What is Age-related Macular degeneration?

There are two types of age-related macular degeneration:

Dry type: This type progresses at a slower rate but can cause loss of reading vision and central vision. It does not leak and generally is the better type to have. There is no specific treatment apart from antioxidant vitamins.

Wet type: This type is due to abnormal blood vessels (called choroidal new vessels) growing at the macula (central part of the retina used for reading and central vision). This causes leakage and bleeding under the retina, which can occur quite rapidly. This may lead to rapid loss of vision and blindness. Drusen are proteinaceous deposits under the macular and may be a precursor to wet ARMD development. They may remain stable for long periods of time.

In both these types of macular degeneration the central vision is damaged but the peripheral vision is usually not affected.

Treatment of Age-related Macular Degeneration

Age related macular degeneration is a leading cause of blindness. Treatment can be difficult and may involve intravitreal injections or laser treatment.

LATEST TREATMENTS: Anti-VEGF Intravitreal injections

Avastin (Bebacizumab) and Lucentis (Ranibizumab) are new anti-vascular endothelial growth factor (VEGF) drugs, which have shown great promise in treating macular diseases such as macular degeneration and macular oedema. They have also been useful in cases of diabetic retinopathy and central retinal vein occlusion. These drugs act by inhibiting the growth of abnormal blood vessels and help prevent leakage of these blood vessels.

In macular degeneration they are useful in the wet type of macular degeneration in which abnormal blood vessels grow in the retina at the back of the eye. These vessels cause leakage of blood or fluid that result in blurred or distorted vision. The aim of treatment with these anti-VEGF intravitreal injections is to stop the leakage and prevent further damage.

Current research has found these drugs to be well tolerated as an intravitreal injection. Research so far has demonstrated that up to 70% of patients can show improvement with this treatment. Further research is showing good promise in cases of diabetic retinopathy and cases of persisting macular oedema, such as in central retinal vein occlusion.

Injection of these drugs is performed as an outpatient procedure. Topical and local anaesthetic is used and therefore the injection should have minimal pain. Patients are discharged on the same day and may go home with a patch on their eye. This is removed after approximately three hours and antibiotic eye drops such as Chlorsig or Tobrex are administered four times a day for one week to help prevent infection.

Patients need to be aware that in the first one or two days they may have some ocular irritation from the injection, as well as a tearing and redness of their eye. They should notify the Doctor if they notice persisting pain beyond 2 days or sign of infection or severe loss of vision. Generally the side affects of these drugs are rare but can include intraocular infection, which can cause loss of vision and requires urgent treatment. Also very rare complications include lens damage, retinal detachment and very rarely blood pressure rise, stroke, and cardiovascular problems.

Up to 70% of patients do notice some improvement after their first injection. Most patients require injection performed monthly for the first three months, often requiring OCT Scans to monitor the progression. Following this the interval between treatments may be increased up to three months. Treatment will be tapered by your Doctor according to the response that is obtained. Some patients have responded very well and only require one or two injections, whereas others have required repeated injections before they are stabilised. Average is approximately 6-7 treatments per year.

The cost of Avastin is included in the cost of the intravitreal injection; there is no separate charge for this. This drug is used with an off label status as it was originally developed for treatment of colon and rectal cancer but was found to have excellent benefit as an individual injection in the eye and therefore usage has continued with this. Over hundreds of cases have been performed with no significant adverse outcomes.

Lucentis on the other hand has undergone extensive research and the current expense, which is now funded by the Federal Government. Lucentis was derived from Avastin and clinically the effect in the eye appears to be the same. The molecule of Avastin is larger than Lucentis and may have a longer action in the eye, though Lucentis does supposedly have increased effectiveness however we have found no difference in their clinical affect.

Other treatments for Age-Related Macular Degeneration

Visudyne Laser Treatment or Photodynamic Therapy (PDT)

Visudyne Laser is now a second-line treatment of wet type of macular degeneration. Photodynamic therapy involves an injection of a special dye which enables laser treatment of the leaking blood vessels at the back of the retina in such a way that the retina lining is spared from damage by the laser. This has shown the most benefit in wet age related macular degeneration and has also been used for other types of macular degeneration and chronic central serous retinopathy. Research has shown approximately 67% stabilization of the macular degeneration with this treatment.

This treatment requires a fluorescein angiogram photograph to be taken to assess the size of the degeneration before the photodynamic therapy. This is usually performed sometime before the photodynamic therapy.

Treatment is not painful. Vision may be blurred for several days after treatment. Any improvement is slow over 1-2 months. It is important to stay out of direct sunlight for three days after treatment, as there is a risk of severe sunburn. Other side-effects include allergy, nausea, back pain, rash, all of which are quite rare.

Follow-up will be performed at around 2 months post treatment, and another fluorescein angiogram and OCT will be performed. Further treatment is usually required at 1-2 months after initial treatment, though some may need re-treatment earlier or later than this. Regular checkups will be required every 2-3 months to check for any recurrence in leakage from the macular degeneration.

The cost is expensive as the Visudyne is imported from the USA. Each ampoule costs $2000 but Medicare will fund this.

The Visudyne Laser may still be useful in cases where intravitreal injection is not preferred, and in cases of chronic central serous retinopathy.

TTT laser therapy

This involves a red diode laser used in a low dose to slowly tre at the leaking vessels in wet type macular degeneration. This laser therapy does not require any dye and is therefore less expensive.

This is a relatively new therapy still under research, though hundreds of cases have been done through out the world. Preliminary results have shown benefit in around 50% of cases to stabilize vision or delay decline in vision.

Though not as effective as Visudyne Laser, it is much less expensive, and therefore a reasonable alternative in cost benefit terms.

The cost after medicare rebates are claimed is approximately $200. It is fully covered by DVA.

Treatment may need to be repeated at around 6-8 week intervals depending on the response, and a fluoresein angiogram may need to be performed at that time.

Triamcinolone injection

This has shown benefit in certain types of wet macular degeneration (occult types). This involves an injection of a very small amount of steroid medicine into the vitreous jelly of the eye. It works by drying up the leaking vessels in wet type macular degeneration.

This is performed at the City Eye Centre. The procedure involves local anaesthetic around the eye, then a very fine injection is performed.

You may notice a lot of floaters in your vision for a few weeks after the injection, which should dissolve. Other side-effects include glaucoma, and cataract which are quite rare. You will be placed on eyedrops after the injection to help prevent infection, and glaucoma. You will need to be checked around 1 week after the injection.

Research has shown around 40% stabilization in vision in selected patients. Rarely the injection will need to be repeated in future.

Focal Laser Treatment

Focal laser treatment may be successful in treating wet type of age related macular degeneration, where there is a leaking blood vessel near the centre of the fovea (the retina, where the central vision is detected).

Laser treatment requires a fluorescein angiogram to detect the site of the leaking blood vessel. Treatment with the laser takes approximately fifteen to twenty minutes. This may be undertaken on the same day as the angiogram or at another appointment as indicated by Dr Lee. Sometimes several sessions of laser may be required.

Laser treatment may be successful in reducing the distortion and limiting the growth of the abnormal blood vessels present in age related macular degeneration. Sometimes, however, the blood vessels can return and may require further treatment. Unfortunately, if these blood vessels grow under the central vision, then other treatment such as visudyne or TTT laser may benefit.

Following laser treatment, one may be aware of a dark or blurred patch in the vision where the previously leaking blood vessel was. This may be to one side of the central vision.

A follow-up visit is usually required in two weeks following laser surgery, where another fluorescein angiogram may be performed to determine whether treatment has been successful.

It is important to be aware that laser treatment is not always successful in improving vision. This is due to the difficulty in treating age related macular degeneration, as it is difficult to reverse the aging process. Dr Lee will advise you if any eye drops need to be used following treatment.

Submacular surgery

This is performed in rare circumstances to remove the blood vessels and blood from under the retina. Only useful in certain types of macular degeneration, particularly those which occur in younger patients, or associated with other conditions, or associated with large bleeding under the retina.

This may benefit the vision by decreasing the size of the central blurring of vision.

This requires vitrectomy surgery, and admission to hospital or day surgery.

TPA and gas injection

This technique is used for certain types of bleeding under the retina. The TPA is a medicine which is injected into the eye to break up blood clots and then the gas is injected to disperse the blood. The patient is required to posture face down ½ hour in each hour for 1-2 weeks to position the gas bubble over the macula to disperse the blood.

This is performed as a day case surgery.

Dietary Advice

Use of antioxidant vitamins, such as Macuvision, Lutein-Vision, or Multivision has been reported to be useful in reducing the progression of macular degeneration by reducing oxidation damage to the retinal cells. Patients may take one or two Macuvision daily and some combine this with one or two tablets of Lutein-Vision daily. Multivision combines the active ingredients of both Macuvision and Lutein-Vision. There also is some new research into Omega 3 vitamins, which may also help. A diet including fish, green vegetables and nuts is beneficial. Use of margarine, cooking oils (except olive oil) and processed food should be avoided. Smoking has also shown increased risk of macular degeneration progression and should be ceased.

Low Vision Aids

Low Vision Aids such as magnifiers and a good light may help. Referral to the Low Vision Care Centre at Greenslopes Hospital or QUT Optometry Clinic can be arranged.