Avastin: An Adjunctive Therapy for Proliferative Diabetic Retinopathy

Avastin® is useful for a variety of eye conditions;  it is principally used to treat wet macular degeneration and is becoming a popular option to treat diabetic macular edema.  On occasion, Avastin has also been useful, in my practice, to treat patients with proliferative diabetic retinopathy.

VEGF (Vascular Endothelial Growth Factor) also causes abnormal blood vessels to grow in cases of “wet” macular degeneration and … proliferative diabetic retinopathy.

Proliferative Diabetic Retinopathy (PDR) is defined by the presence of abnormal “neovascularization.”  These are abnormal proliferations of blood vessels that grow inside the eye.  In patients with diabetic retinopathy, the VEGF is produced in response retinal ischemia; retinal demand for oxygen exceeds the supply due to poor blood supply.  VEGF then causes neovascularization to develop.  This neovascularization can cause blindness by causing retinal detachments or neovascular glaucoma.

The  traditional treatment for proliferative diabetic retinopathy has been laser photocoagulation.  The laser treatment, called pan-retinal photocoagulation (PRP), has been the treatment of choice for years.  The PRP destroys enough tissue so that the available blood supply is adequate to meet the oxygen requirements of the tissue.  When this occurs the “ischemia” is cured, VEGF is no longer produced and the proliferative retinopathy becomes stable.

Occasionally, I have  patients that do not respond well, or completely, to pan-retinal photocoagulation.  Lately, on select cases, I have used Avastin as an alternative to pan-retinal photocoagulation for the treatment of proliferative diabetic retinopathy.

So far the treatment works well.  The neovascular tissue regresses quickly and I recheck patients every 4-6 weeks.  The injections do need to be repeated.

What Does This Mean? Pan-retinal Photocoagulation has been the gold-standard for the treatment of proliferative diabetic retinopathy.  The PRP can decrease light to dark adapatation, that is, it takes awhile to get used to light when coming out of a movie theater.  It is a difficult procedure to perform, but has been very effective over the years.  I consider it a good “fix.”

An alternative therapy is welcomed for two reasons.  Avastin injections are certainly easier to perform and seem not too affect the vision.  Avastin also treats the disease by a different mechanism and may increase the chances of achieving stability.  On the other hand, Avastin does NOT change the relative ischemia in the retina, that is, the oxygen demand is still greater than oxygen supply.  It may be less of a permanent “fix.”

“Randy”

Randall V. Wong, M.D.
Retina Specialist, Ophthalmologist
Fairfax, Virginia

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Comments

  1. Prof. M. Hamed says:

    Hi Dr. Randy
    I have taken two AVASTIN injections in both eyes. I have edema in both eyes. I am a type II diabetic (since 25 years). The Doctor told me that I still need to have a laser in both eyes. I did take laser in my left eye (5000 hits) and in my right eye (2000 hits). I am reluctant to take more laser treatment. I have been reading about the AVASTIN and it seems that one can can take the AVASTIN as a replacement for the laser treatment.
    Do you think the frequent use of AVASTIN injection can be usecd as a substitute for the laser treatment? How frequent should I take the AVASTIN injection?
    I very much appreciate your insights.

    Finest regards,

    Prof. M. Hamed

  2. Dear Professor,

    There are two treatable components to diabetic retinopathy; swelling and neovascularization. Both can be treated with Avastin and/or laser. In other words, is your doctor recommending more laser for swelling, or more laser for neovascularization?

    Avastin is given as often as monthly for macular degeneration. In patients with diabetic retinopathy, it does not need to be given as often, but it depends on each case.

    As your doctor if he wants to be treating the macular edema with Avastin, or, proliferative diabetic retinopathy.

    Thanks for asking.

    Randy

  3. Damon Vailati says:

    Dr. Wong,

    I have proliferative diabetic retinopathy in both eyes, and my doctor has given me extensive laser treatments in my right eye as it is showing a partial retinal detachement that he says will detach if not treated.

    He has me scheduled for invasive surgery to fix this problem, but after reading this, am wondering if the Avastin injections coupled with the laser eliminate the need for the invasive surgery (Victrectomy), though I am not clear whether there is a partial detachment, or he feels if not operated on, a detachment will occur.

    I am having Avastin tomorrow, and then the surgery Friday (today is Tuesday).

    I have an appointment with your office for a second opinion but my insurance will not pay. I missed the apt with you, but do want to see you and my family has agreed to pay for the second opinion. What do you suggest? Thanks so much.

    I was very ill and could not make the appointment, so hopefully my brother called your office and cancelled for me as I asked him to do. Thanks so much!

  4. Dear Damon,

    I hope you are feeling better.

    I will ask my office to make sure that you are rescheduled. Hope to see you soon!

    Randy

  5. steve myles says:

    Dr. Wong,

    I have proliferative diabetic retinopathy in both eyes, and my doctor has given me PRP laser treatments about every 3 months for about a year. According to my doctor, new vessels have not been forming, however my right eye has been clouded with blood for 2+ months and I recently had a minor hemorrhage in my left eye. The current plan is to repeat the PRP laser and then wait.

    I got a second opinion. Victrectomy right eye. Extensive additonal laser in left eye. Both doctors feel that Avastin is not a proper treatment for PDR, but at least the second doctor said he would give me Avastin shots if that’s what I want him to do.

    I may see about visiting your office, however I live 8 hours away. Before I commit to having a doctor that far away, I was wondering if I couldn’t find someone in my area Dayton/Cincinnati.

    I have 2 questions. How can I find a doctor familiar with using Avastin after laser. Or, do you have any advice on how to get my current doctor to evaluate the recent studies & medical data on using Avastin?

  6. steve myles says:

    Follow up comment to my post above.
    My current retinal specialist doesn’t want to use Avastin because he said it could cause a traction retinal detachment. The doctor that gave me a second opinion said that Avastin would cause much scarring due to the rapid shrinking of any abnormal vessels. They feel that PRP laser is the best option to avoid these complications.

    The medical literature I’ve been able to find seems to imply that Avastin is less likely to cause these complications, and the scarring from laser is more likely to cause TRD.

  7. Dear Steve,

    In answer to your questions;

    1. I don’t know that you can find a doctor familiar with using Avastin as most people (docs) don’t maintain blogs like this. I do know that Avastin for PDR is a temporary fix and the ultimate, more likely fix is PRP.

    2. Not aware of any studies to link for you.

    3. I would be happy to assist you in any way possible. Just let me know. I do think you should be able to find someone up there to help you.

    Randy

  8. Dear Steve,

    I would suggest, based on this comment and your previous comment, that you get Avastin just prior to surgery. This is my opinion only. I generally will inject (in cases where I suspect significant bleeding) about 1 week prior to the surgery.

    What really matters is the degree of traction present now…if any. Bleeding and traction do not always go hand in hand.

    Randy

  9. steve myles says:

    Dr Wong,

    Thanks for the quick response. Congratulations on the AAO invite!

    I had one additional question about my PDR. After PRP treatment and stabilzation, can Avastin be used as a preventative measure due to it’s anti-VEGF properties, assuming PRP cured the ischemia? I understand that I will be seeing a retina specialist every 1-2 months with or without the Avastin injections.

    Also, I wish all my doctors were as transparent as you.

  10. Harold Pearson says:

    Dear Dr Wong. I have a question. I know that Avastin prevents the growth of new blood vessles as in proliferative diabetic retinopathy and can stop / impede the growth of new vesslesthat are known to break and bleed in the eye, therefore certainly appears to be able to benifit in the treatment of “proliferative”diabetic retinopathy. My question is not about that aspect of diabetic retinopathy but about macular edema. I see in your post that it is becoming popular in the treat ment of diabetic macular edema. Since in patients that do not have the proliferative vessle component but only macular edema, the edema comes from normal blood vessles that have become dammaged from diabetes and have begun to leak blood fluid and exudates. I cannot understand the benifit from avastin since it’s mechanism of action is to prevent new blood vessles from growing and not patching shut already damaged blood vessles that are leaking fluid causing edema. Could you please please help me with this question as to how avastin can help patients with only the edema component and not the proliferative component.
    Thanks Harold

  11. Harold,

    There are at least two ways that VEGF affects blood vessels;

    1. VEGF induces the production of new (albeit abnormal) blood vessels, as in the cases of proliferative diabetic retinopathy and wet macular degeneration.
    2. VEGF also causes normal blood vessels to become leaky…as is the case in diabetic macular edema. The normal retinal vessels are not as “water tight” as they used to be…hence leading to edema.

    Did this work? Great astute question.

    Randy

  12. dr.mona says:

    hi Dr.Wong i want to ask u about my patient,she has PDR with mild TRD in her lt.eye what do u perfer to do another PRP then avastin injection or do vitrectomy after injection without another PRP thanks for answering .

  13. Dear Dr. Mona,

    I am wondering how bad is the TRD? Is the macula involved. Has PRP been performed before?

    I personally would consider Avastin prior to surgery if there is alot of active NVE and traction. This may make dissection easier in terms of reduced bleeding, etc.

    If there is no active NVE, I am not sure pre-operative Avastin is necessary.

    PRP is more a “fix” longterm than Avastin…in my opinion.

    r

  14. I have had my first avastin injections in both eyes this is day three and my eyes are itchy and one hurts quite a bit i have used drops as prescribed and feel somewhat frightened wondering if I should continue with this treatment as i get laser every 3 months also

  15. Dear Lucille,

    I really cant’ say what is causing the itchiness and pain. You must continue your care with your doc.

    r

  16. Anton Saliba says:

    Dear Dr. Wong

    I am 65 and new to this, I have had two courses of three avastin injections for my wet macular degeneration. After the second course, diabetis appeared, which I have never experienced before Is this going to be a temporary affair or permament?
    Since the second course the blood stopped leaking from the veins, but I developed a vision like cloudiness or even like fog when I look straight.
    This concernes the left eye, and the strange thing is when I look sideways towards my left I can see clearly. is there some kind of treatment that can improve my straigh vision
    N.B. the white patches of the retina narrowed a lot
    Thanks
    Anton Saliba

  17. Anton,

    Very difficult for me to say without guessing. I’d have to examine you. Sorry, can’t comment. Too many possibilities.

    Randy

    Randall V. Wong, M.D.
    Ophthalmologist, Retina Specialist
    Fairfax, Virginia
    http://www.TotalRetina.com
    http://www.RetinaEyeDoctor.com

  18. Hi Doctor,

    Could you please tell me how effective the laser/Avastin treatment for proliferic diabetic retinopathy?My friend’s left eye vision is very less after vitrectomy,cataract,laser .Now had an Avastin injection on last day.Also the right is having bleeding .It had undergone cataract surgery ,5 laser treatment and 5 times Avastin.Now after 10 days again one more avatin shot needs to be taken. I am too worried about how to save and improve the current vision and how long we can save it with these treatment ?

  19. Kavi,

    Not sure how good or bad his eyes are as I can’t examine him. There are some patient in whom Avastin/laser just can’t beat the disease…though few.

    r

  20. Hi Doctor,
    Thanks for the reply. But this answer worries lot now :-( .If Avastin/laser is not effective for a patient ,then what are the different options to save/improve the vision?

    Regards.

  21. Kavi,

    Sometimes neither laser nor Avastin is enough. It is very rare, but perhaps < 1% of the time. There is no other effective treatment.

    Randy

  22. Jewel Wellborn says:

    Wow – Great information Dr Wong. What a relief that you are posting this important data.
    I have had Type 1 for 45 yrsI…two laser surgeries 1984 and 2010 – holding very well until just recently. Will be having the first shot of Avastatin today, and I am looking forward to the potential. I have been experiencing right eye “bleeding bursts” , not alot, but leaving the haze of dispersed blood in the virtreous. Doc said I have had all of the laser he wishes to do – at this time. The blood haze does go away…over time, but I am hoping the Avastin will assist!
    Thank you for these posts!! Brilliant
    Jewel

  23. Dear Jewel,

    Thanks for the plaudits!

    Let me know how well the shots are working. Please stay in touch.

    Remember, I don’t believe Avastin to be a permanent “fix.”

    Randy

  24. Any progress regarding gene therapy ROBO4? could it be a possible cure for wet macula condition?

  25. Hey Asalam Elekum
    My father is Diabetics patient from 6-8 years he is just feels little Blur view when he consult to a eye specialist then doctor said that you need avastin injection and noxygen eye drop is it usefull and doctor said he will lost his eyes is it true? what about side effects?

  26. Ameen,

    Don’t really have enough information; however, Avastin is often recommended for patients with proliferative diabetic retinopathy.

    Avastin usually has very, very few side effects. Your doctor should be able to let him know.

    Randy
    Randall V. Wong, M.D.
    Retina Specialist
    Fairfax, VA 22030

    http://www.TotalRetina.com

  27. Hi Doctor,
    I need your Email address because I want to send you my sister’s eye side reports. Doctors suggest her Avastin Injection. Please doctor gives me your Email address.

  28. Sana,

    I apologize, but I am not able to review records.

    Randy

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