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New and exciting treatments are now available for the wet neovascular form of age-related macular degeneration (AMD). For the first time in the treatment of this condition, we now have treatment techniques that in some cases may actually improve vision rather than just preserving a reduced level of vision. These revolutionary treatments have prompted much media coverage and have stimulated great public interest. In this update, we would like to outline our experience with these new treatment modalities at Texas Retina -- where our physicians have a combined clinical experience of well over 200 years.
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Lucentis or ranibizumab (Genentech) - This drug was approved for clinical use by the FDA in June 2006 and is now available. It is injected into the eye in the clinic as a small volume, using local anesthesia. The injection must be repeated several times before the disease can be stabilized.
Pros: It is effective in clinical trials and may improve vision in some patients.
Cons: The drug is very expensive and needs to be injected multiple times over one to two years.
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Avastin or bevacizumab (Genentech) - It is very similar in chemical formula and in use to Lucentis. Avastin was initially developed to stop the unwanted growth of blood vessels in advanced colon cancer.
Pros: It is much less expensive than Lucentis but seems equally effective in the clinical experience of most retina specialists who
have reported on its use.
Cons: Avastin has not been subjected to formal clinical trials yet. However, multiple articles now exist in scientific journals
that document the safety and effectiveness of this agent. Also, it is not specifically approved by the FDA for eye use, although well over 10,000 patients throughout the United States have been treated to date with Avastin. In some states, including Texas, Medicare does not yet cover the cost of this drug. The physicians of Texas Retina have treated more than 1,000 patients with Avastin without any apparent drug-related complications to date.
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Macugen or pegaptanib (Eye Tech/OSI) - This was the first drug approved for injection into the eye for wet AMD and is effective in slowing further deterioration of vision in eyes with wet AMD.
Pros: It is thought to be safe and has been tested in clinical trials. There have been rare adverse systemic side effects.
Cons: Macugen is expensive and needs to be injected every six weeks for one to two years. Additionally, it does not seem as
effective as Avastin or Lucentis in protecting or improving vision.
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Photodynamic therapy with Visudyne or PDT (Novartis) - This method of treatment employs a low-intensity laser light to activate a dye (verteporfin or Visudyne) that is injected into a vein in the arm. The activated dye damages and destroys the abnormal blood vessels under the retina that cause visual loss in wet AMD. It avoids the scarring caused by conventional hot laser treatments.
Pros: It is effective in some special cases with early disease.
Cons: PDT often needs to be repeated and does not appear to be as effective in preserving vision as Avastin or Lucentis for many cases of wet macular degeneration. The injected dye is almost as expensive per dose as Lucentis.
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At present, there is no one treatment that is the clear “ideal choice.” Treatment still needs to be individualized based on each patient’s situation. Combination therapy utilizing two or more of the above agents may ultimately prove to be the best approach rather than using a single agent. National studies are currently underway.
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Unfortunately, no proven treatment is currently available to improve vision in cases of dry macular degeneration. We have learned that the use of oral antioxidant vitamins and zinc in some cases of dry AMD will significantly slow down advancement of the disease. The physicians at Texas Retina are currently involved in clinical trials of new therapies for dry AMD which may help preserve or even improve vision in certain stages of the disease.
Also, most patients who have lost central vision due to wet or dry macular degeneration over several years probably will not benefit from any of the new therapies described above. For patients with recent wet macular degeneration, however, these new treatments represent a significant breakthrough. There is no doubt that even more effective treatments will emerge in
the future. As with most diseases, early detection and treatment intervention are important in yielding the best treatment outcomes.
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