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.
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.
Two common retinal causes of vision loss are wet age-related macular degeneration (wAMD) and diabetic macular edema (DME). In both of these conditions a signaling protein (called VEGF) is released that promotes blood vessel leakage with loss of vision. A major advance in treatment came about with the development of drugs that block the effect of VEGF. These drugs (called antiVEGF) reduce the risk of vision loss and offer some improvement in vision in patients with wAMD and DME. Unfortunately, these drugs need to be administered as an injection into the eye. Consequently, drug manufacturers work to design drugs offering the best vision with the longest interval between injections (fewer injections).
What drugs are available and how effective are they?
The first drug to reduce the rate of loss of vision in wAMD was Macugen (pegaptanib). It is no longer used because newer drugs are more effective in offering improvement in vision. While Lucentis (ranibizumab) was under development, its parent drug Avastin (bevacizumab) was found to be effective for wAMD. Both Avastin and Lucentis appear more effective than Macugen. Eylea (aflibercept) was developed to block the effect of VEGF and another factor (placental growth factor) involved in blood vessel leakage; consequently, there is moderate evidence that it is more effective than Avastin and Lucentis in DME and offers a longer treatment interval in wAMD. Newer drugs include Beovu (brolucizumab) and Vabysmo (faricimab). There is little evidence to know if they are more effective than Eylea. Finally, Eylea is now formulated in a higher concentration (Eylea HD).
What is the cost of these drugs?
All of the drugs used to treat wAMD and DME are expensive with the exception of Avastin. Avastin was manufactured and priced to treat colon cancer. After it was released, doctors at the Bascom Palmer Eye institute discovered it was effective in treating wAMD. Thus, the small dose needed to inject into the eye costs about $50. This is in contrast to the other drugs on the market, which cost around $2000 per injection.
What are the adverse effects of these drugs in the eye?
Problems may occur from the injection of medications into the eye. The injection itself has risks apart from the drug that is injected; we will not discuss those risks here, but they include pain, elevated eye pressure, hemorrhage, infection, retinal detachment, and loss of vision. The drugs themselves may cause inflammation in the eye. Usually, inflammation causes pain, redness, light sensitivity, floaters, and decreased vision. Typically, it can be treated with drops and it resolves without permanent damage. However, sometimes the inflammation can be severe with permanent loss of vision. Inflammation induced by drugs is very rare with Avastin and Lucentis. It occurs in about 1% of Eylea injections, 2% of Vabysmo injections, and 4-5% of Beovu injections. The inflammation with Beovu may be especially severe with permanent loss of vision. The risk of infection appears less in drugs that are pre-packaged in a syringe for injection (Lucentis and Eylea), and greater in drugs that must be prepared for injection (Avastin, Vabysmo, Eylea HD, and Beovu).
What are the adverse effects of these drugs outside the eye?
There is concern about effects of these drug outside the eye. All of these drugs leave the eye, enter the blood vessels and are removed from the body through the urine. On their way out of the body, there is concern that they may increase the risk of heart attack and/or stroke. There is considerable debate as to whether there is a measurable effect or not. Some have estimated that the systemic risk may be about 1%. However, patients with known risk factors (hardening of the arteries, tobacco use, high blood pressure, high cholesterol, overweight, and diabetes) may be more likely to suffer a heart attack or stroke with the use of antiVEGF drugs. In one study, patients with diabetic macular edema were at 17% (range: 2-33%) higher risk of death when undergoing frequent injections up to 2 years. Another study, demonstrated increased risk of stroke or heart attack in diabetic patients with a history of past stroke or heart attacks. Therefore, this group of patients may benefit from careful drug selection. Of all the drugs, Lucentis is cleared the most rapidly from the body and has the least systemic effects.
Want a summary of the cost, effectiveness, and safety?
Summary:
AntiVEGF drug
Cost
Effectiveness
Safety
Avastin
Cheap: ~$50
Good
Repackaging*
Lucentis
Expensive: ~$2,000
Good
safest systemically**
Eylea
Expensive: ~$2,000
Better
1% inflammation
Eylea HD
Expensive: ~$2000
?Better
1% inflammation or greater?
Vabysmo
Expensive: ~$2,000
?Better
2% inflammation
Beovu
Expensive: ~$2,000
?Better
4-5% inflammation
A list of drugs available in the US approved for injection into the eye
* Repackaging increases risk of infection, floaters, and discomfort for dull needles
** Especially relevant when repeated injections are required in diabetic patients
What is my professional preference?
I have employed all of these drugs for my patients. When cost is an issue, an insurance company may insist on the use of Avastin. I generally prefer Lucentis in my diabetic patients for its superior systemic safety. Eylea can be helpful to extend treatment intervals (longer time between injections) in wet macular degeneration. Eylea may also be safer in patients who also have glaucoma, or at risk of developing glaucoma. I have been favorably impressed with Vabysmo in extending treatment intervals even further in wAMD, but I am less impressed with any advantage in my patients with DME (diabetic macular edema). I am currently exploring the role of Eylea HD, especially to extend the treatment interval in patients with wet AMD. Due to the risk of inflammation with loss of vision from Beovu, it is not my preferred agent. Lucentis biosimilars (Cimerli and Byooviz) are not my preferred agents at this time…I am awaiting further evidence on their safety and effectiveness.
Are doctors paid by drug companies to use their drugs?
There are varying amounts of profit margins and rebates given to doctors by drug companies in an effort to promote the use of their drugs. Usually, the newer the drug, the greater the inducement. To determine if your doctor is receiving large payments by drug companies, visit the CMS website and enter your doctor’s name in the search box.
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.
Vabysmo therapy (pronounced, “vah-BYE-smo”) is a treatment for wet-type macular degeneration and diabetic macular edema. It involves repeated injections of medication into the eye to stop abnormally leaky blood vessels. Vabysmo is the trade name of the medication and faricimab is the research/generic name. On January 28, 2022, the FDA approved Vabysmo for use in the United States based on standard phase 3 study results (Yosemite/Rhine Studies for diabetic macular edema and Tenaya/Lucerne Studies for wet macular degeneration).
How effective is Vabysmo therapy?
Vabysmo may last longer than other drugs currently available to treat these conditions. However, it has been my experience that Vabysmo offers little additional benefit in diabetic macular edema. I currently prefer Lucentis in patients treated for diabetic macular edema.
In wet-type macular degeneration (wAMD), Vabysmo does appear to last longer than other currently approved medications in some patients. However, there appears to be an increased risk of loss of vision from RPE tear in patients with serous retinal pigment epithelial detachment in the setting of age-related macular degeneration.
What are the risks of Vabysmo therapy?
Severe complications are very rare, but risks of Vabysmo injection include bleeding, infection, retinal detachment, glaucoma, cataract, and loss of vision/loss of the eye. The risk of retinal detachment is about 1 in 5,000 injections, but the visual results are poor despite surgical repair. In initial studies there appeared to be a low risk (1.8%) of stroke with this type of 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. Non-infectious inflammation is less common with Vabysmo than brolucizumab (Beovu), another drug that offered drug treatment at reduced intervals. Although rare, inflammation did occur in Vabysmo (1-2% of cases) more than twice as often as it did with Eylea (1% or less). Pregnancy should be avoided while on Vabysmo therapy.
What do I expect after a Vabysmo 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, 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.
UPDATE October 2022: I have been using Vabysmo in the office. I am pleased with the results in patients with wet AMD in that I can extend the treatment interval further than with older drugs. These findings are in concert with a recent two-year report of the Tanaya Study at the American Academy of Ophthalmology. However, patients with large serous pigment epithelial detachments (PED) appear to be at greater risk of vision loss from rips in the PED. In contrast to eyes with macular degeneration, I have not been impressed with superior effectiveness of Vabysmo in patients with diabetic retinopathy.
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.
There are many conditions, which threaten loss of vision, that are treated by injecting various medications into the eye. The eye conditions include macular degeneration, diabetic retinopathy, retinal vein occlusion, uveitis, and others. The injections may be given into the tissues outside the eyeball (subtenon’s injections) or into the eyeball (intravitreal injections). It is very important to avoid pain as these injections may need to be given repeatedly over time.
Why do I have pain after eye injections?
Although pain during eye injections can usually be minimized with anesthetics given before the injection, sometimes there is pain for hours after the injection. There are many reasons why this may occur:
1.) The antibiotic (betadine) may irritate the eye for hours after it has been applied to the eye.
2.) The eye may become dried out after the injection due to insufficient blinking.
3.) The eye may be accidentally scratched by rubbing the eye while it is still anesthetized.
4.) The drug that is injected into the eye may cause an inflammatory reaction.
5.) Rarely, a severe infection called endophthalmitis may occur after injection into the eyeball.
What can be done to prevent pain after injections?
The key to eliminating pain after eye injections is to identify the underlying cause. This may take some detective work. Although betadine is given at the time of injection to prevent infection, only a small dose is needed. If a large amount of betadine is used or if the betadine has not been thoroughly rinsed off the eye, it may cause blurred vision, persistent burning, itching, and/or a scratchy sensation like sand in the eye (called a foreign body sensation). Therefore, it is important for the eye doctor or technician to completely rinse the betadine off the eye after an eye injection in order to avoid pain later.
Sometimes, the surface of the eye may become dry after an injection because the patient does not blink frequently enough or not completely enough. This often happens as a result of the anesthetic used in preparation for the injection. After the injection is over, the anesthetic may continue to work for 15-30 minutes. During that time, the patient does not have the normal sensation necessary to indicate that it is time to blink. If the eye does not blink often enough, the surface may dry out and cause blurred vision, pain or foreign body sensation. Therefore, the patient may need to purposefully blink frequently or simply rest the eye closed for a while after an eye injection in order to prevent drying. Similarly, if a patient does not close the eye completely with each blink, part of the eye can become dry. In some cases, it may be necessary to forcibly close the eyes with each blink in order to be sure the lids close completely.
At times a patient may unknowingly rub and scratch the eye after an injection because of persistent numbing after an injection. Therefore, it is very important to avoid touching the eye for 15-30 minutes after an injection. If the eye needs to be dried off, a clean tissue may be used with a gently damping or blotting motion in the corner of the eye where the lids come together at the bridge of the nose. It is best not to move the tissue left and right or up and down in a rubbing fashion. Once the eye becomes dry or irritated for any reason listed above, it may take 1-2 days for the pain to go away and the eye to return to normal.
Rarely, a drug that is injected into the eye can cause an inflammation that causes pain or blurred vision. The doctor makes this diagnosis by examining the eye under the biomicroscope (called a slit lamp). If a medication is determined to be the cause of inflammation, it is treated with prescription eye drops and the offending drug is not used again in that patient in the future.
Infection is an extremely rare cause of pain after an eye injection. In about one in several thousand injections, germs may enter the eye through the needle tract after an eye injection. This rare infection is called endophthalmitis (pronounced like “end-off-thal-my-tiss”). Symptoms usually start with pain, redness, and loss of vision several days to a few weeks after an injection. There is no perfect way to prevent endophthalmitis. The doctor uses techniques like applying betadine before the injection. The patient tries to avoid contaminating the eye by avoiding exposure the unclean areas (like a barnyard) and avoid rubbing the eyes after injection. Endophthalmitis is very serious and may result in permanent loss of vision. Therefore, any patient having deep aching pain, increasing redness, and loss of vision starting several days or weeks after an eye injection should notify their eye doctor for prompt evaluation.
What can be done to make the eye feel better?
If the cause of the pain and irritation is from betadine, drying, or rubbing the eye, the best treatment is lubrication. Lubricants are available over-the-counter in the form of eye drops, eye gels, and eye ointments (see examples at the end of this article). The thicker the lubricant, the better the relief of pain and discomfort. However, gels and ointments may be difficult to place into the eye and they tend to make the vision blurry for several minutes or more. Lubricants may be used as often as needed. Resting the eyes closed may also provide relief. Cold compresses help many patients. Over-the-counter pain medications like ibuprofen and/or Tylenol may be helpful. Prescription pain medications are rarely needed and may cause undesirable side effects.
If the cause of the pain and irritation is from a drug reaction or from infection inside the eye, the doctor will prescribe special anti-inflammatory eye drops. If the eye exam shows infection, antibiotic injections must be given into the eye and surgery in the operating room may be necessary.
If pain keeps occurring after eye injections despite taking the measures listed above, sometimes prescription eye medication can help. Non-steroid (NSAID) eyes drops or steroid/antibiotic ointments may help prevent the pain. Most instances of pain after eye injections may be avoidable. Please talk with your eye doctor to help resolve the problem in order to undergo treatment without pain.
Gels are easier to apply than ointments and may be used immediately after an eye injection to prevent eye pain and they may be used later to soothe eye discomfort.
Ointments are more difficult to place in the eye. However, they provide longer duration of action. They may be used immediately after an eye injection to prevent eye pain and they may be used later to soothe eye discomfort.
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The Amsler grid is a test used to detect and monitor macular disease (see Anatomy of the Eye). The macula is the area of the retina in the back of the eye that is responsible for seeing details in the central vision. The retina is a thin layer of delicate nerve tissue that lines the inside wall of the eye like the film in a camera. In the eye, light is focused onto the retina, which “takes the picture” and sends the image to the brain.
How is the Amsler grid used?
The grid is observed one eye art a time with reading glasses if needed for proper focusing at normal reading distance. The patient is asked to fixate on the center of the grid while using “side vision” to see if there are any missing areas. The lines on the grid should appear straight and uniform. If any abnormalities are noted, an ophthalmologist (retinal specialist) may be consulted to determine the cause of the problem.
Below is a link to download or print an Amsler grid chart for use at home.
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.
There are many different kinds of lasers used to treat eye problems and many different ways lasers can be used to help the eye function. For example, the most common type of laser performed after cataract surgery is YAG capsulotomy. In this procedure the YAG laser is designed to open up a foggy window that develops behind the lens implant. It is a very brief, painless laser that usually gives a rapid improvement in vision. Other uses for lasers include treatment for glaucoma, droopy eyelids, and near-sightedness. Lasers with specific properties are chosen for a specific purpose. This blog discusses the photocoagulating laser used to treat retinal problems.
What is the retina?
The retina is a thin layer of delicate nerve tissue, which lines the inside wall of the eye like the film in a camera. In the eye, light is focused onto the retina, which “takes the picture” and sends the image to the brain. The retina has two main areas. The macula is the central area that gives you sharp, central vision and color vision. The peripheral retina is the part of the retina that gives you side vision and night vision.
Most retinal lasers work by producing a carefully measured amount of heat to the retina in very small spot sizes. This heat may help to cauterize leaking blood vessels as in diabetes or macular degeneration. Alternatively, laser may simply seal down the retina to help keep it from detaching from the inside wall of the eye in cases of retinal tears and limited retinal detachments.
What are the risks of retinal laser treatment?
While laser is generally safe and effective, there is always some risk of adverse effects. Depending on the purpose of the laser, risks include blind spots in the vision that may be permanent, loss of central vision, loss of color vision, loss of night vision, and distortion of vision.
What is it like to experience a laser treatment?
Laser treatment is performed in the office in a matter of a several minutes. To avoid pain and discomfort, the ophthalmologist anesthetizes the eye with eye drops. An injection of anesthetic around the eye is rarely required. You sit in the examining chair with your chin in the chin-rest and forehead against the supporting bar. A contact lens is placed on the eye to hold the eyelids open. You may blink normally during the laser. Try not to squeeze your eyes together, because it may push the contact lens off the eye. You may be asked to look in a specific direction or follow a small light in order to keep the eye in position for treatment. It is important to follow instructions carefully to avoid side effects of laser treatment, which may include seeing blind spots in the vision afterwards. During treatment, it is normal to see bright flashes of light. Sometimes, you may feel a pulsing sensation with the flash. If it becomes painful, please notify the doctor. The treatment may last one to fifteen minutes depending on how much retinal damage is present.
What can you expect after a laser treatment?
Immediately after the contact lens is removed, your vision may be temporarily tinted red or blue. The vision is usually blurred for a few hours because of the dilating drops. Temporary blurring from laser sometimes lasts a week or more, but is usually mild. If your laser treatment was for macular degeneration, you may see a new permanent blind spot in the vision where abnormal blood vessels were cauterized. If you had laser for retinal break, it is normal for you to see floating specks in your vision and occasional flashes of light off to the side after laser. There are usually no restrictions to your activities. You may read, watch TV, stoop, bend, and lift objects just as before your treatment. No special eye drops are required after laser treatment, but be sure to continue any eye drops you were using before the treatment. You may use sunglasses for comfort, but they are not required. If you were told that laser is being used to improve your vision, it usually takes weeks or months to see the improvement. Sometimes, more than one treatment is required. Your doctor will give you an appointment to assess the results and determine whether any more treatment is needed.
What warning signs should I report after treatment?
Although it is normal to have blurred vision right after laser, the following symptoms are important to report to your Eye MD:
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There is substantial evidence that fenofibrate is beneficial in the treatment of diabetic retinopathy. The retina in a thin layer of nerve tissue that is sensitive to light and acts like the film in a camera. The retina “takes a picture” of what your eyes focus on. The fine blood vessels in the retina are especially sensitive to high blood sugar levels, which cause the vessels to leak and eventually become blocked. This damage is called diabetic retinopathy.
Fenofibrate is a medication commonly used to control blood lipid levels. Abnormal serum levels of lipid have been shown to increase the risk of hardening of the arteries (atherosclerosis), which may lead to stroke and heart attack. While the goal of controlling lipids in diabetes is important in itself, fenofibrate appears to offer an independent benefit to small blood vessels (capillaries) in the retina. Two large studies (ACCORD and FIELD) demonstrated that fewer laser treatments were needed in a group of patients on fenofibrate compared with other patients who were randomized not to receive treatment with this medication for abnormal serum lipid levels. Fenofibrate may be used along side other medications used for lipid control (such as statins). However, patients with severe kidney damage should not use fenofibrate. A common dose of fenofibrate is 160mg per day. However, fenofibrate 54mg is recommended for patients with glomerular filtration rate (GFR) between 30 and 50. No fenofibrate is recommended if the GFR is less than 30.
There are established treatments for diabetic retinopathy. The mainstay of treatment of vision-threatening diabetic retinopathy remains laser and anti-VEGF injections (Avastin, Lucentis, Vabysmo, and Eylea). In severe cases of diabetic retinal damage, vitrectomy surgery is needed to restore vision or prevent blindness. However, there are patients with diabetes who lose vision despite treatment and those who develop side-effects of treatment. Therefore, fenofibrate is a welcome addition to the medical treatment regimen.
Prevention of diabetic eye damage is far superior to treatment of diabetic retinopathy. Therefore, it is best to prevent diabetic damage to the eyes and other organs in the body through proper management of blood sugar, blood pressure, and blood lipids with the help of a medical doctor. In difficult cases of diabetes, the help of an endocrinologist is necessary. Finally, annual dilated eye exams with an eye doctor skilled in the management of diabetic retinopathy is key to identify retinal damage before vision is lost.
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Ozurdex is a very small tube-like implant that contains steroid medication that is slowly released into the eye for up to 3-6 months. The Ozurdex implant is injected into the eye in the office setting in order to decrease inflammation, swelling, or leaky blood vessels inside the eye. It has been shown to improve vision in eyes with retinal vein occlusion, diabetic macular edema, and inflammation in the eye. The Ozurdex implant completely dissolves in the eye. Repeated injections may be necessary for continued improvement in vision.
How is an Ozurdex injection performed?
Anesthetics are used to make the procedure pain-free. The eye is treated with an iodine solution in an effort to prevent infection and an instrument is used to gently keep the lids open during the injection. A pressure sensation is often felt as the implant is injected into the eye with a very thin, short needle. The procedure is very brief.
What are the side effects of Ozurdex?
Although possible, it is rare to see the Ozurdex implant floating in the vision. In about 30-40% of patients, the pressure inside the eye increases and requires eye drops. About 1% of patients require glaucoma surgery to prevent loss of vision. Most eyes develop cataract and eventually require surgery. Rare risks of steroid injection include bleeding, infection, retinal detachment, and loss of vision/loss of the eye. The risk of infection is about one in 1,000 injections. Please report any severe loss of vision to the doctor without delay.
How do I care for the eye?
You may be given eye drops and instructions on how to use them. Physical activity is not limited after Ozurdex injection. Tylenol or Ibuprofen may be used if there is discomfort, 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. Additional information is available at www.ozurdex.com.
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.
The Iluvien implant is shaped like a small thin tube so that it can be injected into the eye in the office with a needle attached to an injector. The tube contains a corticosteroid medicine that is released into the eye slowly for up to 2-3 years. Repeated injections may be performed. When the tube-like implant is empty it remains in the eye and usually causes no problems.
What is the Iluvien implant used for?
The Iluvien implant decreases inflammation, leaky vessels and swelling inside the eye. It has been approved to treat diabetic macular edema. It helps keep the vision from worsening and may improve vision over time.
How is an Iluvien implant inserted into the eye?
Anesthetic solutions are used to make the procedure pain-free. The eye is treated with an iodine solution in an effort to prevent infection and an instrument is used to gently keep the lids open during the injection. A pressure sensation may be felt as the implant is injected into the eye with a very thin, short needle. The procedure is very brief.
What are the possible side-effects?
It is normal to experience a red area on the white of the eye, which disappears in one to two weeks. It is rare to see the tube floating in the vision. Most eyes require cataract surgery several months after injection of the implant. About 30-40% of eyes experience a pressure increase (glaucoma) in the eye. Although the pressure is not usually painful, it may require eye drops to prevent permanent loss of vision. In 1-5% of eyes, glaucoma surgery is needed. Rare risks of injection include bleeding, infection, retinal detachment, and loss of vision/loss of the eye. Please report any severe loss of vision to the doctor without delay.
How do I care for the eye?
You may be given eye drops and instructions on how to use them. Physical activity is not limited. Tylenol or Ibuprofen may be used if there is discomfort, but severe pain should be reported to your doctor without delay. If you have any questions or concerns, please call the office.
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.
Clear vitreous gel fills the eye (click on image to enlarge)
Why is an intravitreal steroid injection performed?
An intravitreal steroid injection (ISI) is a painless office procedure performed to decrease inflammation, swelling, or leaky blood vessels inside the eye. Conditions that may require ISI include diabetic macular edema, retinal vein occlusion, uveitis, macular degeneration, and other causes of swelling and/or inflammation. The steroid medicine acts to decrease inflammation and leakage from blood vessels from a variety of causes, thereby offering the chance for improvement in vision. The effect of ISI lasts for several months after which repeated injection may be considered if necessary.
How is an intravitreal steroid injection performed?
Anesthetic solutions are used to make the procedure pain-free. The eye is treated with an iodine solution in an effort to prevent infection and an instrument is used to gently keep the lids open during the injection. A pressure sensation is often felt as the steroid is injected into the eye with a very thin, short needle. The procedure is very brief.
Intra-vitreal injection
What medications are injected?
Triamcinolone is a steroid that has been used for many years in the eye. The most common preparation contains preservatives that may be decanted from the preparation to avoid ocular inflammation. Triesence® is a form of triamcinolone for the eye that lacks preservatives, but is more expensive. These steroids usually provide anti-inflammatory effect for several months.
Dexamethasone may be injected into the eye in a slow-release implant, called Ozurdex®. The effect of Ozurdex® may last up to 3-6 months.
Iluvien® is a steroid implant (2014) approved for the treatment of diabetic macular edema. It may last up to 2-3 years.
Yutiq® is a steroid implant approved for the treatment of uveitis. It may last up to 2-3 years.
Intraocular steroid preparations
Will an intravitreal steroid injection affect my vision?
It is normal to see the steroid medication after the injection as many floating particles (triamcinolone) or a single large fiber (Ozurdex®, Iluvien®, Yutiq®), which slowly disappear over several weeks to months in the case of triamcinolone and Ozurdex. The anticipated improvement in vision occurs slowly during this time. Commonly, the pressure inside the eye increases and may require eye drops for several months. Sometimes the high pressure results in optic nerve damage (glaucoma) and rarely requires surgery in 1-4% of cases. There is also an increased rate of cataract formation. For these reasons ISI is best performed in eyes that have already had cataract surgery and are not at high risk of glaucoma damage. Rare risks of steroid injection include bleeding, infection, retinal detachment, and loss of vision or loss of the eye. The risk of retinal detachment is about 1 in 5,000 injections. The risk of infection is about one in 1,000 injections. Please report pain or any severe loss of vision after injection to the doctor without delay.
How do I care for the eye?
You may be given eye drops and instructions on how to use them. Artificial tears may be used hourly until the eye feels less irritated from the iodine solution, which is used to prevent infection. Physical activity is not limited after ISI. 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 your doctor.
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.
Hemoglobin A1C is a blood test that measures the average blood sugar level in the blood over the past two or three months. Specifically, this test measures the amount of sugar that permanently attaches to hemoglobin, a protein in red blood cells. Because red blood cells live for about three months, this test shows the average blood sugar level during that time. This test gives some of the information that you could get if you measured your blood sugar every day continuously throughout the day and night.
Why is hemoglobin A1C important?
We know high blood sugar damages blood vessels and may cause blindness, kidney failure, nerve damage, amputation, heart attack, stroke, and premature death. Managing blood sugar dramatically reduces the risk of these complications. The hemoglobin A1C test helps to determine whether your blood sugar control has been adequate to minimize damage from diabetes.
Do I need both hemoglobin A1C and standard blood sugar testing?
Yes. Each test gives different information about blood sugar control. For example, your fasting blood sugar may be normal, but if your hemoglobin A1C is high, then you know there are times in the day that the blood sugars are too high and you are still at risk of having complications from diabetes. On the other hand, if your hemoglobin A1C is high, you need spot checks of the blood sugar level to know specifically what part of the day in which you may need to manage differently.
How do results from hemoglobin A1C compare with blood sugar levels?
The hemoglobin A1C test measures the percent of hemoglobin that is chemically bound to sugar. The normal range of hemoglobin A1C is 4-6%, which corresponds to an average blood sugar level of 60-120 mg/dl. Your doctor will help determine what level is best for you, but generally a hemoglobin A1C greater than 7% (average blood sugar equal to 140 mg/dl) means that measures must be taken to achieve better management.
The hemoglobin A1C test results may be inaccurate in certain conditions. The test results may be falsely low in the following situations: the use of dapsone, certain types of anemia, mechanical heart valves, recent blood transfusion, enlarged spleen, treatment with erythropoietin, severely elevated triglycerides, high-dose vitamin C or E.
Conversely, test results may be falsely elevated in the following situations: untreated hypothyroidism, after surgical removal of the spleen, Iron deficiency, vitamin B12 deficiency, reduced red blood cell production by the bone marrow, chronic alcoholism, chronic kidney disease.
If there is a question about the reliability of the test results, other means of testing may be considered, such as the fructosamine test.
Hemoglobin A1c
Blood Sugar
A1c
(mg/dL)
4%
60
5%
90
6%
120
7%
150
8%
180
9%
210
10%
240
11%
270
12%
300
13%
330
What can I do if my hemoglobin A1C results are high?
While it is important to keep blood sugar levels from being too high, it is also important not to risk frequent or severe episodes of dangerously low blood sugar levels. You and your doctor will evaluate your situation to determine which of the following factors may be playing a role:
Too little exercise
Inadequate medication type or dosing
Too much food
Wrong types of food
Increased stress
Infection
The hemoglobin A1C test provides you with more information to maintain good management of your diabetes. Better control means a longer, healthier life. And any positive change in your care, no matter how small, makes a difference. For example, each 1% decrease in the hemoglobin A1C reduces the risk of eye and kidney damage by 37% and reduces the risk of diabetes-related death by 21%. The more you are involved with your health care, the greater the likelihood of living a longer and healthier life.
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.
Tobacco use is widely known to cause lung damage, but the eyes are also affected. Bothersome irritation of the eyes is caused by smoke from tobacco especially in patients with dry eyes. However, permanent loss of vision may occur from such problems as macular degeneration, retinal vein occlusion, ocular histoplasmosis syndrome, glaucoma, cataract, Grave’s Disease (a thyroid condition that affects the eyes), uveitis (inflammation of the eye), ischemic optic neuropathy, and diabetic retinopathy. Tobacco appears to play a role in causing and/or worsening these conditions. Tobacco is known to promote hardening of the arteries, and this may harm blood flow to the eye. Tobacco also promotes the development of blood clots, which may block blood flow in the eye. Tissue damage also occurs from toxic compounds in tobacco that cause a chemical reaction called oxidation. More research is needed to fully understand the role of tobacco in causing loss of vision.
What resources are available to help stop tobacco use?
Because most people cannot stop tobacco “cold turkey,” many resources are available to help quit the habit. Counseling may provide much needed support in the process of stopping tobacco use. For free classes and one-month’s supply of nicotine replacement therapy, your doctor can refer you to the Area Health Education Center. Alternatively, you may call 1-877-848-6696. The class schedule may be viewed at www.ahectobacco.com/calendar. If you are interested in talking to informed support staff, please call 1-800-QUIT-NOW. Nicotine replacement therapy plays an important role and several preparations are available over-the-counter. These non-prescription forms of nicotine include gum, lozenges, and patches. Medicare and most insurance companies now cover the costs of prescription medications to help stop tobacco use. These include nicotine nasal sprays, nicotine inhalers, as well as pills (Zyban and Chantix). With the help of counseling, nicotine replacement, and prescription medication, you can live a longer and healthier life without tobacco. For more information please visit www.smokefree.gov.
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.
Vitreous gel fills the eye (click on image to enlarge)
What is vitrectomy surgery?
Vitrectomy surgery is an advanced form of eye surgery that is performed in the operating room under a microscope. It is often used to treat conditions such as retinal detachment, macular pucker, macular hole, vitreomacular traction, diabetic retinopathy, vitreous hemorrhage, dislocated cataract/lens implant, endophthalmitis, and uveitis. Vitrectomy may take thirty minutes to several hours to perform depending upon what task is being accomplished. Despite common tales, the eye is not taken out and placed on the cheek. It remains in its normal position throughout the surgery. Vitrectomy may be performed under general anesthesia to avoid pain and to avoid eye movement during surgery. During vitrectomy, tiny needle-like incisions are made to enter the white of the eye to gain access to the central core of the eye, which contains a gel called vitreous. Various instruments no larger around than needles are placed into the small incisions to perform tasks such as peeling or cutting membranes from the retinal surface, cauterizing blood vessels, removing blood or inflammatory debris from the eye, and applying laser. The surgeon views the tips of the instruments through the dilated pupil with an operating microscope. Sometimes, a gas bubble or silicone oil is placed in the eye to hold the retina in position to heal properly.
What type of anesthesia is available?
Although some surgeons and patients choose local anesthesia, general anesthesia is also available. With local anesthesia the patient is sedated with IV medication so there is no memory of the anesthetic injection around the eye. Surgical drapes are placed over the face leaving plenty of breathing room. During surgery the patient is awake, but generally does not feel pain. It is important to lie still on the operating room table as movement during surgery may result in damage to the eye and affect the final visual result.
General anesthesia offers some advantages over local anesthesia. With general anesthesia the patient is motionless and remembers nothing of the surgery. The anesthesiologist places a tube to hold the airway open. Which type of anesthesia is best for a patient may be determined by the health of the patient, so you may wish to ask your internist for advice. If a person cannot lie still for the surgery or if claustrophobia is a problem, general anesthesia is preferred. Although there are risks with any type of anesthesia, modern techniques offer a high degree of safety for the patient.
How can I prepare for vitrectomy surgery?
Your retinal specialist may schedule an appointment with your primary care doctor if evaluation is needed prior to surgery. Please inform your doctor of any chest pain or pressure, fever, productive cough, or shortness of breath. Unless otherwise notified by your doctor, do not take aspirin-containing products or any herbal supplements for two weeks prior to surgery. Coumadin may be stopped four days prior to surgery. On the morning of surgery, take no medications for diabetes unless instructed differently by your doctor, but please do take all of your other medications with a sip of water. Otherwise, do not eat or drink anything after midnight the day before surgery. If you usually use eye drops in the morning, they may be taken on the morning of surgery. Please click on this link for further information on how to prepare for surgery.
What are the risks of vitrectomy surgery?
Although uncommon, problems such as bleeding and infection may arise from any surgery. Retinal detachment or abnormal scar tissue formation may require additional surgery. Rarely, there may be loss of vision/loss of the eye. The most common problem following vitrectomy surgery is progression of cataract. Although serious problems are not encountered often, the risks and benefits must be weighed for each individual prior to surgery. For many eye problems, vitrectomy surgery is the only way to improve vision or prevent blindness.
What can I expect after vitrectomy surgery?
A soft eye patch and a hard eye shield are placed on the eye at the end of surgery. Leave these in place until your exam on the day after surgery. You may use Tylenol or Advil for aching pain, but call the doctor for a prescription if your pain is not relieved. It is not common to have severe pain after vitrectomy surgery. A scratchy feeling may result from sutures on the white of the eye. These sutures dissolve in about three weeks. At your exam after surgery, you will be given eye drops and/or an ointment to keep the eye comfortable, to prevent infection, and to promote healing. Wearing the eye patch is optional after you are seen in the office, but you may wear the hard protective shield as needed to prevent trauma to the eye. Depending upon the reason for your surgery, it may be very important to lie face down or on either side after your surgery. Be sure you understand any positioning requirements given by your surgeon and feel free to ask about special pillows and equipment available to help maintain head position. If a gas bubble is placed in your eye at the time of surgery, you may not fly on a plane or undergo nitrous-oxide anesthesia until the gas has dissolved, or you could risk severe pain and blindness. You may see the gas bubble as a horizontal, dark, curved line or as a dark ball in the vision. If a gas bubble is used during surgery, please keep a MedicAlert bracelet on your wrist until the gas has disappeared. The vision usually returns slowly over days to weeks after surgery, but may take many months for final recovery. The swelling and redness slowly disappear over weeks to months.
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.
Eylea therapy is a treatment for diabetic retinopathy, retinal vein occlusion and wet-type macular degeneration. It involves repeated painless injections of medication into the eye to prevent blindness by stopping abnormally leaky blood vessels that occur in the eye conditions listed above. Other similar medications that are also used in these conditions include Avastin, Lucentis, Vabysmo, and Beovu.
How effective is Eylea therapy?
Eylea was proven in FDA-approved studies to be effective. In wet-type macular degeneration, monthly or bimonthly injections of Eylea over a one-year period offered a 95% chance of losing less than three lines on a standard eye chart. Eylea was also shown to be effective in the treatment of diabetic retinopathy and retinal vein occlusion to improve vision and prevent severe complications. The results with Eylea are similar to treatment with Lucentis, Avastin, and Beovu. Eylea therapy often starts with injections every 4-6 weeks. Afterwards, the injections may be given less frequently. In some cases the injections may be stopped, but continued monitoring is necessary. There are several medication options apart from Eylea. The best choice of medication may depend on the underlying diagnosis. For example, patient who have glaucoma may have better pressure control while under treatment with Eylea compared with other drugs.
What are the risks of Eylea therapy?
Severe complications are very rare, but risks of Eylea injection include bleeding, inflammation, infection, retinal detachment, cataract, glaucoma, 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 weaken from Eylea 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 Eylea therapy. The possible risk of stroke may be related to the older age of patients with AMD. Further investigation will provide more information. Pregnancy should be avoided while on Eylea therapy.
Intra-vitreal injection
What do I expect after an Eylea 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 doctor’s office.
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.
Avastin therapy is a treatment for retinal conditions involving abnormal blood vessel leakage including wet-type age-related macular degeneration, myopic macular degeneration, retinal vein occlusion, diabetic retinopathy, and cystoid macular edema. The treatment involves the painless injection of medication into the eye to stop the leakage and improve vision. The benefits of treatment last one or more months. Repeat injections are common in order to keep the leakage from returning. When the problem has stabilized, the injections may be given less often or discontinued in some conditions. Avastin has not been reviewed by the FDA for use in the eye; therefore, it is used off-label. Safety and effectiveness has been established through extensive experience with the use of Avastin in the eye for a multitude of problems since 2005. There are other similar drugs that have been FDA-approved for use in the eye including Lucentis,Eylea, Vabysmo, and Beovu. These drugs are much more expensive than Avastin. Avastin costs about $50 compared to $2,000 with the FDA-approved drugs. There may be reasons to use one medication over another depending on the diagnosis.
How effective is Avastin therapy?
Avastin has been found to be effective in the treatment of a variety of retinal disorders of blood vessel leakage. It was shown to be as effective as Lucentis in the treatment of wet-type macular degeneration in most patients. Avastin is also effective in the treatment of macular edema, retinal vein occlusion, diabetic retinopathy and other conditions of the eye.
What are the risks of Avastin therapy?
Severe complications are very rare, but risks of Avastin injection include bleeding, infection, inflammation, 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%. In these cases the zonules that hold the cataract in place may become weaken from Avastin 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 Avastin therapy. Further research is needed. However, pregnancy should be avoided while on Avastin therapy.
There appears to be a greater risk of high eye pressure (glaucoma) in eyes treated with Avastin compared with Lucentis and Eylea. This may be especially important in patients at increased risk of glaucoma due to past high eye pressures or positive family history of glaucoma.
Because Avastin must be measured and placed in a syringe by a compounding pharmacy after manufacture, there may be increased risk of complications with Avastin compared with other similar drugs such as Lucentis, Eylea, Beovu, and Vabysmo. There may be an increased risk of infection due to the introduction of bacteria during repackaging. Some patients experience persistent round floaters due to silicone droplets used to lubricate the syringe from the pharmacy. Over the years, there have been concerns over needle quality (sharpness), which can make injection more uncomfortable.
Intra-vitreal injection
What do I expect after an Avastin injection?
If a patch is placed on the eye, keep it on as directed by the doctor, usually 3-4 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.
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.
Diabetes mellitus is a group of conditions characterized by abnormally high blood sugar levels. Short-term side effects include increased thirst, frequent urination, and weight changes. Long-term complications include numbness of the hands and feet, loss of vision, kidney failure, as well as hardening of the arteries leading to amputation, heart attack, stroke, and premature death. Diabetes affects about one million Floridians and 16 million Americans. It is the leading cause of blindness in America among adults. Several studies have proven that strict control of blood sugar levels dramatically decreases the risk of blindness and other complications of diabetes. The National Eye Institute proved that laser treatment may save vision if diabetic eye damage is detected early. The American Diabetes Association recommends annual eye examinations for all adults with diabetes to prevent blindness.
What is the retina?
The retina is a thin layer of delicate nerve tissue, which lines the inside wall of the eye like the film in a camera. In the eye, light is focused onto the retina, which “takes the picture” and sends the image to the brain. The retina has two main areas. The macula is the central area that gives you sharp, central vision and color vision. The peripheral retina is the part of the retina that gives you side vision and night vision.
What is diabetic retinopathy?
Diabetic retinopathy is a condition that occurs after many years of high blood sugar. It consists of damage to tiny blood vessels within the retina resulting in abnormal leakage of fluid and blood inside the eye. If not detected or treated, diabetic retinopathy may cause bleeding, scar tissue formation, retinal detachment, and blindness.
Stages of diabetic retinopathy:
Non-proliferative diabetic retinopathy: The first stage of retinal damage consisting of a weakening or blockage of tiny blood vessels, which does not require treatment with laser unless macular edema develops.
Diabetic macular edema: Swelling of the central retina (the macula) due to abnormal leakage of fluid from small blood vessels weakened by diabetes. Blurring of central vision may advance to legal blindness.
Proliferative diabetic retinopathy: The second stage of diabetic retinopathy in which abnormal, weak blood vessels begin to grow from the retina into the clear gel (vitreous) which fills the inside of the eye. If not treated, this serious stage often results in blindness from bleeding. Symptoms include new “floaters” or sudden loss of vision. Retinal detachment may occur from diabetic scar tissue, which pulls the retina off the eye wall. Retinal detachment causes a dark shadow in the vision or total loss of vision. Laser and vitrectomy surgery best control these problems if detected early.
How is diabetic retinopathy diagnosed?
Because no symptoms may be present until severe damage to the retina has occurred, it is essential that all adults with diabetes have a complete, dilated eye examination at least once a year. The eye doctor can see into the eye with an ophthalmoscope to diagnose retinopathy. If significant changes are found, photographs can be taken to record the changes. A fluorescein angiogram may be performed in the office by injecting a fluorescent dye into the vein of the arm while photographs are taken of the retina. It supplies important information about the health of the retinal blood vessels.
How is diabetic retinopathy treated?
No treatment is needed if the vision is not threatened. If blood vessel damage is significant, painless injections of medicine (Avastin) may be required to improve vision. Laser treatment performed in the office can often prevent severe visual loss. Laser produces heat, which serves to cauterize the damaged retinal blood vessels. Usually there is no pain, but if extensive laser is needed, an anesthetic injection may be given around the eye. In severe cases of bleeding and scar tissue formation, vitrectomy surgery is performed as a one-day surgery in the hospital. With laser and vitrectomy surgery, most people can retain useful vision. However, some people lose vision despite all efforts with treatment.
What can I do to prevent diabetic damage?
Strict control of the blood sugar has been proven to reduce the rate of progression of diabetic retinopathy by about 70%. In addition, loss of vision can be minimized by optimal control of other health problems such as physical inactivity, obesity, hypertension (<130/<80), cholesterol (<200) and triglycerides (<150), heart failure, and kidney failure. Tobacco use is strongly discouraged. Daily aspirin use is recommended.
PREVENT BLINDNESS THROUGH GOOD MANAGEMENT OF DIABETES AND REGULAR DILATED EYE EXAMINATIONS.
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.
