Byooviz Therapy

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

What is Byooviz?

            Byooviz is a drug used to treat wet-type macular degeneration, wet-type myopic macular degeneration, and macular edema due to retinal vein occlusion.  It involves repeated injections of medication into the eye to stop abnormal, leaky blood vessels.  Byooviz is an FDA-approved biosimilar drug similar to Lucentis.  Consequently, it costs less than Lucentis (About $1100 per injection of Byooviz compared with $1800 per injection with Lucentis).  Unlike Lucentis, Byooviz is not approved for diabetic retinopathy

What is the difference between biosimilar drugs and generic drugs?

While generic drugs are chemically identical with trade-name drugs, biosimilars are not identical to their reference drugs which they attempt to duplicate.  Because biosimilar drugs are different chemically, they may behave differently in terms of effectiveness and side effects.  They may not be as effective as their reference drug and they may have more side effects.  For this reason, biosimilar drugs need to be monitored closely prior to approval by the FDA, as well as after approval by health care providers.  Some adverse effects are not recognized until a drug has been used in thousands (if not more) of patients.  

How effective is Byooviz therapy?      

             Byooviz was shown to be very effective and similar to Lucentis when given every 4wks up to 48 weeks for wet-type macular degeneration.  Currently, therapy often starts with monthly injections until maximal vision is restored. Afterwards, the injections may be given less frequently to maintain stable vision.  It is not known how Byooviz will perform in this setting.

What are the risks of Byooviz therapy? 

            Severe complications are very rare, but risks of Byooviz injection (like Lucentis) include bleeding, infection, retinal detachment, glaucoma, cataract, and loss of vision/loss of the eye. There appears to be a small increased risk (1%) of stroke with these types of medications. The risk of stroke may be related to the older age of patients in which it is used. Pregnancy should be avoided while on Byooviz therapy.              

What do I expect after a Byooviz 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.

What does Dr Pautler think about Byooviz?

It is the opinion of the author that there are several concerns about Byooviz. First, the safety and effectiveness of Byooviz need to be determined on a large scale with many more patients than studied for FDA approval. This may take several years of use. Until then, I prefer Lucentis as it has a proven track record. Secondly, the cost of Byooviz appears too high. The cost of Byooviz is less than Lucentis, but not by much. A lower cost is more appropriate given the unknown risks and long-term effectiveness of Byooviz. If I have a patient whose insurance covers Lucentis, that is my choice over Byooviz at this time. If a patient has a Medicare Advantage insurance plan, I may be forced to use Byooviz.

By Scott E. Pautler, MD

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

Copyright ©2022 Designs Unlimited of Florida.  All Rights Reserved

Blindness from Tattoo

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

How can a tattoo cause blindness?

There are several ways in which a tattoo may threaten loss of vision.  The most obvious situation is a scleral tattoo.  This is a tattoo applied to the outer eye wall, the white sclera.  The tattoo ink may have direct toxic effects on the eye and there is a risk of serious infection.  However, even a skin tattoo applied far from the eyes may risk loss of vision.  This is due to an autoimmune condition called tattoo granuloma with uveitis (TAGU).  Autoimmune conditions occur when your own immune system attacks your body.  

What are the symptoms of TAGU?

Various symptoms may be experienced depending on where the eye is most inflamed.  Symptoms may be mild or they may be severe and disabling.  The eye may be painful, red, tearing, and light sensitive.  Tiny floating spots which move or “float” may be seen.  Sometimes blind spots, blurred vision, distortion, or loss of side vision occurs.  The visual symptoms are frequently associated with inflammation of the tattoo (elevation, redness, warmth, itching, tenderness and/or swollen lymph nodes).  

Who is at greatest risk of TAGU?

Fortunately, TAGU appears to be a rare condition.  However, risk factors that may increase the chance of TAGU include the size of the tattoo.  The larger the tattoo, the greater the risk of TAGU.  Also, a personal history or family history of other autoimmune conditions may increase the risk of TAGU.  Other autoimmune conditions include sarcoidosis, rheumatoid arthritis, lupus, and Harada’s disease.  

How is TAGU diagnosed?

The diagnosis of TAGU is first considered in anyone with inflammation of the eye (uveitis) in a person who has had a tattoo.  A skin biopsy may be needed to demonstrate a typical form of inflammation of the tattoo.  In addition, other tests may be needed to be sure the uveitis is not due to a problem unrelated to the tattoo (see uveitis questionnaire).  

Take some time to carefully review and report to your doctor any unusual or unexplained symptoms such as rashes, back and joint problems.  Tell your doctor if you travel abroad, spend time in rural settings, or may be exposed to animals or infections.  Heredity may also play a role.  Also, review and report your ancestry (for example, Asian, Mediterranean, or American Indian ancestry).  When the doctor diagnoses uveitis, laboratory tests may be ordered to help determine its cause.   

How is TAGU managed?

To limit the damage from inflammation, TAGU is treated with anti-inflammatory medication in the form of eye drops, injections (next to the eye or into the eye), or pills.  When pills are used, the eye doctor frequently coordinates medical care with the expert assistance of a rheumatologist.  Rarely, surgery is required to treat TAGU.  In some cases, uveitis may be long-lasting. In these cases, years of therapy are needed to preserve vision.  TAGU is a serious eye problem and may result in loss of vision or blindness.  However, by seeing your eye doctor and taking the medications exactly as recommended, damage to your vision can be minimized.

In some cases, TAGU can resolve with treatment, but return at a future date.  Therefore, if you become aware of symptoms of uveitis in the future, do not hesitate to contact your doctor.

What are other risks of tattoos?

Apart from eye inflammation, there are a host of health risks associated with tattoo.  They include infection of the skin or blood (sepsis), hepatitis, HIV/AIDS, heart valve infection (endocarditis), scleroderma, scarring (keloid formation), and hypersensitivity reactions.  Remember that the FDA does not regulate the contents of the ink that is injected into the skin.  Also, government regulation is variable as it relates to training, sanitation, and infection control. Current regulations may not be adequate to protect you against harm.

By Scott E. Pautler, MD

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

Copyright  © 2021-2022 Designs Unlimited of Florida.  All Rights Reserved.  

The risk of stroke with treatment of Age-Related Macular Degeneration

The mainstay of treatment of wet-type age-related macular degeneration (AMD) requires the intraocular injection of medication (e.g. Avastin, Lucentis, Eylea, Beovu, and Vabysmo) to prevent loss of vision. Although effective, this treatment entails some degree of risk. For example, infection may occur at a rate of about one in one thousand to one in five thousand injections. Moreover, there may be a low increased risk of stroke.

Although some studies do not show increase risk (Campbell), other large studies have demonstrated an increased risk of stroke. In one study the increased risk of stroke appeared to be 1 in 127 patients within one year after starting treatment for AMD (Schlenker). These studies were unable to prove that the medication itself was responsible for the increased risk of stroke. For example, it may be that people with new-onset wet AMD are at a higher risk of stroke than others. In 2019 a population-based study demonstrated no increased risk of stroke and heart attack related to AMD treatment (see reference). Additional research in ongoing.

Given this information what are the options? Certainly, a patient may decide not to treat macular degeneration and risk loss of vision in an effort to decrease the risk of stroke. Another option may be to minimize the frequency of injections. That is, if the macular degeneration remains stable after several monthly injections, consider extending the time interval between injections. In this manner there is less exposure to the drug. Furthermore, if the wet-AMD appears to have reached end-stage with significant loss of vision, the injections might be stopped altogether. If done carefully, one may reduce the risk of a sudden recurrence of wet-AMD with further loss of vision while off treatment.

The type of medication used for injection has not been proven to make a difference in the risk of stroke. Although Martin et al found a slight increase in stroke risk with Avastin compared with Lucentis, these findings were not supported by Chakravarthy and Schlenker. More research is needed to better define risk of stroke and how we may minimize the risk. A recent meta-analysis of current data as of 2022 (Reibaldi) supports Lucentis over the other agents as being safer from a systemic risk of heart attack and stroke.  Please refer to my blog on medication choices for treating retinal problems.

By Scott E. Pautler, MD

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

References:

Ophthalmology 2012 119:1604-1608 Campbell

AJO 2015 160:569-580 Schlenker

Ophthalmology 2012 119:1388-1398 Martin

Ophthalmology 2012 119:1399-1411 Chakravarthy

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