Good Hope Eye Clinic

Anti-vegf treatment for wet ARMD (neovascular ARMD)

David Kinshuck

Introduction

Wet ARMD can now be treated easily. Wet ARMD is caused by the growth of a tiny network of blood vessels under the centre of retina (the macula), which grow and leak. The growing and leaking can be controlled with the new anti-VEGF drugs and some mother treatments. This treatment stops the new vessel growth in 90% of patients.

summary of macular degeneration

what is happening in macular degeneration: anti-vegf treatment stops the blood vessel growth and leakage (action shown by red X)    enlarge

 

 

Anti-vegf drugs
  • Avastin (Bevacizumab) ~£60, lasts 4 weeks, cost effective Jama 16
  • Lucentis (Ranibizumab) ~£650, lasts 4 weeks
  • Eylea (aflibercept) ~£700, lasts ~2 months

The anti-vegf drugs

There are 3 drugs. Eylea& Lucentis are the drugs approved by NICE. Eylea very slightly more effective than Lucentis BMJ 14   BJO 15 .

Avastin is not approved by NICE but is used widely round the world. It is the cheapest and nearly as good as Eylea/Lucentis. Retina17

The drugs stop or slow down new vessel growth: the new vessels are called CNV, choroidal neovascularisation.  

The risk of anti-VEGF treatment is small

  • 1/1000 serious infection
  • Small risk of other less serious problems such as cataract and retinal tears.
  • systemic effects unusual BJO14
  • we have to do better Eye 16

How are the drugs given..treat and extend

The drugs are given by injection into the vitreous cavity of the eyeball as below. The drugs last 4-8 weeks. There are different protocols, but the most recent is 'treat and extend'. BJO 14  diagram on this site   Retina 14   Eye 15

Lucentis and Avastin

  • 3 injections with 4 week gap,
  • if at this time there is no fluid/leakage, the interval before the next injection can be extended by two weeks to make it 6 weeks.
  • After 6 weeks thee is another injection and OCT: once again, if at this time there is no fluid/leakage, the interval before the next injection can be extended by two weeks to make it 8 weeks, then to 10 weeks, with a maximum interval of 12 weeks in the first year ,longer in the second year.
  • If at the time on injection there is fluid/leakage remaining, the interval to the next injection is reduced by two weeks (to make the minimum interval 4 weeks.
  • So if dry at time of injection interval is extended two weeks; if wet with fluid/leakage, the interval is reduced two weeks.
  • But some CNV respond exceptionally well, such as those in myopes, or peripapillary CNV...here three injections with a one month gap may be enough, though after the three injections, monthly OCTs are needed  to confirm the condition stays dry.
  • Even after one year of a 'dry' appearance, 25% of patients will notice a recurrence in the next 12 months. BJO 16

Eylea

  • Year 1: 7 injection dates first year at months 0,1,2,4,6,8,10,
  • Year 2: OCT scan at each visit, suggest
  • if dry, extend the interval from 8 to 10 then to 12 weeks maximum, so if dry 4  injections year 2
  • if wet, reduce the interval by 2 weeks each visit. If has 3 injections 4 weeks apart with no benefit, stop.
  • We have found that an 8 week interval in the first year is too long for 20% patients

Notes at BMEC,

  • For bilateral cases if one eye dry (no injection needed for >6 weeks) and one wet please do not put in the treat and extend service as active eye may need 4 weekly injections till stable. For simultaneous Bilateral active eyes you can do treat and extend.
  • Confusion and missed treatment has happened if the instructions in the management section of Medisoft are too long. Clearly write number of injections either eye at the top and then copy paste further details if you think they are needed. Injectors cross check with notes and Medisoft and their job is made easier if clear  brief instructions are given at the top especially for nurse injectors.
  • Medisoft is mandatory for any situation with injection request but as per departmental protocol instruction need to be written in the notes as in number of injection and site. If in a rare virtual clinic notes were not available that needs to be noted in Medisoft otherwise all decisions to inject need to be clearly written in the notes.
  • Please ask patients about new cardiovascular events when listing for injections, this should be done for all face to face consultations as well as nurses need to document that in the virtual clinic and assessor needs to check that, as on two occasions patients were booked for injections with history of cardiovascular event in the preceding 4 weeks.

Radiotherapy treatment

This can help (Oraya). It reduces the need for injections, but they are still needed, and may be available in Birmingham 2014. There is a 3% incidence of diabetic retinopathy. It will make diabetic retinopathy much worse and should not be used if diabetic retinopathy is present, or if the diabetes is badly controlled.

  • confirm with FFA
  • cnv less than 4 mm
  • subfoveal
  • Oraya 2 days after first injection
  • takes 10 minutes using a list lamp and contact lens in outpatients
  • eye and head fixed..3 minutes fixed position
  • still need next 2 injections
  • Daily Mail 14

 

PDT laser

This may help some patients, page

 

The benefits

Out of 100 patients

  • 10 of patients will get worse (this includes PED patients who may get a tiny rip in the retina)
  • 40 will notice better sight
  • Another 50 will have stable sight or a small reduction (but not get any improvement)
  • 20 patients: the 3 injections will stop CNV permanently and more injections will not be needed (Eylea patients will still get 7 injections)

To improve success of the treatment

  • Read the appropriate articles and booklets    procedure
  • Follow the advice, particularly not smoking.
  • A healthy lifestyle & diet.
  • Consider Lutein and Xeozanthin ‘vitamin’ supplements (10-20% benefit).
  • Smoking...the treatment will be much less effective. Essentially wet ARMD patients have a choice, smoke or keep the central vision. Nearly all smokers will not have their central vision in 5 years.
  • There is a lot of organisation in involved: if you think you have been forgotten about, contact the department. Patients having treatment generally need injections or scans every 1 (or Eylea every 2 months) .
  • Check sight daily for distortion both eyes. If the other eye has good sight but starts to get distortion of vision, this eye needs a OCT scan to see if wet ARMD is present.
  • After an injection, if the sight is misty, an check is needed right away to determine if there is an infection in the eyeball.
  • Sometimes switching to another anti-VEGF may help Eye 14
  • summer holidays Eye 15

Some research notes

Improvement in vision

comparision of anti-VEGF protocols

 

 

Old data: the most effective protocol is monthly Lucentis or Avastin (Catt 2 Study). As required treatment was not as effective. Enlarge 
With treatment, vision does improve, then may get a little worse very slowly. Eylea should equal Lucentis.

Scarring of the macula wil reduce sight Retina16.

 

The injection procedure

macular oedema / ARMD

Wet ARMD green (yellow arrow) . Macular degeneration affects the centre of the retina which is responsible for sharp vision. The front of the eye is on the left, and the retina is shown in red.

These drugs are given as an injection into the vitreous cavity of your eye. They are given in a clean room or an operating theatre.

The injection procedure itself takes seconds and is usually feels like a tiny prick. You can go home later that day...this is a 'day case' procedure'.

 

 

 

Procedure

intravitreal triamcinolone, lucentis, avastin,

  1. The eye is cleaned.
  2. Anaesthetic drops are instilled,
  3. and a few minutes later the nearly painless injection is given
  4. The eye pressure may go up for a few hours, and extra treatment may be needed
  5. You may see the drug floating around your eye for the next few weeks.
  6. Reflux Retina 14

 

 

 

After the injection

After the injection you usually notice black swirls in the vision, which start to disperse gradually, but are a nuisance for a few weeks. By one month the drug should be working.

 

Common occurrences after injections

  1. Bubbles appear in the vision; they float around the eye. These come from then injection syringe, and the bubbles float to the top of the eye and appear in the lower vision. They can be very upsetting, but they are air bubbles, and always go. Most disappear by the next day, some take a little longer.
  2. The cleaning solution can make the eye very sore for 24 hours. The cleaning solution is strong and may burn the eye. We have found this problem much commoner for patients with dry eyes. Such patients are probably best using a lubricant after the injection itself, such as Viscotears or VitApos, or Xailin night.
  3. 10% of patients notice a red eye from a subconjunctival haemorrhage. This heals over 2-14 days. Bleeding may be related to aspirin or anticoagulant use.

bubble after anti-VEGF injection    bubble shunks and disappears over 1-2 days

A bubble after anti-vegf injection: shrinks and dissappears after 1-2 days. The bubble is air from the syringe. Enlarge

a small haemorrhage afer anti-vegf injections is common    a large subconjuctival haemorrhager may occur after injections

a small haemorrhage afer anti-vegf injections is common enlarge; sometimes the haemorrhage is large

Risks etc

Hours

The injection will put the eye pressure up for a few hours. It is therefore riskier is you have glaucoma, but this is generally not a major problem. There should not be much pain

Night

  • The cleaning solution can burn the surface of the eye, making it very sore during the night. There should be a full recovery over the next 1-2 days.
  • There may be a small haemorrhage on the surface of the eye, and this should disappear over 1-2 weeks (subconjunctival haemorrhage).
  • A bubble may appear in your vision, floating around: a bubble of gas may enter when the drug is injected.

Days

About 1/1000 people will develop a serious eye infection. The day after the injection your eye should be comfortable, there should be very little pain. If your eye starts to get red, with misty vision (there may be no pain), perhaps 2-5 days after the injection, you should suspect an infection and attend your eye department urgently. In Birmingham this is the Birmingham and Midland Eye Centre Casualty at the
Birmingham & Midland Eye Centre, City Hospital, Dudley Road, Birmingham B18 7QH
Tel: 0121-554 3801. Avastin, infection..preventing.

Risks summarised

Summary  Rarely cataracts, retinal detachments, macular haemorrhages (BJO 2008), a rip Eye 2011.

Pregnant

Retina 2012

Anticoagulants ...extra precautions

You should remind your ophthalmic team you use anticoagulants and ask for specific advice. Treatment is safe continuing the anticoagulents (Retina 2010).  Epidemiology 2010

Advanced Glaucoma

Acetazolamide 500mg  1 hour beforehand helps to keep pressure down

 

Predictors of response

  • Early disease responds better and patients are more likely to keep good vision.
  • "Thick Subretinal fluid and macular oedema on OCT may be characteristic of none-responders and may be helpful for tailoring treatment for neovascular AMD". See   
  • Follow up Retina 2012   poor response Retina 2012
  • poor results are mainly due to disease progression, including that caused by fibrosis
  • "About 15% did not sufficiently respond to anti-VEGF treatment. Vitreo-retinal adherences were the only ophthalmologic factor which could be identified to be significantly correlated with insufficient response" BJO 2013.
  • patients with poor sight will benefit if there is little atrophy and fibrosis Retina 15

subretinal fibrosis...a common cause of poor response to anti-VEGF treatment

subretinal fibrosis: subretinal fibrosis (red arrow) ...a common cause of poor response to anti-VEGF treatment. Treatment will reduce fluid but not the fibrosis. enlarge

 

 

Sight at the beginning is crucial: vision at presentation of wet ARMD is crucial...good vision at the onset is maintained, deteriorating just a little compared to initial presentation.

We must try and diagnose patients early  enlarge

Y axis....6/9 is good vision, 6/36 is poor.

 

 

Nurse injectors

Stress on family and care-givers

There is lots of stress on care-givers, who find the treatment porgaram an ordeal. Eye 16