearing on ranibizumab or bevacizumab,” Dr. Dugel urged. “It doesn't really matter
`what you use. You could use water. It's the infrastructure that matters.” That being kept in mind, Dr. Dugel wanted
`to find out why his profit margin had decreased despite an increase in collections. So he conducted ABC analysis.
`“This is not an easy thing to do,” he said. “It's extremely painstaking. It's also very, very detailed, and you really
`have to be committed to doing this.”
`
`Dr. Dugel and his associates looked at each service provided, the place it was provided, how much time was
`spent, and several other variables in conducting their ABC analysis. For instance, one variable Dr. Dugel
`examined was contribution margin. He found that for every dollar that came into his practice, 40 cents came from
`doing vitrectomies, 51 cents came from laser photocoagulation, and 16 cents came from intravitreal injections.
`“But almost everything else,” Dr. Dugel noted, “lost me money — including office visits, OCTs, and and fluorescein
`angiograms.”
`
`Dr. Dugel also discussed his efficiency ratio, which he described as profit divided by revenue. For every dollar
`invested in vitrectomies, he got back 37 cents. Laser photocoagulation yielded 47 cents per dollar invested and
`injections 27 cents.
`
`The conclusion is that, in Dr. Dugel's practice, over two years, traditional services that were more profitable were
`replaced by newer services that are less profitable. Dr. Dugel stressed the importance of not only understanding
`our current economic situation, but also the importance of being able to adapt rapidly to forthcoming changes in
`reimbursement and technology.
`
`“If reimbursement declines for intravitreal injections,” Dr. Dugel continued, “profits will decline accordingly. A 20%
`decrease in intravitreal injection reimbursement would lead to a decline in total profits of 12%, if my practice does
`not adapt. Similarly, if total reimbursement was lowered by 22.5%, my overall profit margin would decrease by
`almost 100%. Most interestingly, when we do find a drug or device to reduce the frequency of treatment, which we
`are all trying to do, the consequences are alarming if I do not rapidly adapt my practice. For instance, if we find a
`drug or device that requires administration every three months, my profit margin will decline by 80% … if every six
`months, then my profit margin will decline by over 100%.”
`
`Again, Dr. Dugel reminded the audience that it was not the procedures that are inherently the problem; rather, it's
`the bloated infrastructure that we currently have to support the treatment burden.
`
`“This is important: ABC is a not a clinical decisionmaking tool,” Dr. Dugel warned the audience. “It is important to
`separate a financial analysis tool from clinical decision making. We will always do whatever is in the best interest
`of the patient … but to do so, we must stay in business. Indeed, our economic house must be in good order for us
`to provide good care.” Noting looming government reimbursement pressures coinciding with new and effective
`treatment modalities that are forthcoming, he said, “Unless my practice is able to utilize scientifically valid tools to
`accurately assess our current economic situation and position ourselves for the rapid change that a new treatment
`modality will bring, our financial viability is likely to be threatened.”
`
`To those who would think their own practices immune to these trends, Dr. Dugel offered two examples: Dr. Tim
`Murray's academic practice at Bascom Palmer Eye Institution and Dr. Paul Tornambe's private practice in San
`Diego. “We now have done the ABC analysis on three very different practices that, in my opinion, represent most
`of the the retina practices in the US. Bascom Palmer represents a large academic practice, Dr. Tornambe's
`practice represents a smaller, medically oriented two-person practice, and my practice is a very high volume,
`eight-person, surgically oriented practice. Remarkably, the results of all three very diverse practices are absolutely
`consistent,” Dr. Dugel said.
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`Dr. Dugel followed-up this talk with a presentation of data from the MERITAGE study, using Neo Vista's Epi-Rad
`brachytherapy device for patients with persistent fluid following anti-VEGF treatment for exudative AMD. A full
`article on this study can be found in the May 2009 issue of Retinal Physician.
`
`LOOKING AHEAD
`
`Next year's Retinal Physician Symposium, the sixth annual event, will be held again in the Bahamas April 21 to 24.
`More information on the symposium can be found in the article 'Re-Flow Strategy With 25-g "One Pars Plana Port"
`Technique: Personal Strategy for Vitreoretinal Surgery' of this issue. RP
`
`Retinal Physician, Issue: October 2009
`Table of Contents
`Archives
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