Macular Degeneration Treatments

How Many Lucentis Injections?

How many anti-VEGF injections of Avastin or Lucentis are needed to treat wet macular degeneration?  We don’t know.  While there is no question that anti-VEGF injections are the gold-standard for the treatment of ARMD, the exact way in which they are used varies from doctor to doctor.

Standard of Care

The standard of care for macular degeneration changed.  The standard treatment for wet ARMD was Visudyne and before Visudyne, laser treatment.

Since Macugen, the initial anti-VEGF medication, other accepted standards have evolved including Lucentis and Avastin.

In the medical world, these are still “new” treatments and we are still finding our way.  We are always looking to improve our treatments.

FDA Approval

In short, FDA Approval is needed to get a new drug introduced to the market.  To state another way, FDA approval is needed to make it legal for a company, in the United States, to sell a drug.

Once available on the market, however, the way in which the drug is utilized varies from doctor to doctor.

Testing Serves as a Guideline

When a drug is initially sent to the FDA for approval, careful testing (clinical trials) must be completed proving safety and efficacy of the drug.  The drug company must prove that it is safe in humans and that the drug does what the company claims it does.

For example, in the case of Macugen or Lucentis the treatment protocol used in the study (to prove the drug works)  may have required injections every 6 weeks for more than a year.  During these studies, there is strict adherence to the protocol.  Little variation is allowed.  For instance, every six weeks means every six weeks.  If a patient were to receive an injection other than the 6 week interval, that patient may be removed from the study.

It’s Called Practice

When first introduced, everyone (doctors) followed a very similar protocol.  We followed the protocol that was recommended by the manufacturer.  They can only recommend the protocol approved by the FDA.  That protocol is usually the same one that was included in the original study series.

With time, doctors get familiar with the drug and gain experience using the drug.  Real life situations are not as stringent as FDA studies.  We may find that if  Mr. “Macugen” missed an injection, he does okay anyway.  We may find that Ms. Lucentis can’t get an injection in 6 weeks, but can come in at 5 weeks.

Other studies, not necessarily for FDA purposes, emerge from our academic colleagues that change protocols, too.  Perhaps a study is published from Johns Hopkins purporting great results using injections every week.  Guess what, it’ll change how we practice.

Studies of related products also change how we practice.  For instance, the protocols used for studies involving any of the anti-VEGF medications impact the use of the other drugs.

What Does This Mean?  Treatments vary from doctor to doctor.  The better a treatment, the more variation…in my opinion.  The best treatments are inherently really good and do not require strict methods of employment.

Like a good recipe, a good treatment is hard to mess up.

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Nutrition Treatments

Tree Bark May Be Beneficial To Diabetics: Supplement or Drug?

“Ever Eat A Pine Tree?  Many Parts are Edible.”

That famous line by Euell Gibbons lives on.  Now, “researchers” have described that Pycnogenol®, an extract from the bark  of the French maritime pine tree, has the potential to improve vision in patients with diabetic retinopathy.  The tree is found  along the coast of southwest France.

In a small study involving 46 patients with early diabetic retinopathy, 24 patients were given Pycnogenol tablets daily and the remainder were given placebo (sugar pill).

After 2 months, patients taking Pycnogenol had statistically significant improvement in vision and decreased macular edema.  An increase in retinal blood flow was also noted.  (The standard treatment for diabetic macular edema is laser photocoagulation.)

The researchers think that Pycnogenol (Horphag Research) works by increasing blood flow to the retina that secondarily decreases the diabetic macular edema.  Pycnogenol is said to be an antioxidant, anti-inflammatory and aids in vascular dilation.

CAUTION: What Does This Really Mean?

Pycnogenol is not a drug.  It is a supplement.  There are big differences in the requirements needed to bring a supplement to market vs. a drug.

Pycnogenol is marketed in the United States as a dietary supplement.  As such, the manufacturers of dietary supplements do not have to provide safety and health information regarding their products as long as they do not claim the supplements can prevent, treat, or cure any specific disease.

On the other hand, drug manufacturers must submit health and safety data from carefully designed clinical trials to the FDA before marketing their products.

Lastly, supplements are not necessarily tested to find out if they interact with medicines, foods, or other herbs and supplements. Even so, such data is not necessarily available or provided.

Be careful out there!  There’s a lot of masquerading of supplements.  Be cautious.


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

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Macular Degeneration My Opinion Retina

Tips On Choosing an "Eye" Doctor: A Retina Specialist?

You suspect you might have macular degeneration or diabetic retinopathy.  How do you choose a doctor?

A little while back, I wrote about the differences between eye doctors.  Now that you know the difference between an optometrist and an ophthalmologist, how do you choose which is right for you?  When do you need to see a retinal specialist?

Remember that optometrists and ophthalmologists both completed additional degree training after college.  Both also treat many eye diseases and dispense glasses.   In addition, a retina specialist (yours truly!) is an ophthalmologist that completed yet more training to sub-specialize.  I sub-specialize, as a retina specialist, in treating diseases of the retina such as diabetic retinopathy and macular degeneration.

You already have an “eye” doctor.

Terrific.  Stay with that eye doctor, be it optometrist or ophthalmologist.  If you have no complaints and your exam is normal, then you are in great shape.  Remember, you have already established a relationship with this guy/gal and you want to use it to your favor.  Your eye doctor should have your best interest at heart, that is, if there is a question about some of your symptoms or a question about your exam, you should be “referred.”

If you were just diagnosed with diabetes and already have an eye doctor, you should feel comfortable staying with your present doc.  If you are not comfortable, ask your doctor to suggest a retina specialist.  Keep in mind; however, most retina specialists do NOT prescribe glasses or take care of other eye problems.

Is My Eye Doctor Qualified?

Yes and no.  Both diabetic retinopathy and macular degeneration make the retina “look” different.  So, while the typical optometrist and ophthalmologist may not be able to treat either disease, they should be able to recognize these diseases and refer you to a retina specialist if there is any question.  If the retina doesn’t look normal, most eye doctors will “refer” you.

You Have Symptoms and Are Worried

You have symptoms of blurry vision, have recently been diagnosed with diabetes, have distortion or some other symptom.  Make sure you get examined………… any eye doctor!  If a referral is necessary, see a retina specialist.

Everything you experience is not necessarily diabetic retinopathy or macular degeneration.

When Do I Need to See a Retina Specialist?

Depending upon your level of comfort, if you have no signs of either disease, you might stay with your present eye doctor.  If you are not confident with this person, then ask for a “referral.”

If your doctor diagnosis you with either macular degeneration or diabetic retinopathy, I would suggest referral to a specialist.  You will need to see one at some point any way.  I always advocate the earlier the better.

If you or your doctor feel that you may benefit from treatment, then seek the help of a retina specialist.

Do I Need a “Referral?”

It depends upon your insurance.  Most insurance does not require an eye doctor to refer to another.  You may need a referral from your PCP (primary care provider).  If your insurance does not require a referral, call a retina specialist and make an appointment.  HINT:  Tell the receptionist that you have diabetes or are suspected of having macular degeneration – this should get you in easier.

How Do I Find a Doctor?

Ask your present eye doctor and then check to make sure that the doctor suggested is in your network.  Remember the difference between medical insurance and vision insurance.

If you do not have a doctor, check with your medical insurance for a list of retina specialists.

Group Practice

There are two types of group practices with regard to retina specialists; a single-specialty group of retina doctors, and, a multi-specialty group of sub-specialist eye doctors, including retina.

I would recommend a multi-specialty eye practice that offers a retina specialist.  It is the “one stop shopping” approach, but more importantly, there won’t be hesitation to referring you to the appropriate specialist as you won’t be leaving the practice.

In the end, the best way to preserve your excellent vision and function is to get examined…………by any eye doctor.


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

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Macular Degeneration

Spinach and Carrots – Good for Your Eyes?

There is a lot of confusing information regarding what you should eat for the health of your eyes.  There is still a lot of confusion about proven supplements that may affect the rate of progression of macular degeneration.

Previous posts included information about the results of AREDS 1, Omega 3 Fatty Acids and their ability to slow down ARMD and the prospects for AREDS 2.  Remember that AREDS stands for Age Related Eye Disease Study.  The AREDS 1 study has been published and the AREDS 2 is presently underway.

What about Spinach? There are two potential advantages to eating spinach.  Spinach is a rich source of beta-carotene.  Beta-carotene is an antioxidant (protects cells against the damaging effects of oxygen at the microscopic cellular level).  It may be beneficial in slowing down macular degeneration, but we don’t yet know.  This is specifically being addressed by AREDS 2.  In AREDS 1, beta-carotene was linked to a beneficial effect in macular degeneration patients, but it also increased the rate of lung cancer in smokers taking the supplement.  AREDS 2 will directly study whether beta-carotene is even needed.

Spinach also is a rich source of macular xanthophylls (pigment related compounds).  Two of these xanthophylls are lutein and zeaxanthin.  Lutein has become very famous/popular for the treatment of macular degeneration.  Many “eye vitamins” tout the inclusion of lutein.  Lutein has yet to be absolutely proven to be effective against macular degeneration.  This question, too, will be answered in the upcoming AREDS 2 study.

And now, Carrots. Carrots are a great source of vitamin A.  Certain meats are also great sources.  Vitamin A is needed in the retina to help with the chemical reaction that allows us to see light.  Vitamin A leads to the function of rhodopsin, a protein/enzyme that allows us to see in the dark.  Vitamin A deficiency can lead to decreased rhodopsin and night blindness.  (Vitamin A  is also vital to the cornea and mucous membranes.)  Vitamin A deficiency is very rare/non-existent in the United States.

Carrots, like spinach, are also a great source of beta-carotene.  For the same reasons listed above (under the spinach heading), we may need to eat more carrots, not for the vitamin A, but for the beta-carotene.

Other sources of beta-carotene included; carrots, pumpkin and sweet potatoes, as well as, cabbage, kale, spinach, beet greens and collard greens.

What does this mean? There are advantages to spinach and carrots; good sources of beta-carotene that may be proven to retard or improve macular degeneration.  At present, no additional supplements, diet or vitamins, have been proven to improve vision or eye health.


Randall V. Wong, M.D.
Ophthalmologist, Retina Specialist

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