How many injections will I get for macular degeneration?

One of the most common questions we get asked by patients receiving injections for exudative (wet) macular degeneration is how many injections that they will have to receive.  Understandably, most patients are anxious to decrease or even stop their injections all together.  The answer, however, is variable depending on the patient.

Exudative macular degeneration is a chronic disease where the blood vessels in the choroid (the back of the eye) grow through a barrier called Bruch's membrane and bleed.  This bleeding leads to fluid in the macula which is what leads to decreased vision.  Chronic fluid and blood can lead to scarring and eventually markedly decreased central vision. The primary driving force between these blood vessels is a protein called vascular endothelial growth factor (VEGF).  The medications that we currently use to treat macular degeneration-  including Avastin, Lucentis, and Eylea-block this protein (anti-VEGF medications).

When the anti-VEGF medications are injected into the eye they only have an effect for about 28 days. After the medications wear off, the VEGF proteins made in the eye rise again and cause the vessels to leak or grow.  That is why the medications have to be injected at regular intervals.  I often compare this to having to take your blood pressure medication every day to keep your pressure under control.  The medications aren't a cure, but a treatment.

In the initial trials for anti-VEGF medications, the injections were continued every 28 days for 2 years regardless of the patient's vision or amount of fluid in the retina.  The results were excellent- stabilization of vision in most patients and increased vision in many patients.  In the years since the initial trials, a few different approaches have been tried to decrease the number of injections including treating only as needed when fluid returns, and a treatment called treat and extend where we gradually increase the time between injections. One medication, Eylea, is often used very 8 weeks after a 3 to 6 month initiation with monthly injections with good success.

One recent trial, HORIZON, examined the use of as needed injections and revealed that patients lost some vision that they had initially gained when only receiving the injections as needed (when fluid returned in the macula) instead of on a strict schedule.  So, many retina physicians concluded that either monthly treatments or a slow treat and extend regimen is more beneficial to the patient.  And, we know that if we stop the injections all together, the blood often returns and leads to severe central vision loss.

As cumbersome as monthly injections seem to you as a patient, it is important to realize the benefit you are likely receiving from your injections.  The anti-VEGF medications have revolutionized the treatment of this blinding disease and have given hope to many patients who did not have a good visual prognosis in the past.

Researchers are working to develop longer acting medications and other methods that could help avoid these monthly or ever other month injections, so some day in the future you may be able to decrease your visits to the retina physician for macular degeneration treatment.

Each patient is different and is evaluated by his or her physician to determine the best course of treatment.

This blog is for informational purposes only and is not intended to be medical advice.  Please consult your physician for any medical advice.

Examining the AREDS2 data

Macular degeneration is the most common cause of vision loss in the United States.  2 million people have advanced AMD and 8 million people are at a risk for advanced AMD.  Many more patients have earlier stages of AMD that can lead to vision loss as they age.

In 2001, the National Eye Institute (NEI) concluded the original AREDS study (Age-Related Eye Disease Study).  In this study, participants were given either a placebo or the AREDS formula- a combination of Vitamins C, E, beta-carotene and minerals zinc and copper.  After 5 years, patients who took the AREDS combination had a 25%  reduced risk of progressing to advanced AMD.  Since the release of those results, many eye physicians have recommended patients with AMD begin taking these vitamins.

In 2006, the NEI began another study, the AREDS2.  This compared patients taking the original AREDS formula to patients taking various versions of AREDS with or without additional supplements.  The additional supplements studied were omega-3 fatty acids, lutein, and zeaxanthin.  The trial also looked at reducing the level of zinc from the original formula and excluding beta carotene from the formula.  (Studies have suggested that beta-carotene increases the risk of lung cancer in former smokers.)

The results of AREDS2 were released earlier this month. Let's review:

1. Omega-3 fatty acids- The study showed no benefit to adding omega-3 to the formula
2. Lutein-Zeaxanthin- There was no benefit of adding the Lutein and Zeaxanthin by themselves.  But, adding them did negate the removal of beta-carotene.  Also, patients who had diets low in these nutrients did gain benefit from having them in the formula.
3. Reducing zinc- there was no increased risk of progression to advanced AMD in patients receiving the reduced level of zinc.

So, what formula should you be taking? In light of the new results, we suggest discussing this with your eye care professional because the answer could depend on your stage of AMD, your smoking status, and your dietary habits.

This blog is for informational purposes only and is not intended to be medical advice.  Please seek the advice of a qualified medical professional.

Retinal tears

Retinal tears are a common diagnosis that we see in our practice.  Patients often wonder when they have flashes and floaters whether they have a retinal tear or detachment.  Many have researched these symptoms on the internet and see the words "retinal tear" and "retinal detachment" and, understandably, become concerned.

The retina is the inner lining of the back wall of the eye.  It is a 9 layered structure that "takes the picture" and sends it to the brain by way of the optic nerve.  The vitreous is a gel layer made up of collagen and other proteins as well as water that is between the lens, the focusing system of the eye, and the retina.  The vitreous is attached at the optic nerve, the macula, and the entire peripheral retina.  As we age, our vitreous becomes less gel-like and more liquid.  When this occurs, it begins to separate from the retina in stages.  When it separates from the peripheral retina, it can cause a retinal tear or hole.

Retinal holes and tears can have many symptoms.  Flashes and floaters are common with a benign vitreous detachment as well as a more serious retinal tear.  That is why we recommend patients with new flashes and floaters be evaluated by an eye care professional.  Some retinal tears have no symptoms and are discovered on routine exam.

A retinal tear is a serious condition because it can lead to a retinal detachment.  A retinal detachment occurs when the fluid of the vitreous tracks underneath the layers of the retina through the tear.

If a retinal tear is discovered, often it can be treated before it leads to a detachment.  The treatment involves a "welding" process where either laser or freezing is placed around the tear to "glue" it in place.  This is not a guaranteed fix because the tear can sometimes pull through the treatment and evolve into a detachment, but is often very successful.

If you have symptoms of a retinal tear please consult an eye care professional.

This blog is for informational purposes only and is not intended to be medical advice. Please consult an eye care professional for medical advice.

What does it feel like to get an injection in my eye?

As retinal specialists, we give hundreds of intraocular injections (injections into the eye) each month.  Patients with macular degeneration, diabetes, vein occlusions, and now macular holes receive injections to treat their disease, often monthly.

When we first tell a patient he or she will be receiving an injection into his or her eye, there is always a degree of fear that the patient feels.  After all, an injection in the arm hurts bad enough, how much pain does an injection into the eye cause?  The answer, more often than not, surprises the patient- not much.  In fact, many patients report not even feeling the injection or feeling only a small amount of pressure.

To prepare for the injection, we numb the eye.  Then, we use a very small (30 gauge) needle to inject the medication.  Between the numbing and the small needle, the procedure is usually over before the patient knows it.

The day of the injection, patients often report mild stinging or burning in the eye. This is due to a combination of the numbing medicine and the betadine, the medicine we use to kill the bacteria in the eye.  The stinging is usually gone by the next day.

If  the patient continues to have pain the day after or increasing pain and swelling around the eye, we encourage them to call us immediately to discuss this as it could be a sign of an infection.

So, if you are having an intraocular injection, you can rest easy knowing that most patients experience only mild, if any, discomfort, from the process.

This is for informational purposes only and is not intended to be medical advice.  Please consult your physician for medical advice.

A New Drug For Exudative AMD?

Exudative, or wet AMD, is a blinding condition that many of our patients deal with. In fact AMD is the leading cause of blindness in the developed world.  Wet AMD is caused by neovascularization, or new blood vessels, that grow under the macula and then "leak" into the center of the vision and create vision loss.

Currently, the standard of care for wet AMD is injections of Anti-VEGF (vascular endothelial growth factor) medications.  These medications, Lucentis, Avastin, and Eylea, all work similarly in that they inhibit VEGF, a compound that encourages new blood vessel growth.  These injections are usually given monthly for 3 months and then either as needed or extended to longer intervals.  Anti-VEGF medications have been very successful in helping patients retain or even improve their vision after their AMD has become wet.

Even though we have seen great strides in vision improvement since the introduction of these medications, patients and physicians are always looking for further improvement. Platelet derived growth factor (PDGF) is another component of the neovascular cascade that creates the complex in wet AMD.  It has been the source of research for several years, and now promising phase 2b data has been released.

Ophthotech is a biopharmaceutical company that specializes in the creation of medications to treat AMD.  They have recently completed phase 2b testing on Fovista.  Fovista is a PDGF-B inhibitor.  The compound inhibits the growth of the lining of the vessel walls, and with the combination of anti-VEGF was seen in lab studies to induce the regression of neovascular complexes.

In phase 2b testing of 449 patients, Fovista in combination with Lucentis was superior to Lucentis alone in terms of vision gain.  10.2 letters of vision gain was observed with combination therapy while on 6.5 letters were gained with Lucentis alone.  This represented a 62% benefit.

What does this mean for you?  Well, Fovista must now undergo Phase 3 testing before it can be presented to the FDA for approval.  Phase 3 testing involves treating larger numbers of people with the drug to insure that it does indeed continue to provide the increased benefit over Lucentis monotherapy in a larger sample of patients.  There is no information on when Phase 3 trials will begin, but our blog will keep you updated with the progress of this potentially beneficial drug.

You can read about Fovista at www.opthotech.com

This blog is for informational purposes only and is not intended to be medical advice.  Please seek the advice of a qualified medical professional.

Genetic Testing for Macular Degeneration

Macular degeneration is a prevalent disease that is becoming more so with the aging population.  9.1 million Americans have macular degeneration today.  A common question of patients is whether they should have a genetic test to determine if they are going to have macular degeneration or if their macular degeneration will progress to the advanced stage.

There are several companies that now offer genetic testing for macular degeneration.  The tests examine certain genes that have been linked to macular degeneration such as complement factors, metabolic genes, energy metabolizing genes, extracellular matrix pathway genes. Then, the patient is stratified into categories based on the combination of their genes.  Often, the testing is covered by insurance companies.  However, the question is whether there is any benefit to the testing.

The American Academy of Ophthalmology recently addressed this question in a statement.  Their position is that genetic testing for macular degeneration is NOT recommended.  The position of the Academy is that screening exams are more productive for a patient than a genetic test that may or may not accurately predict the risk of AMD. Specifically, they state that "Although several genotypes are associated with increased risk for AMD, at this time, genetic testing provides no proven advantage in preventing or treating the disease."  The Academy does suggest that in the future, treatments might be targeted based on genetic typing, at which time the testing would become valuable, but for now no such treatments exist.  However, some argue that if a patient is high risk then he or she should have more frequent screenings to catch a neovascular membrane sooner.  Currently, there are no studies that show more frequent screening in genetically high risk patients to be helpful.

Some patients do still chose genetic testing for macular degeneration for their own knowledge.  This is certainly an option for such patients.  However, even with a low risk score, patients should continue to undergo regular screening exams. 


If you have questions about genetic testing and macular degeneration, consult your eye care professional.


This blog is for informational purposes only and is not intended to be medical advice. Please consult an eye care professional.

Diabetes and Eye Exams

Diabetes in an increasingly prevalent disease in the United States.  One thing that many patients have questions and concerns about is when he or she should be seen for an eye exam to evaluate for diabetes in the eye.

Diabetic retinopathy is a leading cause of blindness in the US.  Diabetes affects the small blood vessels in the retina and can lead to blurry vision and eventual blindness. However, the early, more treatable damage is asymptomatic and can only be discovered by routine screening exams.

So when should you have an eye exam? If you have Type 1 diabetes, your first eye exam should be within 1 year after diagnosis. If you have Type 2 diabetes, you should have an eye exam as soon as possible.  Why the difference? Type 1 diabetes occurs suddenly and patients are usually diagnosed quickly after acquiring the diease.  Type 2 diabetes can be present for years before the diagnosis.  During this time, the damage could already be occurring and you may not even be aware of it!

Diabetic retinopathy occurs in several stages.  The first stage is mild diabetic retinopathy.  This is a few blood vessels that have become damaged and become weak. If you have mild retinopathy, you need at least a  yearly exam. The second stage is moderate diabetic retinopathy.  In this stage the damage is more extensive. We recommend patients with moderate retinopathy be seen every 6-12 months.  Severe retinopathy can lead to permanent vision loss, so we recommend exams every 3-6 months.  Proliferative retinopathy often requires treatment in the form of laser or surgery, so we see these patients every 3 months.  Diabetic macular edema, the leading cause of vision loss from diabetes, can occur in any of these stages.  Treatments such as laser and injections are available to treat this condition so follow-up can vary based on the patient. Only a dilated eye exam by a qualifed eye care professional can determine which type of retinopathy you have.

It is important to know that with regular screening and treatment, vision loss from diabetes can largely be avoided.  So, if you have diabetes, be sure to see an eye care professional within the recommended time frame!

This blog is for informational purposes only and is not medical advice. Please consult an eye care professional.