18 Dec "Cross My Heart, Hope to Die, Stick a Needle in My…"
I give intravitreal eye injections everyday!
It is one of the most rewarding things I do!
And they come back for more! My patients love it because anti-VEGF injections usually work really well, especially if the wet form of macular degeneration is caught early.
Suspicion Confirmed When I examine a patient and suspect that a patient has wet macular degeneration, I’ll usually confirm the diagnosis by performing a fluorescein angiogram. Once confirmed, I’ll usually recommend intraocular treatment with Avastin. I have not used Macugen in about 3 years and only occasionally use Lucentis.
First Injection I usually discuss the whole procedure of delivering an intraocular injection and reassure everyone that it is a painless event. Prior to the actual injection, as I described in a previous post, antibiotic drops are to be used and a second prescription is given for the Avastin. The Avastin is prepared for us by an adjacent compounding pharmacy (a specialty pharmacy that breaks up the Avastin into smaller doses for ophthalmic use).
Series of Injections My usual practice is to commit to 3 treatments given every 6 weeks. After this short series, we reassess and determine if more injections are necessary. Some docs may give injections as frequently as every 4 weeks “come he** or high water.”
More……….please? Aissa and Dick, my teammates, can tell as soon as a patient walks through the door if the injections are working. They are ecstatic. They smile, they bounce, they can’t wait for the next injection! In general, the better the vision, the more aggressive I am at recommending additional injections. If we aren’t getting the visual results we had hoped, then maybe I’ll be less emphatic. So, after the first 3 shots, I’ll recommend more if there continues to be improvement. The additional shots decrease the chance of recurrence…..we think.
No More Needles! This can be good news or bad. I’ll recommend stopping the injections if I don’t expect any more improvement, or, we never improved at all. In this latter case, we are giving up and throwing in the towel. Sometimes the disease wins!
Shot Holiday After we stop injections, I warn that we are looking for signs of recurrence. Initially, I’ll usually see patients every 6 weeks and then less frequently if there are signs of stability. Any time I suspect that there is recurrence, or if there is a decreased vision or distortion, I’ll obtain a fluorescein angiogram to confirm recurrence. The fluorescein angiogram is the best test for this.
An OCT (Optical Coherence Tomography) is another test that is commonly used by retina specialists. In this scenario, it is usually used to detect swelling, or leakage, presumably from the neovascularization. It can not, however, actually confirm active neovascularization. It is used to monitor progress of the treatment.
What Does This Mean? This is how I “roll.” There are lots of variations to this regimen, but most retina specialists practice pretty similarly. Basically, we treat to seek improvement, then monitor for signs of improvement. This is truly one of the most rewarding things I do! Before injections (including PDT – see section on macular degeneration), we offered little hope of improvement from this blinding disease. The ability to change the natural course of this disease is miraculous!