Scott E. Pautler, M.D. Tampa

Treatment of diseases of the retina and vitreous

What is the Difference Between Dry and Wet AMD?

Posted on October 29, 2023 by Scott Pautler

Age-Related Macular Degeneration: Dry or Wet?

What is the difference between dry and wet age-related macular degeneration?

Age-related macular degeneration (AMD) is the most common cause of visual loss in older Americans. Doctors often talk about dry and wet types of AMD. But what is the difference? Simply put, dry AMD means there are no abnormal, leaky blood vessels. Whereas, in wet AMD there are abnormal blood vessels that grow and leak under the macula. However, this system of naming wet and dry AMD can be confusing. Therefore, newer names for the stages of AMD have been proposed.

Why is it important to distinguish between wet and dry AMD?

Dry and wet AMD cause different symptoms and are treated differently. Early and intermediate stages of AMD are often called dry AMD. These stages usually cause few symptoms, which include the need for good lighting. The treatment involves AREDS2 vitamins and a Mediterranean diet. Advanced stages of AMD are called geographic atrophy (advanced dry AMD) and neovascular AMD (wet AMD). Both types of advanced AMD are usually associated with decline in central vision, frequently affecting the ability to read, see the computer, and drive a car. Geographic atrophy (advanced dry AMD) progresses slowly with blind spots that interfere with the ability to see. Neovascular AMD (wet AMD) may advance more rapidly with distortion, blurred areas of vision, and blind spots. It is possible to have both forms of advanced AMD…geographic atrophy (advanced dry AMD) and neovascular AMD (wet AMD).

What is the treatment of advanced AMD?

The treatment of the two forms of advanced AMD is different. Furthermore, the treatment of one type of advanced AMD may aggravate the other form of AMD. However, both forms of advanced AMD benefit from the use of magnifiers and other low vision aids.

What is the treatment of geographic atrophy (advanced dry AMD)?

Geographic atrophy (GA) is currently treated with medications that inhibit the complement systems of proteins in the body that normally cause inflammation to fight infection. The two FDA-approved medications are Syfovre and Izervay. They are both given as an injection into the eye. They do not reverse the damage from GA and do not prevent GA from getting worse. They do slow down the rate of worsening of GA. There is no good evidence to show that one medication is better than the other. Long-term injections are needed over the years. And, unfortunately, both medications may cause wet AMD (neovascular AMD) to start.

What is the treatment of wet AMD (neovascular AMD)?

Wet AMD is treated with injections to stop the leaking blood vessels under the macula. These medications (Avastin, Lucentis, Eylea, Beovu, and Vabysmo) prevent further worsening of vision from wet AMD in about 90% of cases over several years. In about 40% of cases, the vision may improve. Long-term injections are usually needed over the years. There is limited evidence to suggest benefits of some medications over others. There is also some concern that the treatment of wet AMD may aggravate geographic atrophy (advanced dry AMD).

What do you do when an eye has both forms of advanced AMD?

The presence of both neovascular AMD (wet AMD) and geographic atrophy (advanced dry AMD) poses a serious problem. Both forms of advanced AMD may result in legal blindness (the loss of central vision). However, advanced AMD almost never results in complete blindness. Treatment is usually aimed at the greatest threat to vision. Specific treatment plans are made on a case by case basis. In some situations, injections are given on an alternating schedule for GA and neovascular AMD. In end-stage situations in which the chance of further loss of vision is low, all injections may be stopped. Low vision aids and assistance (family and social services) often results in high-level functioning and independence.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Copyright © 2023 Designs Unlimited of Florida. All Rights Reserved.

Syfovre for Dry Macular Degeneration

Posted on February 2, 2023 by Scott Pautler

Syfovre for dry macular degeneration — anatomy of the eye (click on image to enlarge)

What is Syfovre?
Syfovre (pegcetacoplan) is a new medication approved by the FDA in February 2023 for the treatment of geographic atrophy caused by dry-type age related macular degeneration (AMD). It is given by injection into the eye.

What is geographic atrophy?

Geographic atrophy (GA) is a common cause of loss of central vision in AMD. It occurs when retinal receptor cells die. As a result, GA leaves blinds spots and missing areas in the vision. Until now, there was no treatment for geographic atrophy from AMD.

How does Syfovre work?

Syforvre blocks the complement proteins in the body. Complement proteins regulate the normal inflammatory response of the body. The inflammatory response is important to fight infection. However, in AMD the complement proteins appear to cause harm, as they contribute to the development of geographic atrophy and loss of vision.

How well does Syfovre work?

Syfovre is not a cure for dry AMD. Syfovre does not reverse the past damage by geographic atrophy and does not keep it from getting worse. However, Syfovre, when given by monthly injection, slows the rate of worsening of geographic atrophy by 19-22% over two years as compared with sham injection. There was no measured benefit in visual acuity or visual function during the two-year study, perhaps because it would take longer for the benefits to be measured.

What are the adverse effects of Syfovre?

As with all intraocular injections there are risks. The risks involved with the introduction of a needle into the eye include bleeding, infection, and retinal detachment. These complications may require surgery, and they risk loss of vision. The known risks of Syfovre include the new development of wet AMD with blood vessel growth threatening loss of vision. In the phase 2 study, wet AMD developed in 20.9% of eye treated with Syfovre compared with 1.2% in eye with sham injection. This represents a 1,742% increased risk. Post hoc analysis suggests the risk of new wet AMD from Syfovre may be reduced by avoiding treatment in high-risk eyes. It is important to avert the development of new wet AMD because the treatment of wet AMD involves routine, long-term injection of antiVEGF medications to prevent severe loss of vision.

There is risk of infection (endophthalmitis) after eye injections The rate of infection with Syfovre was 1-2%…much higher than the rate of infection with other medications given by injection. This increased risk may be explained by the suppression of the natural immune defense by Syfovre. There is also a 1.7% risk of ischemic optic neuropathy. This is an unusual complication among the various drugs used for injection into the eye.

The decision to use Syfovre with the intent to slow the progression of dry AMD (geographic atrophy) must be weighed against the potential adverse effects in any given patient.

NOTE: As of August 19, 2023 the Syfovre phase 3 study results have not been published or available for review by prescribing physicians. These studies provided the basis on which the FDA gave approval for marketing Syfovre in the US.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Copyright © 2023 Designs Unlimited of Florida

Beovu for Macular Degeneration

Posted on October 22, 2019 by Scott Pautler

globe anatomy — anatomy of the eye (click on image to enlarge)

What is Beovu therapy?

Beovu (pronounced “BEE oh view”) therapy is a treatment for wet-type macular degeneration (AMD). It was approved by the FDA in the United States in 2019. It involves repeated injections of medication into the eye to stop abnormally leaky blood vessels. Other similar medications include Avastin, Lucentis, Eylea, and Vabysmo.

How effective is Beovu therapy?

Beovu was proven in FDA-approved studies to be as effective as Eylea. In wet-type macular degeneration, injections of Beovu over a one-year period offered a 95% chance of losing less than three lines on a standard eye chart. The results with Beovu were similar to treatment with Eylea; however, Beovu appeared to stop leakage in wet AMD more often than Eylea. Beovu therapy often starts with injections every 4-6 weeks. Afterwards, the injections may be given every two or three months to maintain vision. Half of eyes treated in a large study could be managed with injections every three months. At this time, it is not known whether Beovu is more effective than Eylea due to limitations in the studies to date.

What are the risks of Beovu therapy?

Severe complications are very rare, but risks of Beovu injection include inflammation (~10%), artery occlusion (~3.4%), bleeding, infection, retinal detachment, glaucoma, cataract, and loss of vision/loss of the eye. When inflammation occurs, it may affect the blood flow to the retina with an overall risk of ~3.4% in Beovu-treated eyes. This complication may result in permanent and profound loss of vision. The risk of retinal detachment is about 1 in 5,000 injections, but the results of surgical repair are poor. In initial studies there appeared to be a low risk of stroke with Beovu therapy. The risk of stroke may be related to the older age of patients in which it is used. Further investigation will provide more information. Pregnancy should be avoided while on Beovu therapy. Currently, caution is used in recommending Beovu due to the risk of inflammation and loss of vision, which appears greater than other available medications. In 2022, a new medication, V abysmo, was approved by the FDA. Vabysmo may offer the advantage of less frequent injections like Beovu, but with a lower risk of inflammation.

What do I expect after a Beovu injection?

Be careful not to rub the eye after the injection because the eye may remain anesthetized for several hours. You may be given eye drops and instructions on how to use them. Physical activity is not limited after the injection. On the day of injection, Tylenol or Ibuprofen may be used if there is discomfort after the injection, but severe pain should be reported to your doctor without delay. It is normal to experience a red area on the white of the eye, which disappears in one to two weeks. After the day of injection, if you develop new floating dots, new pain, and/or loss of vision, contact your doctor.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Copyright ©2019-2022 Designs Unlimited of Florida. All Rights Reserved.

The Best Vitamins for Macular Degeneration

Posted on February 2, 2019 by Scott Pautler

What are vitamins?

Before discussion about the best vitamins for macular degeneration, just what are vitamins? Vitamins are organic compounds that are needed by your body to function, but cannot be made by your body. Therefore, they must be consumed to promote good health. Vitamin and nutritional supplements are not regulated or tested by the Food and Drug Administration. Claims by manufacturers that these supplements improve health must be scientifically proven.

Should I take vitamins?

Doctors and nutritionists are limited in their ability to make firm recommendations in many situations because nutrition research is still in its infancy. Beware of authors and marketers who make grand claims as to the effectiveness of vitamins and herbs. Most healthy individuals who eat a well-rounded diet do not need to take supplemental vitamins, although there are some situations in which supplements have been shown to be beneficial. In general, vitamins are useful in the following situations: advanced age, age-related macular degeneration, food fads, gastrointestinal absorption abnormalities, and hemodialysis.

Vitamins and nutritional supplements—the more the better?

Although vitamin deficiency causes illness, excess vitamin intake may result in toxicity. Toxic effects are especially seen with the fat-soluble vitamins (Vitamins A, E, D, and K). However, even dosages of vitamin B₆ exceeding 500mg per day may cause light sensitivity, and vitamin C may cause nausea and diarrhea in large doses of 2 grams per day. Vitamin A may cause liver damage, visual changes, and birth defects in dosages as low as 15,000 IU per day and long-term use of vitamin A may cause osteoporosis and increased risk of bone fracture. Beta carotene may cause smokers and former smokers/asbestos workers to be at increased risk of lung cancer. Vitamin E appears safe up to 400 IU, but daily dosages exceeding 800 IU may cause abnormal bleeding and dosages exceeding 1200 IU may cause headache, fatigue, nausea, diarrhea, cramping, weakness, blurred vision, and gonadal dysfunction. Vitamin D may cause abnormal calcium deposits in soft tissues when taken during kidney failure or in doses greater than 2,000 IU.

So what are the best vitamins for age-related macular degeneration (AMD)?

The AREDS2 formula is the most carefully studied vitamin combination proven to reduce the risk of vision loss in AMD. There are many companies that manufacture the AREDS2 formula, but the most economical source (to the best of my knowledge) is Equate Advanced Eye Care Complex from Walmart. Another more expensive brand is Preservision AREDS2. There is NO vitamin A or beta carotene in AREDS2. Be aware that mineral supplements such as zinc in the AREDS2 formula may interfere with the absorption of prescription medications such as thyroid pills. Therefore, take AREDS2 vitamins 4 hours apart from prescription medications to minimize their interactions. Iron supplements may worsen macular degeneration and should be avoided unless prescribed by a physician.

Click here to check updated prices of Preservision AREDS2 on Amazon.

Preservision AREDS 2 — Preservision AREDS 2 (click to enlarge)

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

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Copyright © 2021-2023 Designs Unlimited of Florida. All Rights Reserved.

Retinal Rejuvenation

Posted on November 17, 2018 by Scott Pautler

Retinal rejuvenation is a name given by the company that sells a new-generation laser machine to ophthalmologists. The laser is used to treat the retina with the hope of delaying loss of vision from age-related macular degeneration (ARMD). Although the laser company calls this treatment “retinal rejuvenation,” this name may be overstating the true effects of this new laser.

The scientific basis for the use of the laser for macular degeneration is the LEAD study. This study evaluated 292 patients with ARMD over a three-year period. Half of the eyes were treated with the new micro-pulse laser and the remainder received sham treatment for comparison. Overall, the treatment was not shown to be of benefit in slowing the loss of vision from macular degeneration. However, when looking at subsets of eyes with certain types of macular degeneration (no reticular pseudodrusen), there was a trend toward a benefit. These results, however, had a weak fragility index (meaning that more research is needed). Conversely, eyes with reticular pseudodrusen (subretinal drusenoid deposits) lost vision at a greater rate after undergoing retinal rejuvenation than those eyes that were not treated.

“Retinal rejuvenation” needs more study before it is implemented on a wide scale basis. It is currently (2018) not approved for this use in the United States. More research is needed to better establish its helpfulness in reducing the risk of vision loss from age-related macular degeneration and to identify potential risks involved with its use.

I do not recommend the “retinal rejuvenation” treatment for age-related macular degeneration by the new micro-pulse laser at this time. I look forward to more high-quality research in the future to better establish the potential role of this laser for my patients with ARMD.

By Scott E. Pautler, MD

Copyright © 2018 Scott E Pautler MD. All rights reserved.

Pneumatic Retinopexy

Posted on April 21, 2014 by Scott Pautler

globe anatomy — anatomy of the eye (click on image to enlarge)

What is pneumatic retinopexy?

Pneumatic retinopexy is a surgical procedure to repair retinal detachment, close macular holes, treat vitreomacular traction, and displace blood from beneath the center of the retina as occurs in some cases of wet type age-related macular degeneration. A gas bubble that is injected into the eye is used to gently push against the retina to hold it in position. Strict positioning of the head is essential for success.

How is pneumatic retinopexy performed?

Pneumatic retinopexy can be performed in the office or in the operating room of a hospital. An injection of anesthetic around the eye is used to make the procedure pain-free. The eye is treated with an iodine solution in an effort to prevent infection. If there is a retinal break, cryopexy is used to seal the break. Cryopexy is performed by holding a pencil-like probe with a freezing tip against the white of the eye. It may cause a pressure sensation of coldness. Sometimes, laser is also used to seal retinal breaks. In preparation of the gas injection, fluid is removed from the eye with a small needle to make room for the gas bubble. After the gas injection, the eye is patched.

Will I be able to see the gas bubble?

It is normal to see the gas bubble while looking out of the eye. It appears as a black curved line across the vision, a single black ball in the bottom of the visual field, or as many black “fish eggs.” The gas bubble will move in the vision with head and eye movements. Usually, there is very little vision when looking through the gas bubble when it is large. The vision slowly improves as the gas bubble disappears by dissolving in the fluids of the eye over four to six weeks.

How does pneumatic retinopexy work?

Image of retinal detachment (top) and pneumatic retinopexy (bottom).

The gas bubble in the eye floats upward and gently holds the retina in position. Depending on what part of the retina needs support, the head must be kept in proper position. For example, if there is a break in the part of the retina that corresponds to the twelve O’clock position on a clock, then the head must remain upright so that the bubble floats up against the superior part of the retina. Otherwise, the bubble will not provide proper support and the retina will not heal properly and more surgery may be needed.

A retinal detachment is present in the top left-hand side of the photograph.

Intra-ocular gas bubble seen on photograph following pneumatic retinopexy.

How long do I need to stay in position?

You may need to stay in position from a few days to two weeks depending on your surgeon’s recommendations. It is best to attempt to remain in the recommended head position for 90% of the day and night. While in position, you may use your eyes to read or watch TV. A special pillow may be purchased to sleep in a face down position, which is recommended to close a macular hole. For five or ten minutes of every hour or two, you may stop the positioning to rise, stretch, and quietly move about the house to use the bathroom or eat. Until the gas bubble is gone, you should not fly in an airplane or undergo anesthesia using nitrous oxide, as doing so may result in blindness. Keep a MedicAlert band on your wrist until the gas bubble is gone.

How well does pneumatic retinopexy work for retinal detachment?

The PIVOT study compared the results of pneumatic retinopexy versus vitrectomy in the repair of retinal detachment. On average, pneumatic retinopexy resulted in less distortion and an additional line of visual improvement on the eye chart compared with vitrectomy. However, strict positioning is needed for success with pneumatic retinopexy; therefore, the success rate of reattaching the retina with a single procedure was 81% for pneumatic retinopexy compared to 93% with vitrectomy. Additional surgery, when necessary, usually results in successful reattachment.

What are the risks of pneumatic retinopexy?

Although generally a safe procedure, pneumatic retinopexy is not without risks. Adverse effects include pain, bleeding, infection, scarring, glaucoma, cataract, loss of vision, deformity, blindness, and loss of the eye. When pneumatic retinopexy is recommended, the benefits outweigh the risks of surgery.

How do I care for the eye?

Keep the patch on and use no eye drops in the operated eye until the patch has been removed in the office on the first day after surgery. After the office visit you may shower and shampoo your hair being careful not to bump or rub the eye. The eye can be gently dried by patting it with a clean, dry towel. You may be given eye drops and instructions on how to use them. Tylenol (no more than 4,000 mg per day) or Ibuprofen (no more than 2,400 mg per day) may be used if there is pain. Patients with liver disease should be cautious about taking Tylenol, and patients with kidney disease should be cautious about taking ibuprofen. Prescription pain medication is available if needed. It is normal to have some discomfort, but severe pain should be reported to your doctor. It is normal to experience eyelid swelling and bruising. The eye will be red and watery. Sometimes, there is a sensation resembling an eyelash in the eye. After the patch has been removed, this discomfort is best managed with Lacrilube (available in the pharmacy without a prescription), which may be used in the eye as often as needed. After the first office visit following the surgery, an eye patch is not necessary. However, at night a hard shield may be used to cover the eye to protect it from trauma. If you have any questions or concerns, please call the office.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Copyright © 2014-2022 Designs Unlimited of Florida. All Rights Reserved.

Lucentis (ranibizumab) Therapy

Posted on August 1, 2013 by Scott Pautler

vial of Lucentis — Lucentis vial

What is Lucentis therapy?

Lucentis therapy is a treatment for wet-type macular degeneration, diabetic retinopathy, myopic macular degeneration, and retinal vein occlusion. It involves painless injections of medication into the eye to stop abnormal, leaky blood vessels. It is also used in the treatment of other retinal disorders.

How effective is Lucentis therapy?

Lucentis was proven in extensive studies to be very effective. In wet-type macular degeneration, a large study showed that monthly injections of Lucentis over a two-year period offered a 90% chance of stable or improved vision. Similar benefits are seen in other retinal conditions as well. Currently, therapy often starts with monthly injections until maximal vision is restored. Afterwards, the injections may be given less frequently to maintain stable vision. In some cases, the medication may be stopped and the eye kept under careful observation for reactivation. There are several medications in this class; the best choice of medications depends on the underlying diagnosis.

What are the risks of Lucentis therapy?

Severe complications are very rare, but risks of Lucentis injection include bleeding, infection, glaucoma, retinal detachment, cataract, and loss of vision/loss of the eye. The risk of retinal detachment is about 1 in 5,000 injections, but the results of surgical repair are poor. There may be an increased risk of difficultly with future cataract surgery estimated to be about 1% of cases. In these cases the fibers (zonules) that hold the cataract in place may become weakened from Lucentis injection. When this occurs, special techniques are required to remove the cataract and place a lens implant. Rarely, two procedures are required to accomplish the task. Studies are ongoing to determine if there may be an increased risk of stroke with AMD therapy. Currently, it appears that Lucentis places a patient at lower risk of stroke and heart attack compared with the other medications used to treat macular degeneration and diabetic retinopathy.(Reibaldi 2022) Pregnancy should be avoided while on Lucentis therapy.

intra-ocular injection — Intra-vitreal injection

What do I expect after a Lucentis injection?

Be careful not to rub the eye after the injection because the eye may remain anesthetized for several hours. You may be given eye drops and instructions on how to use them. Physical activity is not limited after the injection. Tylenol or Ibuprofen may be used if there is discomfort after the injection, but severe pain should be reported to your doctor without delay. It is normal to experience a red area on the white of the eye, which disappears in one to two weeks. If you have any questions or concerns, please call the office.

By Scott E. Pautler, MD

For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida. Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.

Copyright © 2013-2022 Designs Unlimited of Florida. All Rights Reserved.