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.
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.
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.
There are various eye conditions that may result in loss of vision with limited potential for recovery with treatment. In these situations, good lighting and magnifiers are essential for making best use of low vision. Magnifying glasses and large closed-circuit TV magnifiers are large and heavy. They are most useful for home use. However, away from home, these devices may be too cumbersome. An ideal solution to the problem, is the portable digital magnifier. The small magnifiers are lighter than an old-fashioned magnifying glass and are easily transportable. And, certainly, they may be used around the home, as well.
A number of my patients endorse the portable low-vision magnifiers listed below. They come in various sizes depending on your needs and the size of your carrying bag. They also vary in the amount of magnification provided. They are particularly helpful when shopping for brands and prices in the grocery store. Reading a menu at a restaurant is made much easier with these devices. The added independence gained with a proper magnifier makes my patients less dependent on others for help and adds to their quality of life.
Please refer to the links below for pricing on Amazon:
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Lucentis therapy is a treatment for wet-type macular degeneration. It usually involves repeated injections of medication into the eye to stop abnormal, leaky blood vessels. It is now also available through port delivery (called Susvimo). After a tiny reservoir is implanted in the eye at surgery, a painless injection to fill the port is performed every 6 months.
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. Traditionally, therapy often starts with monthly injections until maximal vision is restored. Afterwards, the injections may be given less frequently to maintain stable vision. The Lucentis port delivery appears to be as effective as Lucentis monthly injections, but with fewer injections.
What are the risks of Lucentis therapy?
Severe complications are very rare, but risks of Lucentis injection include bleeding, infection, retinal detachment, glaucoma, cataract, and loss of vision. There appears to be a small increased risk (1%) of stroke with Lucentis. The risk of stroke may be related to the older age of patients in which it is used. Pregnancy should be avoided while on Lucentis therapy.
The port delivery method (Susvimo) is associated with more adverse events (19%) compared with monthly Lucentis injections (6%). Among eyes with the implanted port, 5-10% had bleeding inside the eye causing floaters and blurred vision. The blood cleared over several weeks to months. In 5.4% of eyes with the implanted port, the conjunctiva (skin-like layer that covers the eye) does not remain intact overlying the implant and additional surgery is often needed. In 1-2% of eyes with an implanted port, infection may occur. This is a very serious event that requires surgery and may result in permanent loss of vision/loss of the eye. In 1-3% of eyes with an implanted port, a retinal detachment required additional surgery and sometimes resulted in loss of vision. Non-infectious inflammation occurs in about 20% of implanted eyes; it usually responds to eye drops. The benefits of fewer injections with the port delivery method must be weighed against the risks involved with the port. It is the opinion of the author that the risks of the Susvimo port delivery may outweigh the benefits at this time for most patients. Newer medications (Vabysmo) are available that appear to last longer than other treatments such as Lucentis injections. Therefore, Susvimo port delivery may be unnecessary.
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, 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.
Retinal angiomatous proliferation means there is a growth (proliferation) of abnormal blood vessels (angiomatous) in and under the retina (specifically, under the central part of the retina called the macula). Retinal angiomatous proliferation (RAP) is a sub-type of wet age-related macular degeneration (ARMD). Wet ARMD affects the central vision in older patients due to abnormal blood vessels growing under the macula. 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 through the lens onto the retina, which “takes the picture” and sends the image to the brain.
What causes retinal angiomatous proliferation (RAP)?
Retinal angiomatous proliferation (RAP) appears to be caused by the release of blood vessel growth factors in the retina in response to age-related changes. The age-related changes include the accumulation of cellular waste products under the retina (call subretinal drusenoid deposits). The build-up of waste products (SDD) under the retina interferes with retinal function. For one thing, the build-up of SDD separates the retinal cells from the normal blood vessels that nourish them. Without proper nourishment the retinal cells do not work well. Furthermore, when the retinal cells perceive that they are not getting enough oxygen and nutrients, they release growth factors (including one growth factor called VEGF). These growth factors stimulate the growth of new blood vessels to assist in delivering oxygen and nutrients. In other parts of the body, new blood vessels may grow to help or replace old blood vessels and it is a helpful response to poor blood supply. However, in RAP the new blood vessels cause loss of vision due to fluid leakage, bleeding, and scarring of the macula.
What are the symptoms of retinal angiomatous proliferation (RAP)?
Retinal angiomatous proliferation (RAP) may cause no symptoms in its early stages. Over time, symptoms may include blurred central vision, distortion of straight lines and/or a central, gray spot in the vision. In its advanced stages without treatment, RAP may cause a large permanent blind spot in the center of vision. At this stage no treatment is possible and low vision aids are used to compensate for loss of vision. If one eye develops wet AMD, there is about a 50% chance the other eye will be affected within the next five years.
How is retinal angiomatous proliferation (RAP) diagnosed?
Retinal angiomatous proliferation (RAP) is diagnosed in patients with known dry-type age-related macular degeneration. Before the proliferation or growth of blood vessels under the retina develop in RAP, subtle yellow deposits may be identified under the retina. These deposits are called subretinal drusenoid deposits (SDD). SDD develop many years before RAP occurs. A dilated eye examination can detect SDD and alert the retinal specialist to be on the lookout for RAP. Retinal angiomatous proliferation is suspected when a patient with SDD develops blurred vision and swelling (edema) is present in the retina on a retinal scan called OCT (optical coherence tomography). The diagnosis may be confirmed on a more extensive test called fluorescein angiography. This is a procedure where the ophthalmologist injects an organic dye into the vein of a patient’s arm. Then, photographs of the retina show the presence and location of the leaking blood vessels marked by the organic dye.
Why is this diagnosis important?
It is important to recognize RAP because it guides treatment recommendations. This type of wet ARMD is especially sensitive to antiVEGF therapy (injections with Avastin, Lucentis, and Eylea). RAP is so sensitive to antiVEGF therapy that the medication injections are sometimes not required as often as they are in other types of wet age-related macular degeneration such as PCV. Older treatments such as photocoagulation and photodynamic therapy historically do not work well in RAP and can be avoided. Treatment rarely returns vision to normal, but may limit the amount of vision loss from blood vessel growth and leakage. Frequent office visits and photographs are needed. It may be useful to stop smoking, avoid becoming overweight, exercise daily, and control blood pressure and cholesterol. Aspirin should only be used if required to treat disease as recommended by a doctor. Relatives should be checked for macular degeneration, as well.
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.
Polypoidal choroidal vasculopathy (PCV) is a type of age-related macular degeneration (AMD), the most common cause of visual loss in older Americans. 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 through the lens onto the retina, which “takes the picture” and sends the image to the brain. PCV is a disease that affects the central vision. It does not affect peripheral vision— the ability to see objects off to the side when looking straight ahead. This means that PCV alone does not result in total blindness.
In PCV, abnormal blood vessels grow under the macula from a deep layer of normal blood vessels (the choroid). The normal blood vessels in the choroid are usually separated by a tissue membrane from the macula. However, in PCV abnormal blood vessels start growing from the choroid and invade the tissue beneath the macula. These abnormal vessels leak fluid and blood under the macula causing loss of vision.
Image of the retina with bleeding due to PCV causing a blind spot in the vision
What causes polypoidal choroidal vasculopathy (PCV)?
Polypoidal choroidal vasculopathy appears to be an inherited condition. PCV may occur in anyone, but it is more common in people who descended from Asia or Africa. Therefore, genetic factors likely play a role in the cause of PCV. It may be aggravated by factors that cause hardening of the arteries like aging, high blood pressure, high cholesterol, overweight, physical inactivity, and tobacco use.
Before abnormal blood vessels grow under the macula, there are usually findings that predict eyes that are at risk of developing PCV. For example, the choroid (normal blood vessel layer under the macula) is usually thicker than average. A thicker choroid may result in higher blood flow beneath the macula that may cause the growth of abnormal blood vessels. In addition, pale deposits (drusen) may appear under the macula prior to the development of abnormal blood vessel growth. These deposits may contain waste products of cellular function, as well as cholesterol. Perhaps, newly growing blood vessels are called on by the macula to clear away the waste deposits. Regardless, the abnormal blood vessels threaten loss of vision due to leaking, bleeding, and scarring beneath the macula.
What are the symptoms of polypoidal choroidal vasculopathy (PCV)?
Polypoidal choroidal vasculopathy may cause no symptoms in its early stages, especially if the abnormal blood vessels are located away from the center of the macula or if they have not begun to leak significantly. Eventually, symptoms may include distortion of central vision or a blind spot in the vision.
How is polypoidal choroidal vasculopathy (PCV) diagnosed?
A dilated eye examination can often detect changes in the macula before visual loss occurs from PCV. The hallmark of PCV, as well as other forms of macular degeneration, is the presence of drusen—tiny yellow deposits of waste products from the retinal cells that appear as spots under the retina. After the diagnosis is made, a fluorescein angiogram may be needed. This is a procedure where the ophthalmologist injects an organic dye into the vein of a patient’s arm. Then, photographs of the retina show the presence and location of the leaking blood vessels marked by the organic dye.
How is polypoidal choroidal vasculopathy (PCV) treated?
There is evidence that taking vitamin/mineral supplements in specific dosages decreases the risk of visual loss from PCV. For high risk eyes, the following supplement is recommended: Preservision Soft Gels AREDS 2 Formula one capsule twice-a-day. To avoid toxic side effects, be careful about taking additional vitamins or zinc. However, you may take calcium, iron, and vitamin D if recommended by your doctor for problems not related to your eyes. Check pricing of Preservation on Amazon.
People with PCV can often be helped with medication injections and a special laser (PDT) performed in the office. The Everest Study found that the combination therapy with medication injection and PDT (photodynamic therapy) was more effective than medication injection alone. The combination treatment group recovered more vision and required fewer treatments by injection. This treatment regimen differs from other types of age-related macular degeneration.
Treatment rarely returns vision to normal, but may limit the amount of vision loss from blood vessel growth and leakage. Frequent office visits and photographs are needed. It may be useful to stop smoking, avoid becoming overweight, exercise daily, and control blood pressure and cholesterol. Aspirin should only be used if required to treat disease as recommended by a doctor. Relatives should be checked for polypoidal choroidal vasculopathy, as well.
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.
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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.
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.
Please note: As an Amazon Associate I may earn from qualifying purchases. You pay no additional fees by accessing the link. These funds help defray the costs of maintaining this website. Thank you for supporting this blog.
Although there is on-going research to refine the use of stem cells to treat conditions like macular degeneration with the hope of halting or recovering lost vision, there is currently no proven therapy available in the United States. Unfortunately, private clinics have started promoting potentially blinding “cell therapy” for numerous problems including macular degeneration. The concept is that cells will be harvested from a number of sites (usually fat) and then injected into the eye. The promise is that this treatment will help treat eye disease.
What is the danger of stem cell therapy given in this fashion?
Stem cell therapy provided in these clinics has resulted in blindness/loss of the eye. Injections given into the eye have caused bleeding, scarring, and retinal detachment with loss of vision. The reason for the loss of vison may include the types of cells that are injected and the method of injection. There does not appear to be any uniformity of cell type that is used. In addition, the method of injection appears to be into the vitreous gel of the eye. This may create inflammation in the vitreous that results in scar tissue and traction on the retina. Inflammation and scar tissue formation in the vitreous may result in blindness from retinal detachment.
What is a patient to do?
It is very frustrating to lose vision from macular degeneration. Currently, FDA-approved treatments help many patients, but fall short of a cure. It is understandable for a desperate patient to seek care where hope is offered. However, current “cell therapy clinics” are not the answer. Seek the advice of your trusted ophthalmologist and utilize low vision care with magnification. Await the results of FDA-sponsored clinical trials to find safe and effective treatments for macular degeneration.
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.
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, Vabysmo, 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.
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 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.
anatomy of the eye (click on image to enlarge). Image courtesy of Caitlin Albritton.
What is metamorphopsia?
Metamorphopsia (“meta-more-FOP-see-ya”) is a medical term used to describe an abnormal visual perception in which images appear distorted. For example, straight lines appear curved or jagged. It is an important symptom of retinal disease. Metamorphopsia is not caused by the need for new glasses, cataract, glaucoma, or optic nerve damage. Metamorphopsia is a sign of a retinal problem. It is detected and monitored with an Amsler grid.
Distortion of lines on Amsler Grid in right eye (click on image to enlarge)
What causes metamorphopsia?
The retina is a thin layer of nerve tissue that acts like film inside a camera. The retina “takes a picture” and sends the image to the brain. The root cause of distortion in vision is a retina that is not smooth and flat against the eye wall. This distortion of the retina may be caused by many different conditions. Sometimes, problems under the retina cause fluid leakage resulting in metamorphopsia. Such conditions include macular degeneration, central serous retinopathy, histoplasmosis, high myopia, angioid streaks, and inflammation. In other situations, distortion may be caused by scar tissue under the retina from inflammation, trauma, bleeding, or chronic leakage of fluid under the retina. Distortion of the retina may also be caused by vitreomacular traction, macular hole, or macular pucker. The ophthalmologist (retinal specialist) will undertake examination and testing to determine the cause.
Is metamorphopsia an urgent situation?
Metamorphopsia may be an urgent situation if it is new in onset or has significantly increased recently. If the cause of distortion is inflammation or bleeding, prompt treatment is needed to prevent further loss of vision and worsening of symptoms. Longstanding distortion is less likely an emergency but merits an eye examination to determine the cause.
What is the treatment?
Metamorphopsia is a symptom rather than a diagnosis, so the treatment depends on the underlying cause of the distortion of vision. This is the reason why it is important to have an eye examination in order to determine the best course of action. Contact your eye doctor or retinal specialist if you have this important symptom.
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:
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.
There is confusion between PreserVision AREDS-2 and “new” PreserVision AREDS-2. In September 2013 Bausch and Lomb changed the contents of PreserVision AREDS-2 and renamed the new vitamin, “New” PreserVision AREDS-2. The color of the box and the label on the bottle remain the same. The difference between the old and new vitamins is the “new” formulation lacks omega-3 fatty acids. They were removed because the AREDS study group was unable to demonstrate a benefit in patients with age-related macular degeneration (AMD). Other smaller studies have suggested a benefit and additional studies are needed to confirm or refute the value of omega-3 fatty acids in AMD.
Why is the difference important to me?
The importance in the difference for patients lies with the dosage. The recommended dosage for the older PreserVision AREDS-2 was two softgels twice a day. The recommended dosage for the “New” PreserVision AREDS-2 is one softgel twice a day. To avoid an error in dosing, patients need to be aware of which of the two similar vitamins they are taking.
Is there a cheaper version of AREDS-2 vitamins?
Yes. As the patent expired on the ARED-2 formula, there are less expensive options now available. The least expensive AREDS-2 vitamin that I am aware of at the time I write this blog is Equate Advanced Eye Health Complex by Walmart. This vitamin is equivalent to the “New” PreserVision AREDS-2, but much less expensive. It is taken one pill twice-a-day.
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.
