CALL US AT 1-855-962-2852
RESEARCH • HOPE • EDUCATION • EMPOWERMENT
Feedback

Ask the Doctor

Many Macular Degeneration patients have similar questions. Please take a moment to search our Q&A below.

Problems after injection

I recently had my first injection in my left eye. My eye was pretty sore that night and the next day, I ended up taking off work. My eyelids were also swollen, and my eye stayed bright red for about a week. Can I expect this with every injection? Your Concerns I am only 46 years old and my controlled blood pressure is about 135/80. Would asking my doctor to see if we can lower it more possibly preserve sight in my other eye?

 

Answer: After injections, patients should expect to have some degree of irritation, though not always. It depends on the technique used by your physician, as well as your own sensitivities to some of the medications and drops used during the procedure. In general, I tell my patients that they can expect some foreign body sensation (like an eyelash or grain of sand under the eyelids), and some mild ache for about 24-48 hours, but this is not universal. If you have more irritation, then you might have an allergy to one of the medications used during the procedure. I think the most commonly irritating medication is Betadine (povidone iodine), an anti-microbial commonly used to prevent infection. One way to minimize this irritation from any of these is to irrigate the eye copiously with eye wash after the injection. Also, using artificial tears and warm/cold compresses can also help with these symptoms. However, some patients have a very real allergy to povidone iodine which can result in severe inflammation around the eye, and may involve the surrounding skin if it is used around the eye prior to the injection. Also, sometimes redness after injection is due to bleeding on the surface of the eye. These “subconjunctival hemorrhages” generally do not cause vision problems, and resolve on their own. They are essentially “post-surgical bruises” in the treatment area, and are just unsightly and cause the annoyance of having other people ask you “what happened to your eye?” No matter what the cause of the irritation, redness and swelling, though, you should definitely contact your doctor if you have any problems after your treatment. As to your question about high blood pressure… hypertension and other cardiovascular risk factors are also risk factors for advancing macular degeneration, so I definitely recommend sure that blood pressure is also under ideal control. I hope this helps!

ForeseeHome

Is the ForeseeHome monitoring program showing good results? Your Concerns Need to carry instrument on trips seems awkward. Is it worth the price?

 

Answer: I personally have not used or recommended the ForeseeHome monitoring program. There is some evidence that it may be slightly better than Amsler grid use. I have not yet seen any follow up evidence to support this. I think it is a good device to use as it helps to communicate with your regular eye doctors, but an Amsler grid is probably sufficient for use while traveling. I hope this helps!

Any more injections?

I have been diagnosed with Macular Degeneration, wet, age related. I received injections of the drug lucent for several months being paid for by the Chronic Disease Association out of Plano Texas. After see the Dr at the Omaha Eye and Lazur clinic, the continuation of the shots was agree byu us both would not continue as they were not helping any longer. Your Concerns I ask if there is other treatments available and if I should see another Dr about treatment. The injections were to help prevent the degeneration from getting worse.

Answer: There are several injections available to treat the wet form of macular degeneration: Avastin, Lucentis, and Eylea. Injected steroids may also have some effect, and there are also some older laser treatments that can be considered. Unfortunately, if the vision is very poor, or if there is scarring in or under the retina, then further treatments will not help. Surgery to remove scar tissue also does not seem to help, and may in fact cause worsening of vision. And as you stated, the overall goal of treatment is to prevent further worsening of vision in eyes with wet ARMD. Unfortunately, this is not always the case. I hope this helps.

Glaucoma or Macular

I Have been diagnosed with macular by my ophthalmologist. However on my right eye when I hold up my right hand shoulder level and do same on the left, lose sight of hand on.right still can see hand on left Your Concerns Do I have glacoma and macular?

Answer: Unfortunately, without actually doing an exam of your eyes with special testing, I cannot tell if you have glaucoma or macular degeneration. However, macular degeneration tends to effect the central vision, and rarely the peripheral vision. Glaucoma tends to effect the peripheral vision, but may also cause central changes depending on the type of glaucoma and overall severity. Both eye problems can occur at the same time, as well. I would recommend that you discuss this further with your regular eye specialist(s).

Will I get macular degeneration if my mom has it?

My mother has wet macular degeneration, does that mean I may get it? Also I have been hearing a lot about Genetic testing can you tell me about this test, also am I a candidate for it? Thank you for your answers.

MICHAEL TOLENTINO MD SAID…

Unfortunately your risk could be as high as 50% of inheriting macular degeneration. If your father also has macular degeneration then the risk could even be higher. Scientists have identified the genetic variations (polymorphisms) that appear to increase the likelihood of developing macular degeneration furthermore if one tests for this variation and considers, factors such as smoking history, severity of early findings of dry macular degeneration and ones body mass index ( how your body is shaped: straight, pear like etc.) one can predict with high degree of certainty the chance of progression of the disease to the blinding form of macular degeneration.

Currently there is a genetic test that can be performed by your eye doctor to determine your risk of progressing to advanced macular degeneration, but you as the child must have signs of dry macular degeneration before the test can be utilized to predict progression. The ability to identify people who progress is excellent. As test goes, this test is better than almost any other genetic test for any disease in its ability to predict progression of disease. The currently available test is called Macula Risk and eye doctors can administer this test in the office by using a cheek swab.  In the future other companies are working on similar tests and should be available also from your eye doctor in the future.

If you have signs of dry macular degeneration as identified by your eye doctor you can get this test and it can help determine what your likelihood of progressing could be. Depending on your risk category, you may need to be monitored more closely by your eye doctor, you need to stop smoking which is the greatest modifiable risk for blindness from macular degeneration, you should also be taking supplementation with the carotenoids ( Mesozeaxanthin, Lutein and Zeaxanthin) along with Omega 3- Fish oils, Zinc, Vitamin C and E.

Macuhealth is the only vitamin regimen that provides the correct ratio of Carotenoids and can be obtained through the internet at www.nomoreamd.com. This is the only formulation that has therapeutic levels of mesozeaxanthin which is a patented nutrient.

I hope this helps.

Michael Tolentino MD
Scientific Co-Founder Macular Degeneration Association
Center for Retina and Macular Disease
www.crmd.net

What are Floaters?

Can anyone explain to me in layman’s terms what “floaters” are? I have dry AMD with “dominant drusen” and the floaters in my eyes are predominant to the point of distraction in well lit conditions, i.e.; bright sunlight.

MICHAEL TOLENTINO MD SAID…

Floaters are  opacified jelly inside the eye. The eyeball is filled with a clear gel which has substance. It is similar to jello in a jello mold. Off course the jello is clear like stretched saran wrap. Sometimes we are born with some fruit ( opaque portions in the jello) that we have or develop. So these pieces of opacities float in the jello and if they are in the visual axis they will result in seeing a spot ( floater in your vision)

Most people develop floaters because of the aging process. If you have ever left a jello mold in the refrigerator for many days, the jello contracts. The gel then folds in on itself resulting in a crumpled saran wrap rather than a stretched transparent saran wrap ( jello) This floats around and if it catches light in a certain way can cause glare or it can appear as a spot in the vision that floats around.

In summary this is a non biologic description of a floater.

My wife has the wet form of Macular Degeneration in both eyes.

She has been treated with Lucentis – 16 monthly injections into the left eye and 12 injections into the right. Her vision is stable and she is able to read and drive the car during daylight. We have recently considered autologous stem cell treatment for further treatment. We have communicated with the X-cell Center in Cologne, Germany.What is your professional opinion of this therapy? Of the Institution? Thanks you in advance for your help.

MICHAEL TOLENTINO MD SAID…

Stem Cells are an exciting and promising technology that is still in its infancy. Having helped develop the injections treatments that you are receiving now it reminds me of when I started working on these injections in the early 90s when I was at Harvard Medical School. I remember many of my colleagues around the world were very skeptical about the utility of these injections even though I was certain as a scientist that the drug would work. It took several years of extensive clinical testing and further research to finally have medicines that would actually preserve vision with macular degeneration and in some cases improve vision. What occurred in those years was constant refinement of the drugs and treatments until it was consider efficacious and adequately safe to be considered Food and Drug Administration approved.

The injections you are receiving are a result of refining the technology and building upon basic discoveries. In many ways it is much more similar to engineering then it is to basic science. The drugs had to be designed so that they could be administered and targeted to help the eye condition. Stem cell therapy has not undergone enough refinement at this time to be considered a effective or safe treatment. While I think that the idea is good, a lot more work needs to be done until humans receive this as a treatment. I will use the Cologne treatment as an example here in terms of what still needs to be refined.

The Cologne treatment is based on using bone marrow stem cells. Now bone marrow stem cell transplants have already been utilized to treat patients who have been treated for blood cancers. This blood cancer treatment eradicate all the cancer cells and stem cells in the bone marrow which then need to be replaced with stem cells derived from the bone marrow of a patient that does not have blood cancer. Most of the stem cells in the bone marrow are useful in producing a type of cell that the bone marrow produces. A short list of these cells include: Blood cells and blood vessel cells. Nerve cells are not typically what these stem cells produce but with some engineering they may be convinced to produce other cells besides blood related cells.

Now lets say you get this bone marrow treatment for your macular degeneration. How can that help you see better or treat your disease? Well what those stem cells need to do is become something that they are not normally known to become, a light sensing cell of the eye. If that is accomplished then that light sensing cell has to connect to the brain in a way that paralells the destroyed light sensing cells . This definitly happens in science fiction movies but as of the time of this writing, no one has been able to demonstrate this. In the future will this be possible? The answer is yes, but it will require several discoveries worthy of the nobel prize in medicine before we are able to do this.

One could say that there is no harm in doing this treatment so lets proceed, while there may not be any documented harm in getting this treatment, I can postulate several theoretical problems. The one that is closest to wet macular degeneration is by understanding the source of these new blood vessels that lucentis is currently preventing from overgrowing your vision. Wet macular degeneration is when new blood vessels grow in the center of the vision and leak and bleed resulting in visual loss. Lucentis slows the growth of these vessels and stops them from leaking.

The question that one asks is where do these new blood vessel cells arise from. Well scientists have identified that new blood vessels are derived from bone marrow stem cell. So lets say you get a treatment with bone marrow derived stem cells into the eye. What you may be doing is trying to put out the fire (blood vessels leaking and growing in the macular) with gasoline (stem cells which are providing the building blocks of the blood vessels growing inside your eye.) Tell me does this make sense?

So what I am saying is stem cells are very promising, but a lot more work needs to be done to prove that they are safe for the conditions that they are targeting and also effective. Also in the current state of the art, I do not see stem cells as able to restore vision mainly because of the complexity of the visual system. I think that stem cells have easier proving grounds such as in skin grafts, cartilage growth and muscle regenerations these are much simplers structures that may benefit because they only require regeneration and not integration.

The real promising treatments are currently being tested in clinical trials seeking FDA approval. Currently we are involved in an eyedrop clinical trial that may prove beneficial in terms of reducing the number of injections that you need. We are currently working on genetically based therapies. You may not be aware that the genes that seem altered that cause macular degeneration have been discovered, and we are designing drugs that are geared to interrupt the pathogenesis of the diseases. One such therapy being developed is drugs that modulate the inflammatory system since inflammation and oxidation appear to be the root cause of macular degeneration.

I hope this helps

I receive Avastin injections for bilateral macular degeneration.

I receive Avastin injections for bilateral macular degeneration. Are NSAID contraindicated. Is there a list of medications that I should avoid?

MICHAEL TOLENTINO MD SAID…

NSAIDs ( Non Steroidal anti-Inflammatory Drugs such as Aspirin, Motrin, Advil, Naproxen etc. ) are not contraindicated in wet AMD. But they may theoretically increase the risk of bleeding of the conjunctiva ( the white part of the eyeball) and may increase the risk of bleeding inside the eye from the wet macular degeneration. So my advise is to consider not taking NSAIDs if you can replace them with something else such as Acetominophen ( Tylenol) which does not increase the risk of bleeding.

Michael Tolentino MD
Center for Retina and Macular Diseases
www.crmd.net

A patient, who is 81 and has had two Transient Ischemic Attacks (TIA’s)…

A patient, who is 81 and has had two Transient Ischemic Attacks (TIA’s), was subsequently diagnosed with DMI. Since the TIA attacks, the patient has been taking Plavix. Should he discontinue his TIA medication now that he has started to have Lucentis injections for the treatment of DMI? What would be the implications if the two treatments (Plavix and Lucentis) were to be followed concurrently? If indeed Plavix should be discontinued what can be done to prevent further TIA attacks?

MICHAEL TOLENTINO MD SAID…

Monday, January 10, 2011

I apologize for the long delay in the response to this question.

There are 2 issues in your question.

1) The anti-coagulation issue
2) The TIA issue.

1) The use of Plavix and Coumadin is standard for the care of patients who have had TIAs. These medicines prevent clotting and disrupt the clotting cascade. By preventing clots from forming, this has been shown in several studies to reduce the risk of having a true stroke instead of a TIA. So one can call it preventative therapy.

The mechanism of these medicines can affect the eye injection procedure in several ways. First of all thinning the blood will increase the chance of bruising. A bruise on the eye is actually common place after an eye injection but can be disconcerting for the patient. The chances of getting a bruise ( subconjunctival hemorrhage) is much greater. Below is a picture of such a bruise. Some patients whose blood is too thin may continue to bleed from the eye but it is very unlikely that a patient will lose enough blood to be life threatening.

If the eye injection is being used to treat a bleeding condition in the eye such as macular degeneration or diabetic retinopathy, theoretically this may increase the risk of bleeding into the eye resulting in loss of vision. The studies have not been done to answer this question definitively but theoretical risk is great. These risks though must be balanced with the risk of having a true stroke. In most cases the risk of stroke should outweigh the risk of bleeding in the eye or on the eye.

The next issue is in regards to using these injections in a patient who has had true TIAs. Lucentis( Ranibizumab) and Avastin( Bevacizumab) have been suspected of increasing the risk of stroke. One trial using Lucentis has shown a possible increase in the risk of strokes receiving lucentis injections if the patient has previously had a stroke or has many risk factors for strokes. There are many reasons for this which I can explain if someone is interested in learning more about it.

Avastin used systemically has also shown an increase risk of stroke in patients receiving it for Cancer therapy. The food and drug administration has actually given Avastin the highest level of warning that it can give a drug in regards to this. But because Avastin was not designed for the eye and will not be studied in a systematic way for safety, then we will never have true data demonstrating if Avastin is safe. Having studied the basic science of these molecules it would be hard for me to believe that Avastin would not increase the risk of stroke in patients who have had strokes in the past. Furthermore a recent study which is not published as of the time of this response has demonstrated safety concerns regarding Avastin vs Lucentis. So to extrapolate this information one could deduce that Avastin is more likely to increase the rate of stroke than Lucentis. Lucentis as I already mentioned has already been shown to potentially increase the risk of stroke when analyzing the standardized trial data that has been produced to get Lucentis approved. Currently the only approved injection treatment for age related macular degeneration  that has not shown safety issues in regards to stroke happens to be a drug called Macugen.  A drug that I personally use in patients who have increased risk factors for stroke.

Conclusion to this answer is that taking Plavix or Coumadin to prevent stroke from TIA in patients receiving eye injections has not been shown to be detrimental to the vision but there is a theoretical risk of this. But one should be informed of the risk of Avastin and Lucentis use in patients that may have an increased risk of stroke. In patients with an increased risk of stroke I would consider trying to minimize the injections with Avastin and Lucentis and balance them off with injections of Macugen which is a drug that has not shown any increase in stroke risk. Furthermore the use of Lucentis is likely far safer than the use of Avastin which is a drug that has not been evaluated by the food and drug administration for use in diseases of the eye.

References

Tolentino M. Systemic and ocular safety of intravitreal anti-VEGF therapies for ocular neovascular disease Surv Ophthalmol. 2011 Mar-Apr;56(2):95-113.

Friberg TR, Tolentino M; LEVEL Study Group, Weber P, Patel S, Campbell S, Goldbaum M.Pegaptanib sodium as maintenance therapy in neovascular age-related macular degeneration: the LEVEL study. Br J Ophthalmol. 2010 Dec;94(12):1611-7. Epub 2010 May 14.

Michael Tolentino MD
Scientific Co-Founder of the Macular Degeneration Association
Vitreo-retinal surgeon
Center for Retina and Macular Disease
Winter Haven, Lakeland, Zephyrhills, Villages, Clermont, Haines City, Sebring , Plant City.
Florida.
http://www.crmd.net/physicians/drtolentino/

Back to Top