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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