The Power of Lucentis, Avastin, Eylea

Last week I had a patient with diabetes come in with massive growth of new blood vessels on the disc — “proliferative diabetic retinopathy.”  Because of the extent of the proliferative retinopathy, I gave him an injection of one of our wonder drugs, the VEGF inhibitors, the most common of which are Lucentis, Avastin and Eylea.  In this case I used Avastin.  I saw the patient 48 hours later to treat the other eye, and when I looked into the eye I had treated two days ago, I saw the amazing effects of the drug — the vessels had shrunk away.  They weren’t gone, but they were reduced from florid, plump, juicy vessels of death, to wimpy little strands.

Even though I see these dramatic changes often, I’m still truly amazed by the effect of these drugs.  Before 2005, it took ongoing laser treatment and months to see this kind of regression of proliferative diabetic retinopathy.  But with the advent of these drugs, led by Genentech, the maker of both Lucentis and Avastin, the results are miraculous.

Florid neovascularization of the disc from diabetic eye disease

Florid neovascularization of the disc from diabetic eye disease

 

48 hours after Avastin injection - the blood vessels on the disc are massively reduced

48 hours after Avastin injection – the blood vessels on the disc are massively reduced

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Why is my eye red after the Lucentis, Eylea, Avastin injection?

Subconjunctival hemorrhage (Licensed under Wikimedia Commons)

Subconjunctival hemorrhage (Licensed under Wikimedia Commons)

I get this question often.  After an Avastin injection, whether it’s given for diabetic macular edema, age-related macular degeneration, central or branch retinal vein occlusions, or any of the vascular or inflammatory diseases of the eye for which Avastin is used, often the eye gets red.  Really red.  Like blood red.

And of course, this doesn’t occur just with Avastin.  It occurs with Lucentis, Eylea, or any injection into the eye.  The redness isn’t caused by the drug. It’s caused by the needle.  It’s not an infection. It’s simply a blood vessel that has leaked blood.

You see, when we enter the eye with a needle, the needle passes through the conjunctiva — a thin tissue covering the white part of the eye, the sclera.  The conjunctiva has tiny blood vessels within it, and sometimes as a needle passes through the conjunctiva, it nicks one of these blood vessels. The blood vessel leaks some blood which collects beneath the conjuncitiva, and causes a bright red patch on the eye.  We call this a subconjunctival hemorrhage.  

It’s a pretty bad looking thing.  After all, the eye gets really red, and everyone that sees you is going to say, “Yikes, what happened to your eye.”  But the truth is, as bad as it may look, a subconjunctival hemorrage is one of the least significant things that you can experience. The blood clears away in a few days or weeks.  It’s completely painless, and has no consequence.  I tell my patients that it’s a little like a bruise (which is bleeding under the skin). Because the “skin” of the eye, the conjunctiva is clear, the blood isn’t purple (as it is when we see it through skin), but bright red.  And just like a bruise, it will go away without any consequence.

Subconjunctival hemorrhages happen about one out of five injections, so if you’re getting regular injections, chances are that you’ll experience one sooner or later.

There are other much more common causes of subconjunctival hemorrhages.  Trauma is probably the most common cause.  Any slight bump to the eye can cause a bit of bleeding from one of the conjunctival blood vessels. Sometimes just rubbing the eyes can cause a subconjunctival hemorrhage.  The other common cause is straining.  So, for example, coughing, sneezing, bearing down while constipated, can all cause bleeding of the conjunctival blood vessels.

Fortunately, when we inject drugs such as VEGF inhibitors into the eye, we place the injection through the lower part of the eye, and as a result, small hemorrhages are hidden by the lower eyelid, and not often noticeable.

If you develop a patch of bright redness immediately after an injection, it is most likely a conjunctival hemorrhage.  But if the redness develops after a few hours or days, or if it is associated with pain, decreased vision, sensitivity to light, or any symptoms at all, it may be an infection, which can be vision threatening and which should be checked by your ophthalmologist immediately.

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How fast will my diabetic retinopathy progress?

The normal retina, (From "Diabetic Eye Disease - Don't Go Blind From Diabetes")

The normal retina, (From “Diabetic Eye Disease – Don’t Go Blind From Diabetes,” by David Khorram, MD)

A 77 year-old woman with diabetes for 15 years wrote with the following question on Diabetes Forum.  I thought it could serve more people if I answered it here.

“My eye doctor recently told me that I had a bit of diabetic retinopathy, and that I should come back in 9 months instead of the usual 12 months.  He also said that I might need laser in the next year.  He was pretty vague about these things.  How fast will my retinopathy progress?”

Great question!  Here is what I have to say.  I’m sorry you left your doctor’s office feeling like things were “vague.”   At our clinic, we take retinal photographs of our patients’ retinopathy, and review the photos with them and their families, so they have a very clear understanding of what is going on, and what my concerns are.  Of course, “what is going to happen” may not be clear, but “what is going on” should be very clear.  So, even though you shouldn’t have to, ask the doctor to take a retinal photograph and review it with you.  I think that will help in the future.

In a more general sense, the rate of progression depends on the current level of retinopathy (is it mild, moderate, severe, very severe), and on how well your blood sugar and blood pressure are controlled.  I also find that whether or not someone smokes makes a huge impact on how quickly retinopathy progresses.  If you’ve had diabetes for 15 years, your general medical status hasn’t changed much, and you don’t smoke, the retinopathy is probably going to progress at the same rate that it already has, which sounds to be “slowly”.

On the other hand, a lot depends on where the retinopathy is at the moment.  The macula is the area of the retina that is involved with your sharpest clearest vision.  If the retinopathy is near the macula, even if it is mild, then the concerns are higher, because even a little bit of progression can cause some loss in vision.  When your doctor says, “you may need laser soon” it sounds to me like the retinopathy may be close to the macula (or more specifically, to the fovea, which is the name we give to the center of the macula), and thus of greater concern.

There is quite a bit of retinopathy present, but it’s only that little bit of hard exudate (HE) and edema (E) close to the fovea (the center of the macula) that is threatening the vision and must be followed closely. (From “Diabetic Eye Disease – Don’t Go Blind From Diabetes,” by David Khorram, MD)

In my book, I spend a chapter discussing the various types of findings in diabetic retinopathy, when those are of concern, and also a chapter on what affects how quickly we need to see you again.  It also has pictures to illustrate the sorts of things I explain.  I also spend a lot of time explaining the new “standard of care” for treatment of some forms of diabetic retinopathy (it’s no longer just laser), and I think that’s important for you to understand since your doctor is mentioning laser.

I hope this brief explanation is helpful.  I don’t want this to be a sales pitch for my book, but the truth is, I’ve found that those people who have a better understanding of how diabetes affects their eyes are the ones that keep their vision.  And that’s why I wrote it.

I welcome questions.  Just post them in the comments section, and I’ll take some of them and incorporate them into posts like this one.

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Diabetes Eye Disease Book Now Available

I’m happy to announce that my new book, “Diabetic Eye Disease – Don’t Go Blind From Diabetes” has been published and is now available on Amazon. The book has received excellent reviews, and in just a few days since its release, as already risen to the #1 spot on Amazon for books about diabetic eye disease.  You can get to the book by clicking on the link on the sidebar.

If you or a member of your family has diabetes, this easy to understand guide will help you understand how diabetes affects the eyes, and more importantly, how you can prevent blindness.  Here is what one of the reviewers had to say:

“This book is a magnificent work and an absolute must-read for people with diabetes. Dr. Khorram has taken one of the most well-known and most serious complications of diabetes — diabetic eye disease — and presented it in a way that is fun and engaging while also reinforcing the serious side of diabetic eyecare. It is such a pleasure to have one of the world’s leading diabetic eye specialists provide his expertise in very plain English to a world of diabetic patients that are literally starving for specific advice about diabetic eyecare and how to avoid their ultimate fear — blindness. As someone who has had diabetes for over 25 years, I am deeply grateful to have a resource like this. Thank you, Dr. Khorram, for a landmark book in diabetes education!”

I’m humbled by this review.  First, I have to make a disclaimer.  I don’t consider myself “one of the world’s leading diabetic eye specialists.”  I just take what I learn from the real giants and geniuses in our field and apply them to my patients, and work hard to teach as many people as possible about the disease and preventing blindness.  Second, I knew this book was needed when I set out to write it, and I believe it’s a great book.  But there is always a bit of surprise — for any writer, perhaps — when others find our work useful  I’m always humbled when someone writes me to tell me that something I’ve written has had an effect on their life.  And there is a part of me that is surprised to have such impact.  I’m grateful to hear back from my readers.

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Laser Cataract Surgery

ts_120702_laser_eye_surgery_140x106In my book, Diabetic Eye Disease – Don’t Go Blind From Diabetes, I have a special chapter on cataract surgery, and I discuss that although everyone is likely to get cataracts, with diabetes, you are prone to getting cataracts at a younger ages than someone without diabetes.  Modern cataract surgery is an amazing procedure, where we dissolve the cataract inside the eye, and suck it out through a tiny incision, less than 3 mm in size.  Because it is so small, the incision is usually self-sealing, requiring no stitches, and so the recovery time is essentially 24 hours.

The major method we remove in the western world to remove cataracts through a small incision is called “phacoemulsification.”  Phaco means “lens,” and “emulsification” means to dissolve or emulsify.  The instrument that we use to dissolve the lens is a tip that vibrates at very high frequency (like 100 times faster than a bee’s wings).  It’s a great technology, but it is “mechanical,” which means it relies on vibration to break up the lens, and the vibration can effect other tissues inside the eye, especially if the cataract is very hard and we need to use a lot of vibration to break it up.  We use the fast vibrating energy ultrasound energy because the tip is vibrating faster than the vibration of sound waves — faster than 20,000 times per second.

So, along comes a new technology that has been developing in the past few years — laser cataract surgery.  There is a type of laser called the femtosecond laser which is proving useful in cataract surgery.  The femtosecond laser is used to place much more precise incisions than we are able to place with our regular incision techniques, and more direclty related to the cataract, it is used to break up and soften the cataract as preparation for the traditional phacoemulsification.  By fragmenting the cataract with with the laser, it allows the phacoemulsificaiton to go quicker.  This is especially useful for really hard cataracts as it then allows us to remove the cataract with less vibration energy.

At the American Society of Cataract and Refractive Surgery Symposium being held this week, several cataract surgeons reported on the benefits of using the femtosecond laser to assist with traditional phacoemulsification.  It sounds like there are definite advantages, but I’ll have to say, I think that it yet remains to be seen if those advantages will be significant in the real world.  After all, it’s not cheap to add this technology.  The femtosecond laser technology costs about $500,000 (yeah, that’s half-a-million dollars).  Add to that a maintenance contract of around $20,000 per year, and a usage fee of between $150-400 per eye, and you can see that it adds significantly to the cost of cataract surgery.

Time will tell if the technology is beneficial enough to be used routinely.  And with time, we can expect that the price of the technology will come down.  In any event, now when you hear “laser cataract surgery” you know what the issue is all about.  It’s used as a supplement to traditional phacoemulsification, not a replacement.

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Diabetic eye disease and kidney disease linked

51BDaYQGjNLThere is a new study I want to share with you that is important for you as a diabetic.  It was published on the April 25 online version of Diabetes Care and is based on data from the Japan Diabetes Complication Study (JDCS).  First a bit of background.

Diabetic kidney disease (or renal disease) is a big problem.  The high blood sugar in diabetes damages blood vessels in the kidneys, which leads to poor kidney function.  The job of your kidneys is to filter your blood, removing the bad stuff from your blood and getting rid of the toxins through your pee.  When lots of damage occurs to the kidneys, they can’t filter the blood very well, and in severe cases, the kidneys fail almost completely.  You can’t make pee, and the toxins build up in your body.  In such cases, where the kidneys have failed, we use a machine instead to filter your blood.  We call this machine a dialysis machine.  People who are on renal dialysis typically need to get hooked up to the dialysis machine for about four hours, three times a week, to get their blood filtered, purified, and put back into their bodies. This is an effective, but not a very convenient way to purify your blood.  Better to keep your kidneys if you can.

If we want to see early damage to the blood vessels in the retina, we just look into the eye.  But we can’t look into the kidney.  So how can we tell if the kidney is being damaged?  Well, it turns out that there is a small protein in our blood called albumin.  Usually, the albumin stays in the blood and doesn’t come out in your pee.  But when the kidneys start to get damaged, the kidneys start to leak albumin.  We can test your urine to see if it has albumin in it.  Microalbuminuria,  which means small amounts (“micro”) of albumin in the urine (“urea”), is a sign that kidney damage is starting.

The JDCS found that damage to the blood vessels in the retina, diabetic retinopathy,  is a risk factor for development of kidney failure.  They also found that microalbuminuria is also a risk factor for kidney failure.  Basically, if either of these were present, they were predictive of a faster rate of decline of the kidney’s ability to filter the blood, or what we call glomelular filtration rate (GFR).

In their study of 1475 patients who were followed over 8 years, they found that those who had either retinopathy or microalbinuria had increased rates of decline in GFR, but they found that those patients who had both retinopathy and microalbuminuria and a 2-3 times greater risk of progressive kidney disease than those who had neither.

Because it is so important to catch the beginning stages of kidney failure, we now have markers that can tell us someone is at higher risk.  It is vitally important that eye doctors and diabetes doctors communicate about the findings of retinopathy, even when mild, because we now know that the retinopathy is a predictor of worsening kidney disease.  Make sure your eye specialist is communicating your retinal findings to your other doctors.

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Diabetic Eye Disease – My New Book!

Don't Go Blind From DiabetesAs you know, one of the major complications of diabetes is diabetic eye disease, and it is a leading cause of blindness in working-age adults.  Over years of treating thousands of patients with diabetes, I’ve seen that the more  a person knows about diabetic eye disease, the more likely they are to take action needed that can save their vision.

I looked for resources to give my patients, and realized there really wasn’t anything out there.  It was for this reason that I decided to write Diabetic Eye Disease – Don’t Go Blind From Diabetes.  It is an easy to understand guide to keeping your vision for people with diabetes.

Because new information becomes available every year, I’ve also created special reports to keep you up-to-date on new developments in diabetic eye disease.  My book is in the final stages of publication, and should be available within two weeks.  I look forward to being in touch with you!

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