Scheie Eye Institute, University of Pennsylvania
Wet age-related macular degeneration (AMD) can cause rapid vision loss. Learn how recent advances in treating wet AMD have decreased the rate of vision loss, and about research that may eliminate the need for injections.
Wet AMD occurs when new blood vessels grow into the retina. These vessels leak and bleed, eventually damaging the macula (the center of the retina) unless the affected eye is treated.
Prior to 2005, most patients with wet AMD would lose much of their central vision over the course of a few months to years, depending on the severity. The disease would often progress until scar tissue replaced the vision cells in the macula, and patients wound up losing their central vision, keeping only the peripheral vision, which provides an acuity of 20/200 or less.
In 2005, the first of the new drugs that inhibit vascular endothelial growth factor (VEGF) became available and began providing remarkable vision protection. VEGF promotes the growth and leakage of abnormal vessels in the retinas of patients with wet AMD. Drugs that block VEGF typically work for 4-12 weeks, and then need to be injected again. These drugs include brolucizumab (Beovu®), aflibercept (Eylea®), ranibizumab (Lucentis®), and bevacizumab (Avastin®). Clinical trials indicate that in some patients, Eylea can last as long as 8 weeks and Beovu as long as 12 weeks.
VEGF drugs are administered by injection into the vitreous jelly in the center of the eye. The eye is numbed with drops, cleaned, and the injection, which is only moderately uncomfortable for most patients and takes only a few seconds, is done through a tiny needle. Some ophthalmologists prefer to give the injections on a regular schedule, while others will base the re-injection decision on the results of a special type of retinal photograph called optical coherence tomography (OCT).
The injection risks are low: about a one in a thousand chance of retinal detachment or bacterial infection in the eye (endophthalmitis). Beovu causes inflammation in about 4 percent of eyes, and this has been associated with diminished vision caused by inflammation of blood vessels (occlusive vasculitis) in 11 out of 46,000 injections so far in the US.
After the first few injections of an anti-VEGF drug, on average, vision improves by a couple of lines on the eye chart. Over the course of a few years, the vision tends to drop a bit, down to the pre-treatment level. It can get even worse, especially in patients who opt to have only very infrequent, or no follow-up injections. Some patients find it challenging to get frequent follow-up injections for a variety of reasons, including difficulty with transportation (some can no longer drive), other simultaneous health issues that need urgent attention, or cost. Avastin, which is used off-label, is the lowest cost drug.
Many patients have asked me when longer-lasting drugs will become available, and some are in clinical trials. One is an implanted, inside-the-eye, storage device for Lucentis, which in some patients can last more than a year between refills. Also, two types of gene therapy, one injected into the vitreous, and the other injected under the retina, are now being tested, and early results suggest they may decrease or eliminate the need for further injections.
Joshua Dunaief, MD, received his BA magna cum laude in Biology from Harvard (1987), MD/PhD from Columbia College of Physicians and Surgeons (1996), completed ophthalmology residency at the Wilmer Eye Institute, Johns Hopkins in 2000, and medical retina fellowship at Scheie Eye Institute, University of Pennsylvania in 2004.
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