Reader Question: Treatment of Second Eye
The following question (paraphrased for brevity) came to me:
After about 18 months of Visudyne treatments (w/o great results), my 77 y.o. mother switched to intraocular Avastin at the end of December 2005. To date she's had 2 treatments (28 Dec & 25 Jan) and on 11 Feb she began reporting little, daily improvements in vision -- can see shredded carrots in her soup and low & behold, her toothpaste has stripes! As refractory as she'd been to the Visudyne (w/o Kenalog), I’ve been delighted with stabilization. The rest is icing on the cake.
The next treatment & full exam are 08 March. It would be useful to know if or how to discuss management of the inactive eye at that time.
Thanks for your balanced & insightful postings on this topic.
Response: Retinal specialists don’t yet know for sure how many treatments of Avastin are enough. We usually give another injection if any of the following are present:
- The patient returns with worse vision
- The area of the neovascularization is larger.
- The patient still has fluid within or under the retina
- The patient has subretinal hemorrhage. Hemorrhage is a bit trickier however, because it takes a long time to go away. Therefore hemorrhage can still be present even after the neovascularization has become inactive.
- The neovascularization leaks on a fluorescein angiogram.
- Fluid within or under the retina is seen with optic coherence tomography.
A fluorescein angiogram involves the injection of a into an arm vein. The dye circulates up to the eye and then photographs using special filters are taken of the area of neovascularization. If the neovascularization has grown in area or is still leaking, that usually means it’s active and another injection should be given.
Optic coherence tomography uses a low-powered laser beam to take cross-sectional pictures of the retina. Fluid within or under the retina is seen as a dark space. The doctor usually gives another injection if he or she sees fluid on the OCT. Sometimes a small pocket of fluid may remain in the retina despite further treatments.
We used to believe that neovascular membranes grew and leaked, then scarred up and remained inactive forever. The careful long-term follow-up of patients within the Macular Photocoagulation Studies revealed however that the neovascularization can reactivate later. Therefore, even patients with “inactive” scars need to be followed and told to return if they develop new symptoms of decreased vision or distorted vision.
To answer the present question: I would not try Avastin if the vision in the inactive eye was lost more than a year ago. I would also ask your mother’s doctor whether there is leakage on the fluorescein angiogram or fluid on the OCT. If either were present, I might try an injection even if there was some scar tissue under the retina. The vision probably won’t improve much but anything helps.
Conversely, if neither leakage nor fluid were present, I would just follow the eye. I would also take your mother to someone for visual rehabilitation, (a low vision appointment), so she can learn to make the most of her remaining vision. Thanks. JCF
Optic coherence tomography uses a low-powered laser beam to take cross-sectional pictures of the retina. Fluid within or under the retina is seen as a dark space. The doctor usually gives another injection if he or she sees fluid on the OCT. Sometimes a small pocket of fluid may remain in the retina despite further treatments.
We used to believe that neovascular membranes grew and leaked, then scarred up and remained inactive forever. The careful long-term follow-up of patients within the Macular Photocoagulation Studies revealed however that the neovascularization can reactivate later. Therefore, even patients with “inactive” scars need to be followed and told to return if they develop new symptoms of decreased vision or distorted vision.
To answer the present question: I would not try Avastin if the vision in the inactive eye was lost more than a year ago. I would also ask your mother’s doctor whether there is leakage on the fluorescein angiogram or fluid on the OCT. If either were present, I might try an injection even if there was some scar tissue under the retina. The vision probably won’t improve much but anything helps.
Conversely, if neither leakage nor fluid were present, I would just follow the eye. I would also take your mother to someone for visual rehabilitation, (a low vision appointment), so she can learn to make the most of her remaining vision. Thanks. JCF
posted by James C. Folk, M.D. at 1:02 PM
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