Tag: wet macular degeneration

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Macular Degeneration Treatments

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.

“Randy”

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

Categories
Macular Degeneration Treatments

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 “MyVisionTest.com.”  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.

“Randy”

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

Categories
Macular Degeneration Treatments

"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!

“Randy”

Randall V. Wong, M.D.

Retina Eye Doctor
Ophthalmologist
Fairfax Virginia

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How I Practice

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!

“Randy”

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

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