“Cross My Heart, Hope to Die, Stick a Needle in My…”

I give intravitreal eye injections everyday!

It is one of the most rewarding things I do!

And they come back for more!  My patients love it because anti-VEGF injections usually work really well, especially if the wet form of macular degeneration is caught early.

Suspicion Confirmed When I examine a patient and suspect that a patient has wet macular degeneration, I’ll usually confirm the diagnosis by performing a fluorescein angiogram.  Once confirmed, I’ll usually recommend intraocular treatment with Avastin.  I have not used Macugen in about 3 years and only occasionally use Lucentis.

First Injection I usually discuss the whole procedure of delivering an intraocular injection and reassure everyone that it is a painless event.  Prior to the actual injection, as I described in a previous post, antibiotic drops are to be used and a second prescription is given for the Avastin.  The Avastin is prepared for us by an adjacent compounding pharmacy (a specialty pharmacy that breaks up the Avastin into smaller doses for ophthalmic use).

Series of Injections My usual practice is to commit to 3 treatments given every 6 weeks.  After this short series, we reassess and determine if more injections are necessary.  Some docs may give injections as frequently as every 4 weeks “come he** or high water.”

More……….please? Aissa and Dick, my teammates, can tell as soon as a patient walks through the door if the injections are working.  They are ecstatic.  They smile, they bounce, they can’t wait for the next injection!  In general, the better the vision, the more aggressive I am at recommending additional injections.  If we aren’t getting the visual results we had hoped, then maybe I’ll be less emphatic.  So, after the first 3 shots, I’ll recommend more if there continues to be improvement.  The additional shots decrease the chance of recurrence…..we think.

No More Needles! This can be good news or bad.  I’ll recommend stopping the injections if I don’t expect any more improvement, or, we never improved at all.  In this latter case, we are giving up and throwing in the towel.  Sometimes the disease wins!

Shot Holiday After we stop injections, I warn that we are looking for signs of recurrence.  Initially, I’ll usually see patients every 6 weeks and then less frequently if there are signs of stability.  Any time I suspect that there is recurrence, or if there is a decreased vision or distortion, I’ll obtain a fluorescein angiogram to confirm recurrence.  The fluorescein angiogram is the best test for this.

An OCT (Optical Coherence Tomography) is another test that is commonly used by retina specialists.  In this scenario, it is usually used to detect swelling, or leakage, presumably from the neovascularization.  It can not, however, actually confirm active neovascularization.  It is used to monitor progress of the treatment.

What Does This Mean? This is how I “roll.”  There are lots of variations to this regimen, but most retina specialists practice pretty similarly.  Basically, we treat to seek improvement, then monitor for signs of improvement.  This is truly one of the most rewarding things I do!  Before injections (including PDT – see section on macular degeneration), we offered little hope of improvement from this blinding disease.  The ability to change the natural course of this disease is miraculous!

“Randy”

Randall V. Wong, M.D.

Retina Eye Doctor
Ophthalmologist
Fairfax Virginia

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Comments

  1. “Cross My Heart, Hope to Die, Stick a Needle in My…..”

    Randy, that’s gross….!!

  2. Dick Marquis says:

    Dr. Wong,
    Can Avastin injections be used as a preventive treatment prior to any signs of wet AMD?

  3. Randy,

    A great post. I’ve just put it on the MD Forum, where a bunch of AMD patients discuss their disease and treatments with each other, moderated by Dr. Dan Roberts.

    For any of you interested in joining the Forum, here’s the link:
    http://forums.delphiforums.com/MDforum/messages

    Irv Arons

  4. Wouldn’t the use of the new spectral Fourier OCT’s reduce the need for the fluorescein angiograms? These devices can register to the exact scan location so that now cross section (or volume) differential changes can be monitored. If the scan is looked at x weeks later one could tell if the fluid is increasing, decreasing or what.
    Not a fan of FA’s.
    One other question if I may. Doesn’t fluid precede neovascularization?

    Thanks. Nice site.

  5. The issue with the the OCT is that it is not a dynamic (time) study as is a fluorescein. While the new OCT’s are able to offer hi-resolution and diagnose swelling, aka macular edema, there is no way to determine active leakage. Fluid can present without neovascularization. OCT is a great way to monitor treatment effect.

    If I understand the latter part of your question, I don’t have a great answer and would say that both occur at the same time, but fluid is easier to detect at an earlier stage than neovascularization.

    Do you not like FA’s from the perspective of a patient or diagnostician?

    Thanks for commenting. I hope I made sense. Great comment/remarks.

    Randy

  6. I do not think “pre-treatment” is worthwhile. The half-life, or the time Avastin remains in the eye, is a matter of hours.

    Thanks for reading and commenting!

    Randy

  7. Some one has to do it…………..it isn’t glamorous.

    Thanks for reading!

    Randy

  8. If I understand it correctly (big if), FA’s show the rate of fluid leakage and the OCT’s (hi-def, registered) show the accumulation of this total leakage (volume). Then, if subsequent OCT’s are taken, spaced at appropriate time intervals, one could tell if the fluid was increasing, stable or decreasing (maybe, hopefully, perhaps, as a result of the anti-VEGF shot).

    My understanding is correct?

    I prefer the OCT to the FA (as a patient) since it is less invasive.

    Thanks.

  9. You write: “… and it does not hurt”. I bet you say to the patient “I didn’t feel a thing”. Best wishes, Ron.

  10. You are right. I like a sense of humor.

    r

  11. After a shot of Avastin, (for example) some patients complain that there is a black blob rolling around the retina. This usually goes away in several days.

    Please comment. Some people are concerned about this

    Thank you.

    D. Wilgus

  12. Commonly, small air bubbles are injected into the eye at the same time as an intraocular injection. They usually are small round black blobs as you describe, but they should be in the lower portion of the vision. Remember, that the bubbles will float “up” which will appear in the lower part of the vision.

    Air usually is absorbed quite quickly by the retinal vessels – the air bubbles are usually gone by the next day.

    I think I got this one right?

    Thanks for the comment,

    Randy

  13. Dr. Wong,
    Thank you for your comment.
    It has been most helpful.
    Don W.

  14. You are welcome!

    R

  15. A,Drenikow says:

    I had the Lucentis eye injection on Tueday. It is now Thursday and I still have the air bubble in the lower part of my viosion how long will it take to go away?

  16. Sorry for the delay. The dark spot is probably an air bubble. If it is still there, please let your doctor know.

    Randy

  17. Won’t bore you with the facts; but I do want to thank you . You have raised my hopes and while each case is differant hope is no small thing. I wish you a good life.

  18. Many thanks.

    r

  19. Ahmad Abdullah says:

    Dr. Wong

    One quick question, is some one with keratoconus won’t be able to be an eye specialist?
    I’m one of the house officers in Ireland anyway.
    Thanks for your answer.

    Ahmad

  20. Dear Ahmad,

    I have a great friend who is both an optometrist and ophthalmologist….he, too, has keratoconus.

    r

  21. Michael Myers says:

    I had the Lucentis eye injection on Tuesday. It is now Thursday and the air bubble in the lower part of my vision no longer is there. I’m being treated for macular edema. Are the shots for macular degeneration to the same part of the eye and would you get bubbles with either? Fake Avastin from Turkey, that could be anything being sold as anything, how did they discover it was fake?

  22. Dear Michael,

    The injections are exactly the same for either of the two conditions. Bubbles occur all the time.

    I believe the bogus packaging gave the it away.

    r

  23. Michael Myers says:

    Thank You for clearing that up, no worries

    Mike

  24. Hi Randy, here goes for a second perspective. .. I have macula oedema after brvo 18/12 ago. After 6 Avastin, 2 laser, 1 steroid and now 3 Lucentis (over 12/12) I have to say that for me the Lucentis was like water! I’ve had improvements but they only lasted a couple of weeks. My doc is great and as a nurse I check the web before before meeting with him so I can be part of the decision making. ‘We’ are now considering Avastin 3 weekly since at 56 years of age and with otherwise good health and fantastic vision, none of the previous rx has given any lasting improvement. Lucentis – 0! I can’t find any info on Avastin 3/52…. do you have any experience with this or an opinion?
    I would appreciate your input, and I really do trust my doc, he loves eyes!!!
    Thanks, Susan

  25. Dear Susan,

    I have a few patients who must get Avastin or Lucentis every 3 weeks or the vision declines.

    r

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