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Symptoms of Macular Degeneration | Randall Wong MD Retina Specialist

Signs and Symptoms of Macular Degeneration

is the deterioration of the central portion of the retinathe macula, which is the area of the retina that controls visual acuity and color perception. Macular degeneration usually occurs in people over the age of 55 and is more common in people of northern European ancestry.

Symptoms of Macular Degeneration

The most common symptoms of macular degeneration are blurry vision, blind spots, and distortion.  

New distortion should always be examined and can be monitored at home with the use of the Amsler grid.

Blurriness, blind spots, and distortions are also common symptoms in the following eye diseases:

  • macular edema (swelling) from many causes
  • epiretinal membrane
  • macular hole
  • diabetic retinopathy

Distortion is a common symptom of a disease of the macula and is does not signify a particular disease (i.e. get examined).

The Macula

The macula provides our central “20/20” vision.  As you are reading this article, your eyes are moving to keep the text focused on your macula.  When you are staring at an object, you are focusing the object on your macula.

Macular degeneration can be wet or dry and both types progressively affect the central vision causing blurriness, blind spots, and distortions. However, the wet form causes more serious vision loss.

Retinal Degeneration

For reasons yet to be discovered, the macula degenerates with age.  There are probably environmental risk factors, such as smoking, which increases the chances of developing macular degeneration.

The vast majority, 90% of cases, are the dry variety, which causes very slow, yet progressive blurry vision.  Wet ARMD causes the development of abnormal blood vessels within the layers of the macula.  These blood vessels cause destruction of the normal retinal tissue and can leak fluid and bleed.

Regardless of the type of macular degeneration, the initial symptoms are the sameblurriness, blind spots, and distortion.  However, wet macular degeneration can destroy vision rapidlyin days or weeks.  

What Can You Do?

If you have symptoms such as persistent blurry vision, blind spots, and/or distortion, make sure you get a complete dilated eye examination. 

While there are many causes of blurry and distorted vision other than macular degeneration, you want to make sure that you get an early diagnosis so whatever eye condition is causing your visual symptoms, the proper treatment can be initiated early in the process.  

Early diagnosis and treatment of eye diseases may prevent or limit permanent vision loss.

 

Drusen and Macular Degeneration

Do Drusen Diagonse Macular Degeneration?

The simply answer is, no, not all patients with drusen have macular degeneration. Drusen can be associated with macular degeneration, but are not diagnostic of the disease.

In other words, a person can have drusen AND macular degeneration which means that the two conditions are associated because they can occur together, but the presence of drusen by themselves without other signs or symptoms does not mean macular degeneration is going to occur or is in the process of occurring.

What are Drusen?

Drusen are spots (lesions) that form in the layers of the retina. There are two types and can be “hard” or “soft.” based upon appearance.   The presence of a few small drusen is normal with advancing age.

Drusen can be found anywhere in the retina.  When they are located outside the macula, they are usually of no consequence and are not related to any disease, especially macular degeneration.  I am only concerned when they are located within the macula.

Unfortunately, most non-retina doctors do not mention that drusen away from the macula are of little consequence and can simply be a family trait.

When Should Macular Degeneration be Diagnosed?

Let’s take the scenario of a patient having only hard drusen and no other signs of macular degeneration such as pigment changes, fluid, or blood.

Is there vision loss?  If there is vision loss, the next thing I do is determine if there are reasons for it other than macular degeneration, such as cataracts.

When a patient has no vision loss or a loss of vision that is explained by something such as cataracts, I do not necessarily diagnose macular degeneration.

I know that many doctors DO diagnose macular degeneration every time they see drusen, and in my opinion, this is not correct or fair. Unnecessarily pronouncing this diagnosis to patients causes many people worry, anguish, and stress as they wait to go blind from a disease they do not have.

Best Test for Macular Degeneration Diagnosis

If there is any question about the diagnosis of macular degeneration, have your doctor order a fluorescein angiogram.

A fluorescein angiogram (FA) is the best test for a definitive diagnosis of  macular degeneration (ARMD).  The test is performed by a retinal specialist and each eye is injected with a dye (not iodine based) called fluorescein.  As the fluorescein dye travels through the retinas, pictures are taken which help the retinal specialist diagnose or rule out macular degeneration.

In cases of a positive diagnosis for macular degeneration, a fluorescein angiogram will also distinguish between wet ARMD and dry ARMD, so that the proper treatments can be undertaken as soon as possible.

All the best,

Randall Wong, M.D.
Retina Specialist
Fairfax, Virginia 22030

Eye Examination for ARMD: Macular Degeneration

When You Need Eye Exam for Macular Degeneration.  Randall Wong, M.D., Retina specialist, Fairfax, Virginia.Routine eye examinations for macular degeneration in patients without symptoms are probably not necessary.

Unlike conditions such as diabetic retinopathy, where the disease is likely to occur  yet still be asymptomatic, macular degeneration is not “silent” and does have associated symptoms.

Once diagnosed with macular degeneration; however,  routine examinations are important.

Family History Does Not Matter

While it is true that patients of northern European descent have a greater chance of developing the eye degeneration, brothers and sisters and children of patients with the disease are not necessarily at any higher risk.

For example, if I contract the disease, my twin brother is not necessarily going to get the disease.

Vision Must “Degenerate”

The most common symptoms of macular degeneration are decreased vision (e.g. blurry vision) and/or the development of distortion.  Both signify a change in vision.

Without a change in vision, that is, if your vision remains 20/20 it is unlikely you have ARMD.

Signs vs. Symptoms of ARMD

Signs of a disease are those things we, as doctors, see or find during an examination. If you have no  signs of macular degeneration, you do not have it.

For instance, drusen and pigment changes in the retina are common signs, or findings, of dry macular degeneration.  Fluid, edema and blood are common findings of wet ARMD.

Pigment changes, fluid and blood may cause blurry and distorted vision….symptoms (subjective, what the patient experiences) of macular degeneration.

Often, patients are diagnosed with drusen.  Drusen alone, especially without loss of vision, do not make the diagnosis of macular degeneration.

Advancing Age and Macular Degeneration

The National Eye Institute has a nice review of macular degeneration.  The incidence of developing macular degeneration does increase with age.  This means the chance of getting the disease does increase with age, but not without signs and symptoms.

What Does This Mean?

In short, unlike diabetic retinopathy, a disease that may develop without symptoms,  you can safely monitor yourself for any symptoms of the ARMD, regardless of ethnicity, age or family history.

If you develop symptoms of decreased vision or if you develop decreased vision you should get an eye exam.  Often, patients are directed to test themselves with an Amsler Grid.  This is a simple way to monitor changes in your vision.

If you have signs of the disease, for example, drusen and changes in the retina, you might ask your doctor about getting examinations on a routine basis.  This will be more important in the future if/when we discover changes in our diet or behavior (i.e. quitting smoking) alter the course of developing the disease.

If you have neither symptoms nor findings, you most likely require exams periodically as directed by your doc.

 

Eylea As Good As Lucentis

Last month, the FDA approved Eylea (VEGF-Trap, aflibercept) for the treatment of wet macular degeneration.  The new drug does not need to be injected as often as Lucentis, yet it seems that the visual improvement is the same; that is, fewer injections yield similar improvement in vision…for the first year of therapy.

Keep in mind that we are always interested in a drug’s ability to improve vision, and sustain these improvements.

Eylea Improves Vision and is Sustained

This week, results from patients receiving these eye injections for a second year were reported.  It was disclosed that little benefit was seen between the two drugs for the second year of treatment, i.e. the visual results were sustained and comparable.

During the second year of treatment, both drugs were given “as needed” in contrast to the first year with regimented dosing;  monthly injections for Lucentis and bimonthly for Eylea.

Stock Drops After News

Regeneron’s stock (Regeneron manufactures Eylea/aflibercept) apparently plummeted after the news.  Wall Street seems disappointed that the the new drug may not be as cost effective nor as convenient as initially hoped.

What Does This Mean?

I think this validates the new drug.  The study confirms that visual improvement is indeed achieved with Eylea and is also maintained.

Clearly, I expect that Eylea will yield the same visual results over the first year of treatment, yet requiring fewer injections.  This means fewer trips to the doctors, fewer diagnostic texts, fewer rides from family and friends.

The data recently presented only confirms that Eylea works.  Remember, few drugs, including Lucentis, are actually used in the same fashion as when they were FDA approved, that is, we should be happy that Eylea improves vision for the 2nd year…nothing more.

More convenience, equal results, cost savings (from fewer office visits) can be translated into improved compliance (patients willing to continue treatment) and that also means MORE patients may be willing to undertake treatment!

This is exciting!

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October is the AAO Meeting

We are leaving for Orlando, FL in a few days to attend the American Academy of Ophthalmology meeting.  It is our industry’s largest meeting of the year…worldwide.

The meeting has become so large that only a certain cities can host the event;  Atlanta, Dallas, Chicago, San Francisco, Las Vegas, New Orleans and Orlando.  Literally tens of thousands of people will attend;  doctors, administrators, technicians, vendors, etc.

This will be the largest collection of eye related people anywhere in the world.

New scientific discoveries will be announced, new products for patients will be displayed, advanced technology will be highlighted, and hundreds of courses will offered. It’s a huge showcase for anyone related to “eyes.”

We, too, are going to launch MME.

Iluvien Has New Data for the FDA

It is anticipated that Alimera will announce successful completion and submission of some long-awaited data to the FDA.

Alimera Sciences has been trying to obtain FDA approval for a sustained intraocular drug delivery system called Iluvien.  This is similar to Ozurdex (Ozurdex is used for the treatment of retinal swelling due to vein occlusions).

Iluvien will release steroids inside the eye for a period of months to control diabetic macular edema.  It is anticipated that this last bit of data will satisfy the FDA and prove that it is indeed safe and effective.

Stay tuned.

Treatment of Macular Degeneration

I don’t think there will be any earth shattering news in this field. VEGF-Trap Eye is probably going to get some press as this is another drug that promises to be quite effective in the treatment of wet macular degeneration.

VEGF-Trap Eye, or afilbercept, is a compound similar to Avastin and Lucentis, but may need to be injected less often than the aforementioned.

Medical Marketing Enterprises

This is our baby.  Amy and I are very excited.  We will be teaching no fewer than 4 courses on medical marketing using websites, blogs, SEO and social media.  There are only about 10 courses offered in total!

I have been invited to address the “Young Ophthalmologists” about marketing.  This group is comprised of young doctors who are still in training (aka residents, fellows) or those who have been in medical practice fewer than five years.

What Does this Mean? I’ll be wearing several hats this time.  I’ll be wandering the floors and attending lectures to learn more about being a retinal specialist.

On the other hand (or under another hat), Amy and I’ll be teaching other doctors how they, too, should create websites such as this to enhance patient education, improve the Internet, and provide marketing solutions.

 

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Implantable Telescope is Available!

CentraSight Now Available, CMS to reimburse for implantable telescope to treat macular degeneration

CentraSight, the implantable telescope for macular degeneration, is now available! CMS (Centers for Medicare and Medicaid Services) has approved the telescope for those patients with macular degeneration meeting the eligibility criteria for the surgical procedure.

Medicare/Medicaid will cover the cost of the implant and the surgery in certain patients as October 1, 2011! For now, the procedure has a designation of a transitional pass-through payment, that is, CMS will approve the procedure for 2-3 years until enough payment data can be collected.

The Telescope Improves Vision

To achieve this milestone, Visioncare, the parent company, needed to show that the implantable telescope for macular degeneration met several criteria;

  • FDA Approval
  • CMS deems reasonable and necessary
  • Device offers Substantial Clinical Improvement

FDA Approval: VisionCare received FDA approval for their telescope last August.

Substantial Clinical Improvement may be difficult to attain as the device must surpass some steep challenges.  In order to achieve this status, one of the following situations must be true;

  1. the new device must be better than other available treatments
  2. the device improves the ability to diagnose a condition
  3. the device significantly improves the patient (i.e. clinical outcomes)

Availability of the CentraSight Telescope

For now, according to my contact at VisionCare, CentraSight will be offered at the locations where the original clinical trials were performed.  This has been their plan all along.  With time, as more physicians become trained, the availability will widen.

What Does This Mean? This is the first real step to helping patients with significant visual loss in both eyes.  The surgery to insert the “telesope” is similar to cataract implantation, yet the CentraSight will modify the images so more of the retina surrounding the macula is utilized for vision.

While patients with either form of the disease might be candidates, this is the first FDA sanctioned “therapy” for patients with severe loss of vision from dry ARMD.

This is not a cure or a “fix” for loss of central vision, however, the telescope does improve function for those that have no central vision from the disease and can lead to am improvement in the quality of life.

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Avastin Does Not Cause Infection

One of the most feared complications of eye injections is blindness.  This infection is called endophthalmitis.  Last week the FDA issued an alert the 12 cases of endophthalmitis were caused by the injections.

The cause of the infections is NOT Avastin.  There is nothing wrong with the drug itself.

Avastin Must Be RePackaged

Upon further investigation, a common denominator was a single pharmacy and, possibly, a single lot of tainted syringes.

Avastin is not FDA approved for injection into the eye, but it is standard of care.  Also, Genentech manufactures Avastin and its close cousin, Lucentis.  Lucentis is FDA approved for the treatment of wet macular degeneration.

Thus, in order for physicians like me, to get Avastin, a larger dose of Avastin is ordered.  Once received the “repackaging” of the ARMD drug involves breaking up the larger dose (usually used for chemotherapy) into many more smaller doses for the eye.  The doses are commonly broken up and placed in small syringes ready for injection.

“Repackaging” sounds kind of haphazard, but it’s not.  A licensed pharmacist will distribute the Avastin in smaller allotments under strict sterile conditions.  There are specific protocols for such “repackaging.”

Compounding Pharmacies Routinely Divide Drugs

Apparently, in one particular pharmacy, either the protocol was breached and/or the sterile laboratory conditions were not maintained and they shipped out a few contaminated syringes.  Unfortunately, this caused 12 individuals loss of vision or blindness.

Fortunately, there was a plausible explanation and widespread panic was avoided.

Avastin, itself, is safe.  The mechanisms used to deliver the drug to your doctor’s office are proven safe, too.  Realize that over 2 million injections have been given.

What Does this Mean? Normally, informed consent is obtained prior to the delivery of an injection.  We inform the patient that there is a risk of infection that could lead to blindness.  That risk is estimated to be about 1:1000 to 1:2000 (approximates the risk of cataract surgery).

The source of the infection is thought to be the bacteria that reside on your eyelashes and the surface of the eye, not the actual substance injected nor the container in which it was shipped.

In the end, this was a very rare and unfortunate event for the 12 patients, their families and their doctors.  The culprit; however, was not Avastin.

 

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FDA Delays Decision on VEGF Trap Eye

VEGF Trap-Eye was not approved by the FDA for the treatment of wet macular degeneration.  The parent company, Regeneron, was hopeful to gain FDA approval last week, but the FDA delayed its decision until November of this year.

VEGF Trap-Eye Treats Wet Macular Degeneration

VEGF Trap-Eye, or aflibercept, is another anti-VEGF drug formulated to treat wet macular degeneration.

Like its competitors, aflibercept is designed to neutralize the effects of the Vascular Endothelial Growth Factor a key component in the pathway of wet macular degeneration.  It, too, will be administered as an injection into the eye as are Lucentis and Avastin.

If you recall, Lucentis is FDA approved for wet macular degeneration.  Avastin is not FDA approved, but is commonly used by retinal specialists, hence, it has become the standard of care.

Fewer Injections into the Eye

Unlike its competitors, aflibercept may be injected less frequently than its competitor, Lucentis.  Instead of monthly injections, VEGF Trap-Eye may be injected every 2 months!

What Does this Mean? There is a potential new drug near FDA approval for the treatment of wet macular degeneration.

Assuming that Eylea (the proposed trade name) is just as effective as Lucentis, there are two particular advantages to the new drug:  cost and frequency of administration.

Eylea will be the third drug to be used for wet ARMD, but only the second that is FDA approved (Lucentis is FDA approved, but Avastin is used “off label”).  It is conceivable that that Eylea will be priced between the two drugs…

Fewer injections means fewer office visits, fewer complications and this means….cost savings (thus an argument to increase the price compared to Lucentis!).

Personally, I think there is room for a drug that doesn’t have to be given monthly.  There are substantial savings to realize;  costs in terms of office visits, costs of injections and the intangible costs…the costs involved to have a family member or friend accompany the patient…

 

 

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Stem Cells for Stargardt's Macular Dystrophy and Macular Degeneration

RPE Transplantation for Stargardts Disease

 

Advanced Cell Technology recently announced the beginning of their landmark trial where stem cells are transplanted into patients with Stargardt’s Macular Dystrophy (aka Stargardt’s Disease) and dry macular degeneration.

Clinical Trials for Stargardt’s Begin

The company announced that their phase I/II clinical trials started in mid-July with one patient each of either Stargardt’s or macular degeneration.  Each patient received a relatively small dose of cells and subsequent patients will receive larger amounts of cells.  The first patients received about 50,000 cells.

The goal of the study, at this phase, is to test the safety and tolerability of the stem cell treatment over a 12 month period, that is, phase I/II will answer the question as to “how safe is the procedure?” and will also asses if this is a viable way to transplant stem cells.

Retinal RPE Cells are Replaced

The cells to be replaced are called RPE (retinal pigment epithelial) cells and are located underneath the top layer of the retina.  If you liken the retina to be an open faced sandwich with a slice of ham with cheese on top, the RPE cells are the slice of ham.  The “rods and cones” (otherwise known as photoreceptors) are located on the underside of the cheese.  The RPE cells nourish the photorecptors.

In cases of Stargardt’s disease and dry macular degeneration, the faulty RPE cells can no longer nurture, or feed, the photoreceptors, hence, the loss of vision.  It is hoped that by replacing the sick retinal pigment epithielial cells with stem cells, the vision can return.

What Does This Mean? This is really promising and exciting news.  On the horizon is the potential for a true “fix” for two of the most common forms of “blindness” in the world.  Actually, most of these patients are legally blind as you remember that the macula gives us central vision.  Thus, RPE transplantation should improve the central vision.

In my view, there are two large variables or areas of concern.  First, the actual technique of implanting the cells must be refined and perfected and at the same time, we need to see how long the stem cells can live or remain healthy.

While this is very promising, this may still be years away from becoming a viable treatment option.

Here is further information about patient inclusion into the study for either Stargardt’s Macular Dystrophy and dry ARMD.

 

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offices

Currently, I see patients with retinal diseases; macular degeneration, retinal detachment, macular holes, macular pucker within several different practices.....it's a different arrangement, but it allows more continuous care with many eye specialists. In addition, I am very accessible via the web. To schedule your own appointment, call any of the numbers below.

Virginia Lasik | Office of Anh Nguyen, M.D.
Randall V. Wong, M.D.
Contact: Layla

A: 431 Park Avenue, Suite 103 • Falls Church, Virginia 22046
Ph: 703.534. 4393
F:703.992.8158
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Dressler Ophthalmology Associates, PLC
Randall V. Wong, M.D.
Contact: Ashley (Surgery/Web)
Chrissy Megargee (Web)

A: 3930 Pender Drive, Suite 10 • Fairfax, Virginia 22030
Ph: 703.273.2398
F: 703.273.0239
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