Download Treatment Options for WET MD

Treatment
Options for
WET MD
FACT SHEET
Treating Wet Macular
Degeneration
The first point of contact for treatment
options should be with your eye specialist
(ophthalmologist). In many cases this will
be a retinal specialist.You should always
discuss any concerns with your eye
specialist who will advise you on your
treatment options.
Wet Macular Degeneration (MD) occurs
when new abnormal blood vessels
grow from the choroid into the retina.
This process is called choroidal neovascularisation (CNV). Neo = new and
vascularisation = vessel formation.
There are a number treatments, both
proven and experimental, available for
people with Wet MD. The treatments
target these new abnormal blood vessels
that grow into the retina. The treatments
are not curative and aim to keep the best
vision for as long as possible.
TREATMENTS PROVEN TO BE
EFFECTIVE BY CONTROLLED
TRIALS
The abnormal growth of new blood vessels
in Wet MD causes bleeding, leakage and
scarring which results in severe loss of
central vision. This can occur very rapidly,
requiring urgency in seeking appropriate
treatments.
The new blood vessels are prompted to
grow by a protein called Vascular Endothelial
Growth Factor (VEGF).
1. Lucentis (ranibizumab)
Lucentis is currently the treatment of
choice for Wet MD. Lucentis is an antiVEGF drug which is injected into the eye
to block the protein responsible for the
growth of new blood vessels. This anti-VEGF
drug is injected into the eye cavity where
it can spread to the retina. The injections
are generally administered at four week
intervals.
How the eye works
Retinal Pigment Epithelium (RPE)
Choriod
Cornea
Retina
Pupil
Macula
Lens
Optic nerve
In controlled trials Lucentis has been
proven to be a safe and clinically effective
treatment for Wet MD. With monthly
injections Lucentis has shown to effectively
control Wet MD and preserve vision in
the majority of cases, and even improve it
somewhat in a minority of cases.
Lucentis is funded under the Pharmaceutical
Benefits Scheme (PBS), but only for the
treatment of subfoveal (under the centre
of the central area of the macula) choroidal
neovascularisation due to age-related
Wet MD.
Patients should discuss details of the
injections with their eye specialist.
Trials are looking at varying the frequency
of injections and using it in combination
with Photodynamic Therapy with Visudyne.
PDT treatment causes minimal damage to
the surrounding retina. It therefore can be
used to treat new vessels that are under the
centre of vision (the fovea).
PDT is a course of therapy and several
treatments are needed to keep the
leaking blood vessels closed and stop the
progression of Wet MD. Close follow up and
monitoring with the attending eye specialist
is needed to determine if further treatment
is required.
PDT is no longer used as a monotherapy
as patients continue to lose vision in the
first six months. If used in conjunction with
Lucentis this vision loss can be prevented.
There is one type of new vessel called
polypoidal for which this combination is
being investigated as it may be preferable to
giving Lucentis by itself.
3. Laser Photocoagulation
This treatment consists of a concentrated
beam of high energy thermal light which is
directed on to the retina to destroy and
seal the leaky blood vessels. A contact lens
is placed onto the eye. The eye specialist
will give instructions on where to look, so
that the eye remains still while the laser is
focused on the area being treated. This is
not a painful procedure.
Above: Lucentis injection
2. Photodynamic Therapy (PDT) /
Visudyne Therapy
This is a two step process combining a
light-activated drug (Visudyne) and the
light from a cold laser directed on to the
abnormal retinal area. Once activated, the
drug causes the blood vessel to close off.
The laser not only destroys the new vessel
(CNV) but also destroys the retina adjacent
to the new vessel. Therefore it should only
used for treating new vessels that are not
under the central vision. This treatment is
only for a small percentage of patients with
a particular type of Wet MD.
Close follow up and monitoring with
the attending eye specialist is needed to
determine if further treatment is required
as there is a 50% recurrence rate.
EXPERIMENTAL TREATMENTS
1. Avastin (bevacizumab)
Avastin is an anti-VEGF drug, like Lucentis,
which is injected into the eye. It was not
designed for use in the eye. It was primarily
tested and approved for the treatment of
cancer.
Avastin has been used worldwide in the
past 2 to 3 years for treating patients with
Wet MD. Many case reports suggest that
it is safe and highly effective. In order to
prove this it is undergoing a head-to-head,
controlled clinical trial comparing it to
monthly Lucentis injections. Like Lucentis,
it appears that Avastin needs to be injected
repeatedly to maintain its effect. It is still not
clear AS TO how often the injection should
be given.
Avastin is primarily used because it is
substantially cheaper for patients who are
not eligible for Lucentis under the PBS (eg
because of their age or the location of their
lesion).
2.Triamcinolone (Kenacort)
A slow release steroid designed for
injection into joints, it has been used
‘off label’ by some retinal specialists to
supplement CNV treatments particularly
PDT. It appears to have a beneficial effect
when used in conjunction with PDT but
has been shown in a controlled trial to be
ineffective as a sole treatment.
It is injected into the eye but promotes
cataract formation and in a third of patients
increases the intraocular pressure often
necessitating glaucoma treatment. Side
effects increase with repeated injections.
DIAGNOSING WET MD
If the eye specialist suspects Wet MD, you
will probably undergo a number of tests
to help determine the best course of
treatment.
Fluorescein Angiogram
An angiogram is a study of the blood
vessels. Fluorescein is the type of dye used.
This is a test which provides information
about the blood circulation in the retina
that cannot be seen by routine eye
examinations. The Fluorescein dye is
injected into the blood via a vein in the
arm and rapidly reaches the eye. The dye
circulates through the retina and highlights
any abnormalities or damage. The abnormal
new blood vessels seen in Wet MD have
weak, fragile walls and the dye leaks through
them, outlining them clearly.
A camera with special filters takes a series
of photographs as the dye passes through
the retina. This procedure takes only a
few minutes. The photographs taken are
essential for the diagnosis and appropriate
treatment planning. They may also assist in
monitoring changes. Fluorescein tends to
turn your skin and eyes yellow for up to 24
hours until the dye is excreted through the
urine. It may also cause nausea and allergic
reactions.
Any decisions made about treatment options for Wet Macular Degeneration
should be made in consultation with your Ophthalmologist.
Indocyanine Green Angiogram
This is the same procedure as a Fluorescein
angiogram but uses a different dye called
Indocyanine Green (ICG).
Below: An OCT scan shows elevated pigment
epithelial detatchment due to Wet MD.
ICG has different properties to Fluorescein
and highlights the deeper layers of the
retina and the choroidal circulation (the
source of the abnormal blood vessels),
which is normally hidden from view. It
enables different types of new vessels to be
identified.
ICG stays in the retinal circulation much
longer than Fluorescein. Photographs are
taken up to one hour after injection. ICG
contains iodine which may cause allergic
reactions.
If you are concerned about the effects of
the dye, discuss this with your eye specialist.
Optical Coherence Tomography
Optical Coherence Tomography (OCT) is
a non-invasive diagnostic imaging technique
that uses light to produce very highresolution cross-sectional images of the
tissue layers within the retina. These layers
at the macula can then be studied and
measured in microscopic detail.
By comparing the structure and thickness
of the layers measured by the OCT against
a normal healthy retina, eye specialists can
detect any Wet MD even at a very early
stage.
Above: A Fluorescein Angiogram reveals
blood vessels in the eye caused by Wet MD.
It is an important addition to thorough
clinical examination and is now a standard
diagnostic procedure in the diagnoses and
ongoing management of Wet MD. Repeated
tests are usually necessary to monitor
disease activity.
Medicare funds the angiogram tests but currently does not fund OCT
Disclaimer: Information contained in this fact sheet is considered by the Macular Degeneration Foundation to be accurate at
the time of publication.While every care has been taken in its preparation, medical advice should be sought from a doctor.The
Macular Degeneration Foundation cannot be liable for any error or omission in this publication or for damages arising from its
supply, performance or use, and makes no warranty of any kind, either expressed or implied in relation to this publication.
May 2009
For further support and assistance call the MD Foundation’s free
helpline 1800 111 709 or visit www.mdfoundation.com.au