Tag Archives: antiVEGF

Will I Lose Vision from AMD?

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Will I lose vision from AMD?
anatomy of the eye (click on image to enlarge)

What are the risk factors of losing vision?

If you have been diagnosed with AMD, you may ask, “Will I lose vision from AMD?” There are many risk factors that lead to the worsening of age-related macular degeneration (AMD).  Some are genetic (inherited) and some are environmental.  However, one the greatest risk factors is age.  This is, the older you are with AMD, the greater the risk of loss of vision.  Genetic testing can reveal high risk genes, such as CFH and ARMS2.  Therefore, a family history of vision loss from AMD increases your risk.  Other important factors that affect the risk of losing vision include tobacco use and diet.

What are the stages of AMD?

There are several stages of AMD that affect the risk of severe loss of vision: early, intermediate, and late AMD.  Early AMD presents with medium sized deposits under the retina called drusen.  These eyes usually have no symptoms and the vision is good.  Intermediate AMD have large drusen and/or brown pigmentary changes under the retina.  These changes frequently result in slow recovery from bright light (like coming in from outdoors) and the need for good lighting while reading.  Late AMD causes distortion of straight lines and blind spots in the vision from geographic atrophy (loss of retinal tissue) and/or neovascularization (new blood vessels grow under the retina that bleed and cause blind spots from scar tissue).  Geographic atrophy is also called advanced dry AMD, whereas neovascularization is called wet AMD.  

How can I determine my risk of late AMD with vision loss?

A point system has been developed to determine your risk of loss of central vision from late AMD.  Exam findings in each eye are given a point value.  Then, all the points are added together from the two eyes to arrive at risk of progression to late AMD within 5 years.  

Exam FindingPoint Value
medium drusen0.5
large drusen1
pigmentary changes1
geographic atrophy or neovascularization2
Add the points from findings in each eye
From: Ferris FL 3rd, Wilkinson CP, Bird A, et al. Clinical classification of age-related macular degeneration. Ophthalmology. 2013;120(4):844-851. doi:10.1016/j.ophtha.2012.10.036

At total score of 1 yields a low risk of late AMD of under 5% in five years.  With 2 points, the risk is 12 percent.  Three points means a risk of 25% at five years.  And 4 points means there is a 50% chance of late AMD in five years.  Another way to calculate your risk of late AMD is to use an online calculator.  

How bad can the vision fall from late AMD?

Late macular degeneration may cause a large blind spot in the center of the vision in both eyes.  Although this renders an individual legally blind, it is important to remember that it is extremely rare to lose all vision from AMD.  The peripheral vision usually remains strong and this allows a person to get around a room and care for himself independently.  

Does everyone lose most of their central vision in late AMD?

No.  Many people retain useful vision.  Patients with advanced dry AMD may be treated with Syfovre or Izervay to slow the progression of geographic atrophy.  There are a host of medications that slow the loss of vision from wet AMD, including Avastin, Lucentis, Eylea, Beovu, and Vabysmo.  There is high expectation that further developments from ongoing research will offer even better odds of retaining useful vision in the future.  Those patients who do lose vision from AMD can be helped with low vision aids.  

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.

Izervay for Dry Macular Degeneration

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

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

What is geographic atrophy?

Geographic atrophy is a common cause of loss of central vision in AMD.  It occurs when retinal receptor cells die.  It leaves blinds spots and missing areas in the vision.  Until 2023, there was no treatment for geographic atrophy from AMD.    

What does Izervay do?

Izervay blocks complement proteins (C5) in the body.  Complement participates in the normal inflammatory response.  And the inflammatory response is important to fight infection.  However, in AMD the complement proteins contribute to the development of geographic atrophy and loss of vision.  

How well does Izervay work?

Izervay is not a cure for dry AMD.  Importantly, it does not reverse past damage by geographic atrophy.  Izervay, when given by monthly injection, reduces the rate of worsening of geographic atrophy by 28% over 18 months of treatment as compared with sham injection.  We anticipate this will delay blind spots from interfering with central vision.  

What are the adverse effects of Izervay?

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 risk loss of vision.  

Can Izervay cause wet macular degeneration to start?

The known risks of Izervay include the new occurrence of wet AMD with blood vessel growth threatening loss of vision.  In the phase 2/3 study, wet AMD developed in 12% of eyes treated with Izervay compared with 3% in eye with sham injection over a period of 18 months.  This represents a 400% increased risk of new-onset wet AMD.  It is important to avert the development of wet AMD because the treatment of wet AMD involves routine, long-term injections of antiVEGF medications to prevent severe loss of vision. 

What about the risk losing vision from infection?

There is a risk of infection (endophthalmitis) after any eye injection.  At this time, we do not know if Izervay may increase the risk of developing infection or worsen the final vision after infection.  The suppression of the natural defense against infection by Izervay, explains the concern over increased risk of infection with Izervay.  

Should I receive Izervay injections?

If you have dry age-related macular degeneration with geographic atrophy, Izervay appears to delay the loss of central vision over time.  However, long-term monthly injections are required.  And you must carefully consider the risks of treatment.  Your doctor will help you make this important decision.

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.

Is Eylea HD for Me?

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Is Eylea HD for me?
anatomy of the eye (click on image to enlarge)

What is Eylea HD?

You may ask yourself, “Is Eylea HD for me?” Eylea HD is an FDA-approved medication for the treatment of wet AMD and diabetic retinopathy.  It is a more concentrated form of Eylea, a medication that has been approved for use and effectively used for many years.  Eyela contains 2mg of medication per injection, whereas Eylea HD has 8mg of medication per injection.

When is it helpful to use Eylea HD over Eylea?

There are several reasons Eylea HD may be better than Eylea.  For example, in some eyes with severe macular degeneration or diabetic damage, current medications may not appear to be strong enough to help.  Eylea HD may offer the strength needed to help prevent loss of vision in these cases.  In addition, if Eylea does not last as long as needed, injections may need to be given frequently.  Eylea HD offers a longer duration of action.  Therefore, it may allow more time between injections.  

What are the side effects?

The same side effects of Eylea remain for Eylea HD.  That is, they are both given by injection into the eye.  Therefore, risks include infection, inflammation, bleeding, and retinal detachment, among others.  Over time, these risks are less with Eylea HD if injections can be given less often; the fewer the number of injections, the lower the risk of complications from the injection procedure. However, because Eylea HD is more concentrated, there may be increased risk of complications outside the eye.  As Eylea leaves the eye and enters the blood stream, it may cause increased risk of hypertension, stroke, heart attack, and kidney disease.  There is much debate about whether this risk is significant or not, but evidence suggests the risk may be higher in diabetic patients.   

How can I decide if Eylea HD is right for me?

Your doctor will help you to decide.  If you do not have diabetes, or past history of stroke or heart attack, the decision may be easy.  However, if you have diabetes or are at high risk of stroke and heart attack, you may wish to hold off using Eylea HD until doctors have had more experience with the medication, which was newly approved for use in August 2023. 

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.

Stop Injections for Wet AMD

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

Can I stop injections for wet AMD?

May I stop injections for wet AMD?  This is a common question.  Injections are the mainstay of treatment for wet AMD.  They reduce the risk of vision loss.  However, they are inconvenient, uncomfortable, and costly.  At first, Injections are given every month.  Over time, they may be given every few months.  Unfortunately, long term injections are usually needed to prevent loss of vision.  However, there are situations in which injections may be stopped.  

In what circumstance may injections be stopped temporarily?

In certain situations, the doctor may recommend a period of observation without injection in wet AMD.  For example, a patient may have been unable to return in a timely fashion for injection.  Upon delayed examination, the retinal specialist may find the wet AMD to be inactive.  Moving forward, injections may be held in this case.  Continued close observation is needed to detect recurrent active leakage of abnormal blood vessels in wet AMD.  

Rarely, injections may result in inflammation inside the eye.  Medication is prescribed to quell the inflammatory reaction to protect against permanent damage.  The wet AMD may become inactive in this situation and it may be observed for reactivation.  

When might the injections be stopped for the long term?

After months to years of treatment, the vision may decline despite injection therapy.  This may happen due to atrophy (loss of tissue) or scarring (fibrosis).  If the vision is very poor, injections may be stopped if it is clear that continued treatment will not improve the vision and further treatment is not necessary to prevent worsening of vision.  Furthermore, there is limited evidence that suggests injections for wet AMD may worsen dry AMD. 

What are the risks of stopping injections?

The main risk of stopping injections for wet AMD is that leaking and bleeding from abnormal blood vessels may cause further loss of vision.  This may result in a larger and/or darker central blind spot.  However, rarely it may result in total loss of vision in that eye.  

The chances of further loss of vision off injections largely depends on whether the macula has active leakage at the time injections are stopped.  In a study of 821 eyes observed for one year after stopping injection, Cornish and others found that 8% of all eyes had serious loss of vision.  However, 15% of eyes with leakage at the time injections were stopped experienced severe further loss of vision.  Therefore, if you have usable vision and wish to avoid further loss of vision, continued injections are preferable.  However, if you do not have functional vision and there is no active leakage of the macular degeneration, the risk of further profound loss of vision is low.  

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.