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Tag Archives: wet macular degeneration

Avastin and Lucentis: Neck and Neck

Both Avastin and Lucentis are anti-VEGF treatments for wet macular degeneration.  Both are manufactured by Genentech (Roche).  A small study just published found no clinical difference between the two drugs, that is, one worked as well as the other.

There has been quite a debate over the difference between the two drugs and their ability to treat wet macular degeneration.  There are differences in cost, FDA approval, etc., but this is the first study that has compared the two drugs head to head.

The large difference in cost between the two drugs has led to speculation that the popular use of Avastin among retina specialists is due to price alone.  Avastin costs less than $50 per injection whereas Lucentis is priced at $2000 per injection.  Supporters of Avastin (including yours truly) feel that the use of Avastin is justified by the excellent results.

Other than price there are differences in the number of isoforms that the molecules block; Avastin blocks more isoforms than Lucentis, but is this significant in the eye?  No one knows.  It seems not to matter.

What Does this Mean? This study was a retrospective study, that is, the results were determined looking backwards.  One weakness of retrospective studies is that there are too many variables between patient groups to allow a true “head to head” comparison.  The result, too much bias in the study and it is difficult to make ture, concrete conclusions.  It doesn’t mean that retrospective studies are worthless, but you must keep in mind there may be flaws in the conclusions.

A prospective, randomized study is really the gold standard.  In these studies, similar patients (similar in age, vision, race, etc.) are treated exactly the same and differ only in the treatments they receive.  In this case, similar patients would be randomly treated with either Avastin or Lucentis.  The patients are treated with the exact same protocol with respect to dosage, frequency of injection, etc.  The groups are then followed for a given length of time.

The results of prospective studies have far less bias and results are taken to be more meaningful.  An NIH sponsored prospective study is underway comparing Avastin vs. Lucentis.

For now, there seems to be no clinical advantage to either drug.


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

Testing Your Eyes at Home

The major problem with wet macular degeneration is that the “wet” abnormal blood vessels tend to affect the macula.  This usually causes decreased vision and distortion.  Home monitoring, or self-monitoring, is based on the premise that new distortion may signify presence of neovascularization.

Patients with wet macular degeneration have two major concerns; recurrence in the same eye and wet macular degeneration developing in the other eye.  To alleviate their fears, doctors have long been recommending home monitoring as a method to catch the disease as early as possible.

Distortion from “wet” macular degeneration is similar to the “Princess and the Pea,” where the abnormal vessels are trying to sandwich themselves between the layers of the retina.  This causes the retinal surface to become uneven which translates into distortion.

Amsler Grid Testing – The Amsler Grid is used on a daily basis, testing each eye separately.  In this way, a patient with macular degeneration will become familiar with their own pattern of distortion.  Any new waviness should be reported to their doctor.  This may be a sign of active “wet” macular degeneration.

An electronic version of the Amsler Grid is available at “”  There is also a link on the left side panel if you ever forget.

The ForSeeHome™ AMD Monitor is the first telemedicine device for the home.  According to the company web page, this device offers self-monitoring of patients with known macular degeneration.  It is not a diagnostic tool, but monitors changes in distortion.  This information can then be transferred to the eye doctor for review.  The device has received FDA “510(k)” clearance.

What Does This Mean? The idea of self-monitoring is to catch the “wet” form as early as possible.  Early detection of wet macular degeneration usually translates to a better outcome.  In my experience patients with wet macular degeneration are pretty motivated to self-test regularly and the Amsler Grid seems to be a very good, cheap, and reliable test.  Remember that the macula is very sensitive and any change in distortion is usually pretty obvious.

It seems that a new telemedicine device might be “overdoing” it, at least from what I can tell from the web page and the press release.  It does not make a diagnosis and examination by the doctor is still necessary.

I see three scenarios; however, where this might be useful; 1) a patient is unable to tell, himself, if there are changes in his own vision (yes, it happens), 2)  a patient’s vision is so poor that subtle changes are unnoticed and 3) the device picks up earlier changes than can be noticed by the average individual, that is, the device is super-sensitive.


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

"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!


Randall V. Wong, M.D.

Retina Eye Doctor
Fairfax Virginia

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No Laser for Macular Degeneration…..We've Come a Long Way, Baby!

I have been in practice for about 17 years.  The present treatments for the treatment of macular degeneration are a godsend compared to the standards we used in the 1990’s.  At that time, laser treatment for wet macular degeneration was our only weapon………….and it was horrible.

State of the art treatment in the early 90’s involved using a laser to treat the abnormal vessels, or choroidal neovascularization, in wet macular degeneration.  Patients who developed the neovascular lesion would complain of decreased vision and/or distortion much as they do today.

"Blind Spot" with Laser
"Blind Spot" with Laser

Let’s say that I had a patient complaining that people’s faces were blurred out and distorted.  I established that this was due to wet macular degeneration.  My treatment recommendation would have been laser photocoagulation.  I would warn the patient of the following;  1)  if we do nothing, the large grey spot will only get bigger, if you can’t see someone’s face, you might not see the upper body if nothing is done, 2)  the laser will make your vision worse, but theoretically not as bad as if we do nothing.  We are trying to minimize the size of the area you don’t see with the laser.

That was state of the art.  We caused an immediate loss of vision by creating a dense area of non-seeing in hopes of preventing the disease from creating an even larger area of non-seeing.  State of the art, back then, offered no hope of getting better, but just containing, or minimizing vision loss.

Confused?  You should be………..imagine trying to explain this to patients.

Photodynamic Therapy (PDT) was the first time we (eye docs) could actually help people.  It was the first treatment where patients had a chance of improvement!   It was available in the mid-1990’s and was popular for several years.  It was a huge shift in the way we treated this disease.

Photodynamic therapy (PDT) treated only the “bad” abnormal blood vessels.  Unlike the laser which destroyed both healthy and diseased tissue, photodynamic therapy (PDT) with Visudyne (verteporfin) specifically treated only the abnormal, choroidal neovascularization.  No more blind spots, and, no more making the vision worse!

Intravitreal Injections of antiVEGF are now the mainstay of treatment.  As with PDT, this treatment is directed only at the abnormal, choroidal neovascularization, and destroys only the “bad” tissue.  The results, however, are better than photodynamic therapy, in that substantially more patients are helped with this treatment………..hence the popularity.

Sustained Release Technology is on the way!  In the near future, the injections are likely to be replaced with sustained release systems that are ‘injected’ once and release drug for a long time……….obviating the need for repeated injections.

We’ve come a long way, Baby! Basically, in 15 years, we have gone from causing partial blindness to offering hope and improvement of vision!


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

Photodynamic Therapy (PDT) for Macular Degeneration, Obsolete?

Whatever happened to photodynamic therapy?  Visudyne®, a form of photodynamic therapy, was one of the first “treatments” for wet, or exudative, macular degeneration and quickly became the treatment of choice.  It was approved for the treatment of wet macular degeneration in 2000.  The treatment involves infusion of Visudyne® (verteporfin for injection) into the patient, the drug accumulates in the choroidal neovascular complex (the abnormal leaky vessels) and is then exposed to a “cold” laser for 83 seconds.  The laser energy converts the accumulated Visudyne® molecules into a drug that seals the abnormal leaky vessels.  Vision may improve from absorption of the leaky fluid and blood.

When first introduced, the treatment gained wide acceptance.  It was the first treatment that actually gave us (docs and patients) hope of visual improvement.  Indeed, it did happen regularly.  Treatments are somewhat inconvenient and labor intensive.  Patients need to be warned about light sensitivity and sunlight exposure for 5 days after the treatment.  Even some surgical lights could theoretically convert the Visudyne® still left in the body.   Patients come dressed in hats, gloves and long-sleeves to limit sun exposure.  The preparation from our part is somewhat cumbersome, too.  It used to take us almost 20 minutes to completely set up for one treatment.  The results were exciting.  For the first time, patients were getting better vision!

Nowadays, I think most of the patients receive intraocular injections of either Avastin®, Lucentis® or maybe Macugen®.  There are still patients that may need PDT/Visudyne.  Consider the patients that can not tolerate an intraocular injection, patients with one eye and don’t want the risks of injections and patients that have failed intraocular injections.

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

Systemic Avastin May Be Effective for Macular Degeneration

In select instances, administering Avastin® (bevacizumab) intravenously may be an effective way of treating patients with wet macular degeneration.  In a short study, patients were randomly selected to be treated with either intravenous Avastin® or saline.   Patients received only 3 infusions every two weeks and were followed for 24 weeks.  Patients were observed for changes in the lesion size.  (The “lesion” is the subretinal choroidal neovascular membrane, or abnormal blood vessel complex, which defines the “wet or exudative” form of macular degeneration.)

In about half the patients, the treated eyes became stable over the study period.  Increase in blood pressure was noted after the Avastin® infusions, but was treatable.

The authors contend that intravenous administration of Avastin® may be an effective way to treat wet macular degeneration in patients who refuse intraocular injection, have both eyes involved, stable blood pressure and no history of vascular clotting.

What does this mean? No treatment is the perfect treatment for all patients.  While this was only a small pilot study, there are a few notable points.  Usually in ophthalmology we see trends for getting better drug delivery into the eye.  Usually this means moving away from systemic dosing of drugs as the drugs usually do not get into the eye very well.  This, however, does not mean that systemic therapy is bad.  In this case, systemic therapy may actually be a useful way to treat this devastating visual disease in certain cases.  It may provide  hope to patients that can not tolerate intraocular injections.  It may even require fewer treatments.  Further study is certainly anticipated.

Read more.


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

Combination of Radiation and anti-VEGF Shows Promise

In article released in the British Journal of Ophthalmology, researchers describe a combination of brachytherapy and intravitreal injections of Avastin to treat patients with choroidal neovascularization from ARMD (the so-called “wet” form of the disease).  In this prospective, randomized trial, 34 patients were treated with brachytherapy and two injections of bevacizumab (Avastin®).

The patients were treated and followed for 1 year.  No system complications or side effects were seen.  As Phase III studies are underway, the patients will be followed for an additional 2 years.  91% of patients lost less than three lines of vision, 68% maintained or improved vision and 38% gained at least three lines.

The authors did note that recurrent lesions did occur (the choroidal neovascular membranes regrew) and that these lesions were treated with additional injections.

What does this mean? The significance of this short article is that a combination of radiation and anti-VEGF injections may reduce the frequency of repeat injections, that is, radiation may somehow enhance the effects of anti-VEGF therapy or vice versa.  Either way, patients may experience the same improvement, but with the combination be more stable and require fewer treatments.


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

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What About Vitamins?

What vitamins help macular degeneration?  I am asked this daily.  What should I take?  What should I eat?  What can I do?  The answer is simply………..I don’t really know.  The information about supplements, be they vitamins or foods, is really scarce.  I usually tell patients that my job is to report the hard data to you and not to promote remedies or pills which are unfounded.  I feel pretty strongly about this.  It is why western medicine is superior – most everything is tested (kind of like Google).

In 2001, a gigantic study was completed called the Age Related Eye Disease Study (AREDS).  It was unique in its size and scope.  It was a prospective study (vs. retrospective, prospective studies are better).  It was one of the first studies to show that dietary changes can influence as disease, in this case, macular degeneration.  Patients were examined for the development of macular degeneration while taking (aka the AREDS Formula); Vitamins C and E, Beta-carotene, zinc and copper.  The conclusions of the study;

1)  smokers should not take beta-carotene as it increases the chance of lung cancer,

2)  patients at moderate/high risk of AMD do benefit from the AREDS formulation supplements

Associated findings, but not conclusively studied;

1)  carotenoids such as lutein and zeaxanthin (found in green leafy veggies such as spinach) were associated with decreased AMD in those patients that ate them in the beginning of the study, that is, these were not directly studied.

2) omega 3 fatty acids may be associated with reduced macular degeneration and cardiovascular disease.

What does this mean? The original study was limited in its findings, but several dietary associations were made, but not studied.  From this, we assume that eating green leafy vegetables/foods such as spinach, kale, eggs (yolks!), turnip greens, collard greens, etc., are good for you.  Similarly, omega 3 fatty acids (found in fish) are good for your eyes and possibly your heart.

A second large, prospective, study is underway.  AREDS2 will hopefully answer these questions; 1)  the value of beta-carotene in non-smokers, 2) the role of omega 3 fatty acids, 3) the value of carotenoids lutein/zeaxanthin.

Recommendations about Vitamins and ARMD

If your doctor determines that you have moderate or high risk factors in one or both eyes or you have lost significant vision in one eye from either “wet” ARMD or “geographic” ARMD, and you don’t smoke, you should take the AREDS formulation.

Thanks for reading,

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

Cases of ARMD to Double

In this month’s (April,  2009) edition of Archives of Ophthalmology, a study reports the prevalence of patients afflicted with macular degeneration is expected to almost double by the year 2050.  In other words, the number of patients suffering the disease at a given time is expected to near double in the next 40 years.

All forms of macular degeneration are expected to increase over the next 40 years.  There are two major types of macular degeneration; dry and wet.  The most common form of macular degeneration is the “dry” form (also known as non-exudative macular degeneration).  The most aggressive form of macular degeneration is the “wet” form (also known as exudative macular degeneration).  Significant vision loss may result in either type, although the dry form  usually progresses much more slowly.

There is good news.  The report also predicts that the use of antioxidant supplements will significantly reduce the amount of vision loss as our population ages, that is, current advances in supplements seem to be helping.

Currently there is no approved treatment for dry macular degeneration.  Patients with wet macular degeneration often receive injections into their eye of medications called VEGF (Vascular Endothelial Growth Factor) inhibitors such as; Lucentis®, Avastin® and Macugen®.

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


Currently, I see patients with retinal diseases; macular degeneration, retinal detachment, macular holes, macular pucker within several different'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
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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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