Macular Degeneration Continued
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Fluorescein Angiography
 If your doctor finds an abnormality and suspects the wet form of macular degeneration (abnormal blood vessels), a special test called fluorescein angiography will be done. To do the test, dye is injected into a vein in the arm. The dye travels through the body including the eyes. With a special camera (not X-ray), a series of photographs of the retina is taken as the dye passes through it.
The photographs show what changes have occurred in the retina and where those changes are located. Fluorescein angiography is necessary if the doctor thinks there is a chance that the patient could benefit from laser treatment. The photographs provide a kind of map that the doctor uses during laser treatment. Fluorescein angiography is also usually done a few weeks following laser treatment to be sure that the laser has destroyed the abnormal blood vessels.
There is another photographic test called indocyanine green angiography. This test may give additional information that may be helpful if laser treatment is to be done.
Treatment for Wet Macular Degeneration
Treatment for wet age related macular degeneration is undergoing major shift from primary laser therapy to pharmacologic therapy with intraocular injection of drugs that countertact VEGF. VEGF (vascular endothelial growth factor) is a natural chemical in the body necessary for growth of new blood vessels especially for healing. Unfortunately, VEGF appears to be a major factor in the development of wet ARMD. New agents have been developed to counteract VEGF. These agents are injected into the eye at regular intervals usually about 4 to 6 weeks apart. The results so far have been very exciting.
The first anti-VEGF agent approved was MACUGEN. Macugen is given every 6 weeks. It showed a positive result but only about 6% of patients actually improved in the study group.
Genentech has developed a new drug called Lucentis. Lucentis is very strong anti-VEGF agent. Study results released recently showed 95% of study patients stayed the same or improved with treatment after 2 years. Lucentis has been proven safe and effective in rigorous clinical trials. Lucentis was approved by the FDA and Medicare June 30, 2006. It is very expensive. One dose costs upwards of $2000. Monthly intraocular injections of Lucentis may be required to obtain the excellent visual results obtained by the studies conducted with Lucentis.
Another anti-VEGF agent is currently be used by retinal specialists around the world. AVASTIN, originally approved for treatment of colorectal caner, has been found by retinal specialists at Bascom Palmer Eye Insitute to be very effective in treating wet ARMD. Avastin has not been officially approved for treatment of ARMD by the FDA, but recently Medicare has approved payment for Avastin in Texas and many other states in the US. Avastin is relatively inexpensive. Medicare allowable is about $60.00 for Avastin. Remember the doctor also will charge for the injection which pays about $200 from Medicare. Avastin is widely used my retinal specialists around the world.
PDT with Visudyne is very expensive costing about $2000 for the treatment. Macugen costs about $1250 for the injection and the drug.
Laser Treatment of Macular Degeneration
Treatment for macular degeneration with PDT or photodynamic therapy with visudyne combined with the injection of a steroid call kenalog directly into the eye is still used by many retinal specialists for selected cases. This technique of the so called "cold laser" does not cause a retinal scar. Argon or "hot laser" is still used in selected cases of wet AMD. When the vessels are under the center of the macula, PDT can be used. Some retinal surgeons are using PDT combined with Avastin in an attempt to limit the number of injections required to stablize wet ARMD.
Up to now, most cases of age related macular degeneration (ARMD) ended up with loss of vision over time with or without therapy. However, with therapy, the final vision plateaus far above what the vision would have been without therapy. With these new anti-VEGF therapies, vision in some cases may actually improve. Clinical trials with Lucentis resulted in 95% of patients staying the same or getting better while about 40% actually improved with treatment.
Argon Laser
The Argon laser beam is a high energy light that turns to heat when it hits the parts of the retina to be treated. This heat destroys the abnormal blood vessels causing the wet macular degeneration and stops them from growing, leaking and bleeding. A scar forms as a result of the treatment
Even when laser treatment is considered successful, and the abnormal blood vessels have been destroyed, additional abnormal blood vessels can appear later and further damage vision. The patient who is treated with laser should continually check the vision in the treated eye and tell the doctor immediately if there are new changes, such as a return of distortion or blurriness; in some cases additional laser treatment may be helpful.
One reliable way for a person who has had laser treatment to measure changes is to learn to use the Amsler grid self test with the large "X". It may take some practice to learn to do the test without difficulty and accurately, but with this simple test, using a piece of paper and a pencil, the spot that was caused by the laser can be traced. By tracing it every day, it will be immediately evident when the spot has gotten bigger, or if a new spot has occurred somewhere else. If this happens, it usually indicates that the abnormal blood vessels have recurred. A person who has had successful laser treatment must use the Amsler grid everyday for the rest of his or her life. If there is a change, see your eye doctor promptly.
We recommend you make copies of the Amsler grid and use your copies for drawing the spot. Use the Amsler grid recording chart to test your vision each day.
- Wear your reading glasses.
- Cover the opposite eye.
- Look at the center dot (the center of the crossing "X") and keep your eye focused on the center at all times
- While looking directly at the center and only the center, draw the area of abnormality.
- Use different colored pencil for each day of the week. Change the test sheets each week. At the bottom of the sheet write the date of each test with the same colored pencil for that day. In this way, each Amsler sheet of paper will show a record of your vision each day for one week.
- Bring your Amsler tests to your next exam.
- If you see that the area of abnormality is getting bigger or changing--please call right away.
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Treatment of Dry Macular Degeneration
Although prevention of AMD (age related macular degeneration) is a goal not yet reached by medical research, recent studies (The Age Related Eye Disease Study) have shown that if you have early macular degeneration, taking special vitamins can help reduce the risk of severe vision loss. Dr. Mein and Dr. Chica now have RetinaVites availabe in the office for patients with ARMD. RetinaVites contain the vitamins recommended by the National Eye Institute.
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