May I stop injections for wet AMD? This is a common question. Injections are the mainstay of treatment for wet AMD. They reduce the risk of vision loss. However, they are inconvenient, uncomfortable, and costly. At first, Injections are given every month. Over time, they may be given every few months. Unfortunately, long term injections are usually needed to prevent loss of vision. However, there are situations in which injections may be stopped.
In what circumstance may injections be stopped temporarily?
In certain situations, the doctor may recommend a period of observation without injection in wet AMD. For example, a patient may have been unable to return in a timely fashion for injection. Upon delayed examination, the retinal specialist may find the wet AMD to be inactive. Moving forward, injections may be held in this case. Continued close observation is needed to detect recurrent active leakage of abnormal blood vessels in wet AMD.
Rarely, injections may result in inflammation inside the eye. Medication is prescribed to quell the inflammatory reaction to protect against permanent damage. The wet AMD may become inactive in this situation and it may be observed for reactivation.
When might the injections be stopped for the long term?
After months to years of treatment, the vision may decline despite injection therapy. This may happen due to atrophy (loss of tissue) or scarring (fibrosis). If the vision is very poor, injections may be stopped if it is clear that continued treatment will not improve the vision and further treatment is not necessary to prevent worsening of vision. Furthermore, there is limited evidence that suggests injections for wet AMD may worsen dry AMD.
What are the risks of stopping injections?
The main risk of stopping injections for wet AMD is that leaking and bleeding from abnormal blood vessels may cause further loss of vision. This may result in a larger and/or darker central blind spot. However, rarely it may result in total loss of vision in that eye.
The chances of further loss of vision off injections largely depends on whether the macula has active leakage at the time injections are stopped. In a study of 821 eyes observed for one year after stopping injection, Cornish and others found that 8% of all eyes had serious loss of vision. However, 15% of eyes with leakage at the time injections were stopped experienced severe further loss of vision. Therefore, if you have usable vision and wish to avoid further loss of vision, continued injections are preferable. However, if you do not have functional vision and there is no active leakage of the macular degeneration, the risk of further profound loss of vision is low.
For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida.Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.
Before talking about how to reduce the risk of wet AMD from Syfovre, we must learn about AMD and Syfovre. Syfovre is the first FDA-approved treatment to reduce the risk of losing vision from dry age-related macular degeneration (AMD) due to geographic atrophy. In the phase 2 study, eyes treated by monthly injection of Syfovre showed a reduction in the rate of progression of 29%. It is important to note that Syfovre does not reverse past damage from dry AMD, and it is not a cure for dry AMD.
Does Syfovre increase the risk of wet AMD?
A major concern of treatment is the adverse effect of new wet AMD developing in eyes treated with Syfovre. Wet AMD is another form of advanced AMD in which abnormal blood vessels start to grow under the center of the retina (the macula). The abnormal vessels in wet AMD will cause a large central blind spot in the vision unless treated with regular injections of antiVEGF medicines. Among eyes treated with Syfovre in the phase 2 study, 20.9% of treated eyes developed new wet AMD compared with 1.2% of eyes in the study who did not receive this treatment. Therefore, in an effort to prevent loss of vision from dry AMD, Syfovre raises the risk of vision loss from new wet AMD.
How can we reduce the risk of wet AMD in eyes treated with Syfovre?
There are several things to consider that may be helpful in reducing risk. Table 1 shows the effect of avoiding the use of Syfovre in eyes whose fellow eye already has wet AMD. This is a risk factor for developing wet AMD in the second eye. The risk of the second eye developing wet AMD appears to be further increased with the use of Syfovre. Among eyes undergoing monthly Syfovre injection, the risk of new wet AMD is reduced to 12% compared with 20.9% of all study eyes and 33.3% of eyes with wet AMD in the fellow eye. Similarly, in eyes undergoing Syfovre injection every other month, the risk of new wet AMD is reduced to 3.9% compared with 8.9% of all study eyes and 17.9% of eyes with wet AMD in the fellow eye. Therefore, patients who already have one eye with wet AMD may wish to reduce their risk of developing wet AMD in their second eye by avoiding the use of Syfovre.
Table 1: FILLY phase 2 study: New wet AMD among study eyes. Studying the effect of wet AMD in the fellow eye
Parameters
Sham (no drug)
Monthly drug injection
Every other Month drug injection
All study eyes
1.2%
20.9%
8.9%
Fellow wAMD
0%
33.3%
17.9%
No fellow wAMD
1.9%
12%
3.9%
Eyes without wet AMD in the fellow eye had lower rates of wet AMD (wAMD) among treated eyes.
Table 2 (below) shows the difference among study eyes with and without a known risk factor for developing wet AMD…the double layer sign (DLS). The risk of an eye with DLS in developing wet AMD appears to be further increased with the use of Syfovre. Therefore, among eyes undergoing monthly Syfovre injection, the risk of new wet AMD is reduced to 13.3% among eyes without the DLS compared with 20.9% of all study eyes and 30% of eyes with the double layer sign. Similarly, in eyes undergoing Syfovre injection every other month, the risk of new wet AMD is reduced to 2% among eyes without the DLS compared with 8.9% of all study eyes and 17.9% of eyes with DLS. Therefore, patients who have the double layer sign may wish to reduce their risk of developing wet AMD by avoiding the use of Syfovre.
Table 2: FILLY phase 2 study: New wet AMD among study eyes. Studying the effect of the double layer sign (DLS) which elevates the risk of wet AMD
Parameters
Sham (no drug)
Monthly drug injection
Every other Month drug injection
All study eyes
1.2%
20.9%
8.9%
DLS present
4.2%
30%
24%
DLS absent
0%
13.3%
2%
Eyes without the double layer sign (DLS) had lower rates of wet AMD among treated eyes.
Comments on the use of Syfovre:
Studies show that It may take over two years of treatment in order to see a benefit in vision. Patient selection may reduce the risk of new wet AMD in treated eyes. However, patient selection alone will not reduce the risk of other adverse effects including inflammation, infection, hemorrhage, retinal detachment, and ischemic optic neuropathy. Further risk reduction may be possible by reducing treatment frequency from monthly to every other month, but this reduces the effectiveness of the treatment in slowing the rate of progression of GA from 29% to 20%. Careful assessment is warranted for each patient to determine if the benefits of Syfovre outweigh the potential risks.
For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida.Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.
Sunken eyes from glaucoma drops is not an uncommon problem. Glaucoma is an eye condition that usually requires treatment with drops to lower the pressure in the eye. Some of the drops are known to cause the eyes to appear sunken in the socket. An early symptom is superior sulcus recession, which is a loss of fullness of the upper lid. Later, the eye may appear deeper or lower in the socket.
Sunken left eye due to artificial eye implant. Note the upper lid appears less full. Also the artificial eye is sunken deeper in the socket and is positioned slightly lower compared with the right eye. This appearance is similar to what may occur with the use of prostaglandin eye drops for glaucoma. Image courtesy of the American Academy of Ophthalmology.
Do all glaucoma drops cause sunken eyes?
No. There are many classes of drugs used as eye drops to lower intraocular pressure. Among the many classes of drops available to treat glaucoma, only prostaglandin analogues are known to cause sunken eyes. Examples of glaucoma drops in this class include Xalatan (Xelpros, latanoprost), Travatan (travoprost), Lumigan (Durysta, bitamoprost), Zioptan (Tafluprost), and Vyzulta. This class of eye drops also may cause the color of the iris to turn brown, and the lashes may grow darker and longer. Rarely, macular edema may cause blurred vision.
What can be done to treat or prevent sunken eyes?
There is no treatment for sunken eyes once they occur from prostaglandin analogues. Therefore, if sunken eyes are to be avoided, prevention is the key. Although prostaglandin analogues are among the most effective drops to lower the intraocular pressure, there are other classes of drops to choose from. They include the following:
Beta blockers effectively lower the pressure by 25-30%, but they may aggravate asthma.
Cholinergics may be effective, but make the pupils small, which may affect night vision.
Carbonic anhydrase inhibitors are effective, but may worsen pre-existing corneal edema.
Rho-kinase inhibitors lower pressure, but often cause redness of the eyes. It may also cause tearing due to reversible blockage of the tear duct in the eye lids.
Finally, if the prostaglandin class of eye drops is felt to be the best choice, Omlonti is a new drug (approved by the FDA in 2021) in this class that is less likely to cause sunken eyes. However, among eyes with lens implants there may be a 5-15% chance of blurred vision from macular edema when using Omlonti. Your glaucoma specialist will work to help choose the best medicine for you and will help to determine if laser or incisional eye surgery would be a preferred option to lower the eye pressure.
Two common retinal causes of vision loss are wet age-related macular degeneration (wAMD) and diabetic macular edema (DME). In both of these conditions a signaling protein (called VEGF) is released that promotes blood vessel leakage with loss of vision. A major advance in treatment came about with the development of drugs that block the effect of VEGF. These drugs (called antiVEGF) reduce the risk of vision loss and offer some improvement in vision in patients with wAMD and DME. Unfortunately, these drugs need to be administered as an injection into the eye. Consequently, drug manufacturers work to design drugs offering the best vision with the longest interval between injections (fewer injections).
What drugs are available and how effective are they?
The first drug to reduce the rate of loss of vision in wAMD was Macugen (pegaptanib). It is no longer used because newer drugs are more effective in offering improvement in vision. While Lucentis (ranibizumab) was under development, its parent drug Avastin (bevacizumab) was found to be effective for wAMD. Both Avastin and Lucentis appear more effective than Macugen. Eylea (aflibercept) was developed to block the effect of VEGF and another factor (placental growth factor) involved in blood vessel leakage; consequently, there is moderate evidence that it is more effective than Avastin and Lucentis in DME and offers a longer treatment interval in wAMD. Newer drugs include Beovu (brolucizumab) and Vabysmo (faricimab). There is little evidence to know if they are more effective than Eylea. Finally, Eylea is now formulated in a higher concentration (Eylea HD).
What is the cost of these drugs?
All of the drugs used to treat wAMD and DME are expensive with the exception of Avastin. Avastin was manufactured and priced to treat colon cancer. After it was released, doctors at the Bascom Palmer Eye institute discovered it was effective in treating wAMD. Thus, the small dose needed to inject into the eye costs about $50. This is in contrast to the other drugs on the market, which cost around $2000 per injection.
What are the adverse effects of these drugs in the eye?
Problems may occur from the injection of medications into the eye. The injection itself has risks apart from the drug that is injected; we will not discuss those risks here, but they include pain, elevated eye pressure, hemorrhage, infection, retinal detachment, and loss of vision. The drugs themselves may cause inflammation in the eye. Usually, inflammation causes pain, redness, light sensitivity, floaters, and decreased vision. Typically, it can be treated with drops and it resolves without permanent damage. However, sometimes the inflammation can be severe with permanent loss of vision. Inflammation induced by drugs is very rare with Avastin and Lucentis. It occurs in about 1% of Eylea injections, 2% of Vabysmo injections, and 4-5% of Beovu injections. The inflammation with Beovu may be especially severe with permanent loss of vision. The risk of infection appears less in drugs that are pre-packaged in a syringe for injection (Lucentis and Eylea), and greater in drugs that must be prepared for injection (Avastin, Vabysmo, Eylea HD, and Beovu).
What are the adverse effects of these drugs outside the eye?
There is concern about effects of these drug outside the eye. All of these drugs leave the eye, enter the blood vessels and are removed from the body through the urine. On their way out of the body, there is concern that they may increase the risk of heart attack and/or stroke. There is considerable debate as to whether there is a measurable effect or not. Some have estimated that the systemic risk may be about 1%. However, patients with known risk factors (hardening of the arteries, tobacco use, high blood pressure, high cholesterol, overweight, and diabetes) may be more likely to suffer a heart attack or stroke with the use of antiVEGF drugs. In one study, patients with diabetic macular edema were at 17% (range: 2-33%) higher risk of death when undergoing frequent injections up to 2 years. Another study, demonstrated increased risk of stroke or heart attack in diabetic patients with a history of past stroke or heart attacks. Therefore, this group of patients may benefit from careful drug selection. Of all the drugs, Lucentis is cleared the most rapidly from the body and has the least systemic effects.
Want a summary of the cost, effectiveness, and safety?
Summary:
AntiVEGF drug
Cost
Effectiveness
Safety
Avastin
Cheap: ~$50
Good
Repackaging*
Lucentis
Expensive: ~$2,000
Good
safest systemically**
Eylea
Expensive: ~$2,000
Better
1% inflammation
Eylea HD
Expensive: ~$2000
?Better
1% inflammation or greater?
Vabysmo
Expensive: ~$2,000
?Better
2% inflammation
Beovu
Expensive: ~$2,000
?Better
4-5% inflammation
A list of drugs available in the US approved for injection into the eye
* Repackaging increases risk of infection, floaters, and discomfort for dull needles
** Especially relevant when repeated injections are required in diabetic patients
What is my professional preference?
I have employed all of these drugs for my patients. When cost is an issue, an insurance company may insist on the use of Avastin. I generally prefer Lucentis in my diabetic patients for its superior systemic safety. Eylea can be helpful to extend treatment intervals (longer time between injections) in wet macular degeneration. Eylea may also be safer in patients who also have glaucoma, or at risk of developing glaucoma. I have been favorably impressed with Vabysmo in extending treatment intervals even further in wAMD, but I am less impressed with any advantage in my patients with DME (diabetic macular edema). I am currently exploring the role of Eylea HD, especially to extend the treatment interval in patients with wet AMD. Due to the risk of inflammation with loss of vision from Beovu, it is not my preferred agent. Lucentis biosimilars (Cimerli and Byooviz) are not my preferred agents at this time…I am awaiting further evidence on their safety and effectiveness.
Are doctors paid by drug companies to use their drugs?
There are varying amounts of profit margins and rebates given to doctors by drug companies in an effort to promote the use of their drugs. Usually, the newer the drug, the greater the inducement. To determine if your doctor is receiving large payments by drug companies, visit the CMS website and enter your doctor’s name in the search box.
For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida.Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.
Lucentis therapy is a treatment for wet-type macular degeneration. It usually involves repeated injections of medication into the eye to stop abnormal, leaky blood vessels. It is now also available through port delivery (called Susvimo). After a tiny reservoir is implanted in the eye at surgery, a painless injection to fill the port is performed every 6 months.
How effective is Lucentis therapy?
Lucentis was proven in extensive studies to be very effective. In wet-type macular degeneration, a large study showed that monthly injections of Lucentis over a two-year period offered a 90% chance of stable or improved vision. Similar benefits are seen in other retinal conditions as well. Traditionally, therapy often starts with monthly injections until maximal vision is restored. Afterwards, the injections may be given less frequently to maintain stable vision. The Lucentis port delivery appears to be as effective as Lucentis monthly injections, but with fewer injections.
What are the risks of Lucentis therapy?
Severe complications are very rare, but risks of Lucentis injection include bleeding, infection, retinal detachment, glaucoma, cataract, and loss of vision. There appears to be a small increased risk (1%) of stroke with Lucentis. The risk of stroke may be related to the older age of patients in which it is used. Pregnancy should be avoided while on Lucentis therapy.
The port delivery method (Susvimo) is associated with more adverse events (19%) compared with monthly Lucentis injections (6%). Among eyes with the implanted port, 5-10% had bleeding inside the eye causing floaters and blurred vision. The blood cleared over several weeks to months. In 5.4% of eyes with the implanted port, the conjunctiva (skin-like layer that covers the eye) does not remain intact overlying the implant and additional surgery is often needed. In 1-2% of eyes with an implanted port, infection may occur. This is a very serious event that requires surgery and may result in permanent loss of vision/loss of the eye. In 1-3% of eyes with an implanted port, a retinal detachment required additional surgery and sometimes resulted in loss of vision. Non-infectious inflammation occurs in about 20% of implanted eyes; it usually responds to eye drops. The benefits of fewer injections with the port delivery method must be weighed against the risks involved with the port. It is the opinion of the author that the risks of the Susvimo port delivery may outweigh the benefits at this time for most patients. Newer medications (Vabysmo) are available that appear to last longer than other treatments such as Lucentis injections. Therefore, Susvimo port delivery may be unnecessary.
What do I expect after a Lucentis injection?
Be careful not to rub the eye after the injection because the eye may remain anesthetized for several hours. You may be given eye drops and instructions on how to use them. Physical activity is not limited after the injection. Tylenol or Ibuprofen may be used if there is discomfort, but severe pain should be reported to your doctor without delay. It is normal to experience a red area on the white of the eye, which disappears in one to two weeks. If you have any questions or concerns, please call the office.
For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida.Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.
The retina is a “tissue-paper” thin layer of nerve tissue, which lines the inside of the eye like the film in a camera. In the eye, light is focused onto the retina, which “takes the picture” and sends the image to the brain. After many years of high blood sugar, diabetes causes damage to blood vessels in the retina (diabetic retinopathy). Damaged blood vessels may leak clear fluid (edema) into the retina causing blurred vision and legal blindness. Also, new retinal blood vessels (neovascularization) may grow inside the eye abnormally. These new blood vessels tend to bleed causing floaters in the vision. In severe cases, they produce scar tissue, retinal detachment, glaucoma, and blindness or loss of the eye.
What treatment options are available?
To prevent progressive damage from diabetes, optimal diabetes management includes controlling blood sugar, blood pressure, and serum lipids (cholesterol and triglycerides), as well as weight control (diet and exercise), and avoiding tobacco. However, once diabetic damage occurs in the retinal blood vessels, laser treatment and/or medicine injections may be required. Medicine injections take effect quicker than laser, but the benefits of laser last longer than injections.
How does laser work and what are the side effects?
The laser used to treat diabetic retinopathy coagulates damaged retina and seals leaky retinal blood vessels. Laser treatment may be given in the office or the operating room and is usually well tolerated with minimal discomfort. Side effects may include difficulty with night vision, side vision, and, rarely, central blind spots. Many of the same side effects appear from diabetes over time as blood vessel blockage occurs from high blood sugar levels. Laser provides long-lasting protection from blindness.
How do injections work and what are their side effects?
Injections of medicines are divided into steroid medicines and non-steroid (anti-VEGF) medications. With any injection, there is a low risk of serious infection that may blind the eye. Non-steroid (anti-VEGF) medications work by blocking chemical messages between retinal cells that cause leakage and bleeding in diabetes. Anti-VEGF medications include Avastin, Lucentis, Eylea, and Vabysmo. These medications take effect fairly quickly and are very effective, but the effect does not last very long (unlike laser). Anti-VEGF injections must be given every 4-6 weeks at first. Over months to years, fewer injections are usually needed. There appears to be an increased risk of death from stroke and heart attack among patients who undergo repeated antiVEGF injections for up to 2 years. The risk is about 17% (range: 2% to 33%) higher in diabetics undergoing injections than other diabetic patients not undergoing injections.
Steroid medicines are effective, but are generally considered a second-choice medication because of side effects. They are given by repeated injection. Side effects include a very high chance of cataract over a period of months to years. Steroids may cause the pressure in the eye to rise and this may result in glaucoma, which requires eye drops and may require surgery.
When to use injections and when to use laser?
The two main reasons to undergo treatment for diabetic retinopathy are 1.) swelling of the retina (macular edema) and 2.) the growth of abnormal new blood vessels (neovascularization) that threaten to bleed into the eye. Macular edema occurs when diabetes causes a breakdown of the normal water-tight barrier in the walls of blood vessels in the retina. If edema is located in the center of the macula, injections have been shown to be superior to laser. However, supplemental laser treatment may help to seal leaks after the injections begin to take effect. If macular edema is not located in the center of the retina, laser alone may protect against loss of vision. Injections may be added later if edema extends into the center of the retina at a future date.
Neovascularization (NV) is the new growth of abnormal blood vessels on the surface of the retina. The growth of these blood vessels indicates an advance degree of damage to the retina from diabetes. This stage of diabetes damage is called proliferative diabetic retinopathy. NV causes loss of vision from bleeding (hemorrhage), scarring, and retinal detachment. NV may be treated with laser and/or anti-VEGF injections. If center-involved macular edema is present along with NV, anti-VEGF injections are usually preferred at the start of treatment. However, anti-VEGF injections may be used alone in the treatment of NV in the absence of macular edema, as well. But the injections must be given monthly at first, and the eye must be rigorously monitored. If there is a gap in treatment, the result may be disastrous.
Laser has been used successfully for long-term control of NV since the 1970’s. Laser is performed in the office or the operating room and is well-tolerated. Usually, one to three treatments offer long-term control of NV. Laser is currently considered a standard treatment for NV in the absence of center-involved macular edema. However, anti-VEGF injections remain an option, as well. The advantages and disadvantages of each form of treatment must be weighted in a given case. In some instances, a combination of injections and laser may be preferred. Unfortunately, despite these treatments surgery in the operating room may be needed. Although vision is usually preserved with treatment, diabetes remains the leading cause of blindness in the United States. The best results of treatment are seen in patients who have regular eye exams and manage their blood sugars well.
For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida.Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.
Retinal rejuvenation is a name given by the company that sells a new-generation laser machine to ophthalmologists. The laser is used to treat the retina with the hope of delaying loss of vision from age-related macular degeneration (ARMD). Although the laser company calls this treatment “retinal rejuvenation,” this name may be overstating the true effects of this new laser.
The scientific basis for the use of the laser for macular degeneration is the LEAD study. This study evaluated 292 patients with ARMD over a three-year period. Half of the eyes were treated with the new micro-pulse laser and the remainder received sham treatment for comparison. Overall, the treatment was not shown to be of benefit in slowing the loss of vision from macular degeneration. However, when looking at subsets of eyes with certain types of macular degeneration (no reticular pseudodrusen), there was a trend toward a benefit. These results, however, had a weak fragility index (meaning that more research is needed). Conversely, eyes with reticular pseudodrusen (subretinal drusenoid deposits) lost vision at a greater rate after undergoing retinal rejuvenation than those eyes that were not treated.
“Retinal rejuvenation” needs more study before it is implemented on a wide scale basis. It is currently (2018) not approved for this use in the United States. More research is needed to better establish its helpfulness in reducing the risk of vision loss from age-related macular degeneration and to identify potential risks involved with its use.
I do not recommend the “retinal rejuvenation” treatment for age-related macular degeneration by the new micro-pulse laser at this time. I look forward to more high-quality research in the future to better establish the potential role of this laser for my patients with ARMD.
Steroid eye drops are prescription medications used to reduce pain, swelling and inflammation. This class of medication is separated from non-steroids by mechanism of action, effectiveness, and side effects. There are a number of steroid eye drop brands available. Examples include prednisolone (Pred Forte, AK-Pred), fluorometholone (FML, FML Forte, Flarex), dexamethasone (Ocu-dex), loteprednol (Lotemax, Alrex), difluprednate (Durezol), rimexolone (Vexol).
How do steroid eye drops work?
Steroid eye drops work by inhibiting a wide variety of biochemicals in the body that promote inflammation. Steroid eye drops are usually more effective that non-steorid eye drops (NSAID eye drops) when used alone, but these two classes of anti-inflammatory drops often work best when used together.
There are advantages and disadvantages to the various brands of steroid eye drops. To varying degrees, all steroid drops reduce inflammation and they all have side effects. The most important side effects include cataract formation and elevation of Intraocular pressure (glaucoma). Prednisolone acetate has been the gold standard for treating ocular inflammation. Dexamethasone generally is not as effective and it has comparable side effects. Difluprednate (Durezol®) is as effective as prednisolone and can be used less often, but it is much more expensive. Loteprednol (Lotemax®) and rimexolone (Vexol®) are less likely to cause glaucoma, but they are expensive. Low concentrations of fluorometholone (FML®) is not likely to cause cataract or glaucoma, but it is not as strong as prednisolone and are mainly used for treating inflammation outside the eye, as in cases of blepharitis (inflammation of the eyelids) and keratitis (inflammation of the cornea).
How does the doctor choose which steroid drop to use?
In some cases the doctor has had good experience with a specific agent for a given situation. In other cases the choice may be guided by convenience and cost. For convenience the costlier difluprednate may be used twice a day compared to 4 times a day for prednisolone. Patients with a tendency for glaucoma, may require more expensive medication such as rimexolone or loteprednol.
If you have strong preferences, be sure to communicate with your doctor to be given the best steroid eye drops for your situation. Always use your eye drops exactly as prescribed and keep all appointments as scheduled in order to monitor for effectiveness and safety.
The Amsler grid is a test used to detect and monitor macular disease (see Anatomy of the Eye). The macula is the area of the retina in the back of the eye that is responsible for seeing details in the central vision. The retina is a thin layer of delicate nerve tissue that lines the inside wall of the eye like the film in a camera. In the eye, light is focused onto the retina, which “takes the picture” and sends the image to the brain.
How is the Amsler grid used?
The grid is observed one eye art a time with reading glasses if needed for proper focusing at normal reading distance. The patient is asked to fixate on the center of the grid while using “side vision” to see if there are any missing areas. The lines on the grid should appear straight and uniform. If any abnormalities are noted, an ophthalmologist (retinal specialist) may be consulted to determine the cause of the problem.
Below is a link to download or print an Amsler grid chart for use at home.
For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida.Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.
Prednisone is a very powerful medication related to a hormone produced by your body. Prednisone is very effective at decreasing inflammation. Inflammation in the eye can result from infection, injury, systemic diseases like arthritis, and sometimes from unknown causes. If left untreated, inflammation may cause permanent damage to the eye and loss of vision.
How is prednisone used?
A form of prednisone can be used as eye drops to control inflammation in the front of the eye. Often these drops must be used frequently for best results. If stronger dosages or deeper penetration of medication is required, another medicine like prednisone may be injected next to the eye. This injection is given with little discomfort by using anesthetic eye drops before the injection. If severe, vision-threatening inflammation is present, prednisone pills are prescribed.
What side effects might be encountered?
As prednisone is powerful, many side effects may occur. More frequent and severe side effects are seen the longer the medication is used. Fairly mild, common side effects include temporary mood swings, appetite changes, fluid retention, acne-like rash, trouble sleeping, and difficulty controlling diabetes. More serious side effects usually seen with prolonged treatment include reactivation of TB, stomach ulcer, brittle bones and hip fracture. Any worrisome symptom is reason to contact your doctor. It is important to report all other medication you are taking because interactions between drugs can occur. Finally, serious side effects can occur if prednisone is discontinued too rapidly. Follow the instructions of your doctor carefully.
Your doctor has identified a serious, vision-threatening eye problem that warrants the use of prednisone, a very powerful medicine that should be used with care. Be sure to inform your general medical doctor that you are going to start taking prednisone. Additional tests or medications may be needed to protect you against the side effects of prednisone.
How to take prednisone and protect against side-effects?
To protect yourself against bone loss and fractures, take calcium 1,500 mg (Tums EX) and vitamin D 800 Units every day. Also, make sure your internist approves before starting prednisone. Notify your doctor if you have had a positive TB test or have been exposed to TB (tuberculosis).
Take prednisone after breakfast in the morning. You may use antacids such as Maalox to prevent upset stomach. It is very important for your health to discontinue prednisone by gradually decreasing the dosage as recommended.
Follow a tapering schedule of dosing to avoid serious reactions. Your doctor will make recommendations based on your situation.
AS YOU LOWER THE DOSE OF PREDNISONE, BE SURE TO REPORT TO YOUR DOCTOR ANY SIGNIFICANT WEAKNESS, TIREDNESS, DIZZINESS, OR LOW BLOOD PRESSURE. THESE SYMPTOMS MAY REPRESENT A SERIOUS SIDE-EFFECT OF PREDNISONE WITHDRAWAL.
For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida.Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.
The mainstay of treatment of wet-type age-related macular degeneration (AMD) requires the intraocular injection of medication (e.g. Avastin, Lucentis, Eylea, Beovu, and Vabysmo) to prevent loss of vision. Although effective, this treatment entails some degree of risk. For example, infection may occur at a rate of about one in one thousand to one in five thousand injections. Moreover, there may be a low increased risk of stroke.
Although some studies do not show increase risk (Campbell), other large studies have demonstrated an increased risk of stroke. In one study the increased risk of stroke appeared to be 1 in 127 patients within one year after starting treatment for AMD (Schlenker). These studies were unable to prove that the medication itself was responsible for the increased risk of stroke. For example, it may be that people with new-onset wet AMD are at a higher risk of stroke than others. In 2019 a population-based study demonstrated no increased risk of stroke and heart attack related to AMD treatment (see reference). Additional research in ongoing.
Given this information what are the options? Certainly, a patient may decide not to treat macular degeneration and risk loss of vision in an effort to decrease the risk of stroke. Another option may be to minimize the frequency of injections. That is, if the macular degeneration remains stable after several monthly injections, consider extending the time interval between injections. In this manner there is less exposure to the drug. Furthermore, if the wet-AMD appears to have reached end-stage with significant loss of vision, the injections might be stopped altogether. If done carefully, one may reduce the risk of a sudden recurrence of wet-AMD with further loss of vision while off treatment.
The type of medication used for injection has not been proven to make a difference in the risk of stroke. Although Martin et al found a slight increase in stroke risk with Avastin compared with Lucentis, these findings were not supported by Chakravarthy and Schlenker. More research is needed to better define risk of stroke and how we may minimize the risk. A recent meta-analysis of current data as of 2022 (Reibaldi) supports Lucentis over the other agents as being safer from a systemic risk of heart attack and stroke. Please refer to my blog on medication choices for treating retinal problems.
For a telemedicine consultation with Dr Pautler, please send email request to spautler@rvaf.com. We accept Medicare and most insurances in Florida.Please include contact information (including phone number) in the email. We are unable to provide consultation for those living outside the state of Florida with the exception of limited one-time consultations with residents of the following states: Alabama, Arkansas, Connecticut, Georgia, Minnesota, and Washington.
