Patient Advocacy Treatments

Avastin is Safe | Study Shows No Link to Infection

Avastin is SafeAs reported this week in Jama Ophthalmology , the chance of contracting endophthalmitis from Avastin is no different than with the case of Lucentis.

Both are equally safe.

Several outbreaks of endophthalmitis (infection inside the eye) have occurred over the past few years questioning the safety of Avastin vs. the practices of compounding pharmacies.

What are Compounding Pharmacies?

A compounding pharmacy is NOT Walgreen’s, CVS or Rite Aid.

Compounding pharmacies can make, or “compound.” individualized specialty medications.  In the case of Avastin,  a compounding pharmacy will purchase large amounts of Avastin and divide them into smaller doses for use by retina specialists.

Both a compounding pharmacy and a pharmaceutical company are responsible for packaging and distributing drugs using approved sterile techniques.

Avastin is Repackaged

Avastin is only supplied in massive doses from the manufacturer.  As Avastin is an FDA approved anti-VEGF treatment for certain types of cancer, it is distributed only for chemotherapy treatments.  Genentech, the manufacturer, does not sell the smaller doses used for intravitreal injections (IVT).

Compounding pharmacies purchase the Avastin and re-package the drug in smaller doses for sale to the ophthalmologists.

Lucentis is Directly Shipped

In contrast, Lucentis is sold directly from Genentech to the practicing retina specialist.  As Lucentis is FDA approved for eye treatments, the Lucentis is manufactured, packaged and shipped directly to the ophthalmologist.

In 2011, an outbreak of endophthalmitis caused concern over the practices of compounding pharmacies.  Similar suspicions developed in 2012 over an outbreak of fungal meningitis – caused by contaminated steroid injections, but processed at a compounding pharmacy.

In 2013, the FDA released the Compounding Quality Act offering guidelines to reduce the chance of endophthalmitis.

Study Shows Avastin is Safe

The retrospective study just published in Jama Ophthalmology compared the rates of endophthalmitis between Avastin and Lucentis from 2005 to 2012, in essence, studying the two drugs BEFORE the Compounding Quality Act was created.

The authors found that there was no statistical differences in the rates of infection!  In other words, Avastin itself, does not cause infection.

What Does this Mean?

Historically, the threat of blinding infection (endophthalmitis) is the biggest concern with administering intravitreal injections (IVT).  It doesn’t matter if we are injecting Avastin, Lucentis, Ozurdex, etc.

In 2011, 12 cases of endophthalmitis were reported to have occurred in Florida.  Though all the injections emanated from the same compounding pharmacy, it questioned whether it was the Avastin versus the pharmacy itself.

Similar concerns were noted in cases of endophthalmitis from a compounding pharmacy in Tennessee.  Finally, an outbreak of meningitis, causing many fatalities, was linked to contamination from a single compounding pharmacy.

This study should alleviate concerns over use of Avastin causing blindness from endophthalmitis.  Concerns over the cause of endophthalmitis are limited to the  practices of the compounding pharmacies and not to the actual drugs.

Patients should find relief as Avastin continues to provide excellent treatment results from diseases such as macular degeneration and diabetic retinopathy.


My Opinion Patient Advocacy

How to Find the Best Retina Specialist | Patient Advocacy

How to find the best retina specialist, Randall Wong, M.D., Retina Specialist, Fairfax, Virginia 22031How do you find the best retina specialist?  (In fact, how do you find the best doctor?)

Remember that for me to become a retina specialist, I had to sub-specialize after completing general ophthalmology training.

As a physician and retina specialist in Fairfax, Virginia, even I don’t know how to go about answering this question.

Education of the “Best Retina Specialist”

An easy place to start might be the places of higher education; college and medical school.   Entrance to medical school from one of the thousands of colleges or universities depends upon many variables;

  • caliber/quality of undergraduate curriculum
  • GPA (grade point average)
  • Medical College Admission Test (MCAT) scores
  • Interviews

Having gone through the list, the criteria for admissions to medical school, regardless of curriculum, is based upon selecting the most “qualified” students to succeed with the medical school curriculum – heavily based upon academic success in basic sciences.

Getting into and graduating from medical school simply says that graduates are the smartest of the smart – they did the best in undergraduate studies and passed a rigorous medical education curriculum – of course work.

Smart, but what we are in search of the best retina specialist.

Residency in Ophthalmology

After graduating from medical school, I completed a 1 year “internship” in general internal medicine.  This is required and gave me the first responsibilities as a full-fledged “M.D.”  This was followed by my residency in ophthalmology.

This additional residency gave me the necessary training to become a specialist – an ophthalmologist.

I completed a residency in ophthalmology.  As an ophthalmology “resident” I serve as an apprentice to older, practicing ophthalmologists.

Matriculation to residency is based upon grades in medical school and recommendations from medical school staff.  Matriculation to residency becomes less objective compared to entrance to medical school.

Differences between residency programs?  Not sure, but they are usually a result of polls/questionnaires of all the other residency program directors in the country.

Best Retina Fellowship Training

For completion, for me to become a retina specialist, I needed more training to become a retina specialist.  This last phase of training was based upon recommendations from my residency program.  There is no test to become a retina specialist.

To be continued……..


Randall V. Wong, M.D.
Retina Specialist
Fairfax, Virginia 22031



Patient Advocacy

Eye Specialists in Ophthalmology | Patient Advocacy

Randall Wong, M.D., Retina Specialist, Fairfax, Virginia, 22030There are 8 defined “sub-specialties” in ophthalmology.  I’m defining these by the 8 different areas that exist to train doctors after finishing residency in ophthalmology (basic training if you will).  These “fellowships” offer additional training in branches of ophthalmology and allow us to become sub-specialists.

I am an ophthalmologist and “sub-specialize” in retinal diseases.  Thus, my practice is limited to retinal diseases such as retinal detachment and diabetic retinopathy.

Core Training for an Ophthalmologist

Here’s a typical timeline for becoming an Ophthalmologist;

  • College (4 yrs.)
  • Medical School (4)
  • Internship (1)
  • Residency (3) (General Ophthalmologist)
  • Fellowship (varies) (Sub-Specialists)

In the United States, all of us must complete 4 years of medical school after graduating from a 4 year undergraduate program.  There are a few programs left in the U.S. where students complete both undergraduate and medical school in a combined 6 year program, but these programs are dwindling.

Before starting ophthalmology residency, we are required to complete an internship.  This may be in any primary field (e.g. Internal Medicine, Surgery) and is hospital based, that is, we work in the hospital for one year.  My internship was in internal medicine.

Most ophthalmic residencies are 3 years.  We learn the practice of ophthalmology usually in large hospital centers where patients abound.  When residency is completed, most of us enter private practice and practice “General Ophthalmology.”

A general ophthalmologist can treat all sorts of eye problems:  cataracts, most types of glaucoma, prescribe glasses, prescribe medications, perform laser refractive surgery, treat dry-eye, etc.

Fellowship training is completely optional.  Fellowship training allows us to further “sub-specialize” in an area of ophthalmology.

BTW – the terms I’m using (intern, resident, fellow) are standard through American medical schools.  Other disciplines in the related health fields use the terms differently.

Ophthalmic Specialties

Based upon the system described above, there are 8 sub-specialties of ophthalmology, that is, there are 8 different types of fellowships available after general residency is completed.

The sub-specialties available in the United States:

  1. Cornea
  2. Glaucoma
  3. Retina (yeah!)
  4. Pediatric
  5. Neuro-Ophthalmology
  6. OculoPlastics
  7. Pathology
  8. Oncology

Fellowship training allows us to focus only on those diseases which interest us.  For example, I knew I had no interest in performing routine eye exams and cataract surgery, yet diseases and surgery of the retina fascinated me.

As a retina specialist, I see patients only with diseases of the retina and vitreous (such as those diseases found here on this website).  I do not see “general” patients and while I am qualified to perform cataract surgery, write eyeglass prescriptions, etc., I only perform retina surgery.

What Does This Mean?

We probably have more specialists in the United States than anywhere.  As a result, the level and sophistication of medicine available to the general public is just as complex and sophisticated – one reason we provide some of the best healthcare in the world.

As a sub-specialist, I spend my day seeing patients with types of diseases I find interesting.  As a retina specialist, however, my staff and I can’t take care of the everyday types of problems, such as; eye glass prescriptions, dry eyes, allergies, etc.

As a result, most of my patients  have already been seen by a general ophthalmologist or optometrist FIRST, before being referred to me.

It’s a system which requires more doctors visits, but ultimately, the best care.

In more rural areas of the country, you’ll find the “general ophthalmologist” is better versed to handle a broader range of eye problems because;

1.  There are fewer sub-specialists to refer patients.
2.  The distances patients must travel can be formidable.



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