Tag Archives: injections

What is the Best Drug for Eye Injections?

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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 drugCostEffectivenessSafety
AvastinCheap: ~$50GoodRepackaging*
LucentisExpensive: ~$2,000Goodsafest systemically**
EyleaExpensive: ~$2,000Better1% inflammation
Eylea HDExpensive: ~$2000?Better1% inflammation or greater?
VabysmoExpensive: ~$2,000?Better 2% inflammation
BeovuExpensive: ~$2,000?Better4-5% 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.

By Scott E Pautler, MD

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.

Copyright © 2022-2024 Designs Unlimited of Florida.  All Rights Reserved.

Retinal Angiomatous Proliferation

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globe anatomy
Anatomy of the eye (click on image to enlarge)

What is retinal angiomatous proliferation (RAP)?

            Retinal angiomatous proliferation means there is a growth (proliferation) of abnormal blood vessels (angiomatous) in and under the retina (specifically, under the central part of the retina called the macula).  Retinal angiomatous proliferation (RAP) is a sub-type of wet age-related macular degeneration (ARMD).  Wet ARMD affects the central vision in older patients due to abnormal blood vessels growing under the macula.  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 through the lens onto the retina, which “takes the picture” and sends the image to the brain. 

What causes retinal angiomatous proliferation (RAP)?

            Retinal angiomatous proliferation (RAP) appears to be caused by the release of blood vessel growth factors in the retina in response to age-related changes.  The age-related changes include the accumulation of cellular waste products under the retina (call subretinal drusenoid deposits).  The build-up of waste products (SDD) under the retina interferes with retinal function.  For one thing, the build-up of SDD separates the retinal cells from the normal blood vessels that nourish them.  Without proper nourishment the retinal cells do not work well.  Furthermore, when the retinal cells perceive that they are not getting enough oxygen and nutrients, they release growth factors (including one growth factor called VEGF).  These growth factors stimulate the growth of new blood vessels to assist in delivering oxygen and nutrients.  In other parts of the body, new blood vessels may grow to help or replace old blood vessels and it is a helpful response to poor blood supply.  However, in RAP the new blood vessels cause loss of vision due to fluid leakage, bleeding, and scarring of the macula.  

What are the symptoms of retinal angiomatous proliferation (RAP)?

            Retinal angiomatous proliferation (RAP) may cause no symptoms in its early stages.  Over time, symptoms may include blurred central vision, distortion of straight lines and/or a central, gray spot in the vision.  In its advanced stages without treatment, RAP may cause a large permanent blind spot in the center of vision.  At this stage no treatment is possible and low vision aids are used to compensate for loss of vision.  If one eye develops wet AMD, there is about a 50% chance the other eye will be affected within the next five years.

How is retinal angiomatous proliferation (RAP) diagnosed?

            Retinal angiomatous proliferation (RAP) is diagnosed in patients with known dry-type age-related macular degeneration.  Before the proliferation or growth of blood vessels under the retina develop in RAP, subtle yellow deposits may be identified under the retina.  These deposits are called subretinal drusenoid deposits (SDD).  SDD develop many years before RAP occurs.  A dilated eye examination can detect SDD and alert the retinal specialist to be on the lookout for RAP.  Retinal angiomatous proliferation is suspected when a patient with SDD develops blurred vision and swelling (edema) is present in the retina on a retinal scan called OCT (optical coherence tomography).  The diagnosis may be confirmed on a more extensive test called fluorescein angiography.  This is a procedure where the ophthalmologist injects an organic dye into the vein of a patient’s arm.  Then, photographs of the retina show the presence and location of the leaking blood vessels marked by the organic dye.

Why is this diagnosis important?            

It is important to recognize RAP because it guides treatment recommendations.  This type of wet ARMD is especially sensitive to antiVEGF therapy (injections with Avastin, Lucentis, and Eylea).  RAP is so sensitive to antiVEGF therapy that the medication injections are sometimes not required as often as they are in other types of wet age-related macular degeneration such as PCV.  Older treatments such as photocoagulation and photodynamic therapy historically do not work well in RAP and can be avoided.  Treatment rarely returns vision to normal, but may limit the amount of vision loss from blood vessel growth and leakage.  Frequent office visits and photographs are needed.  It may be useful to stop smoking, avoid becoming overweight, exercise daily, and control blood pressure and cholesterol. Aspirin should only be used if required to treat disease as recommended by a doctor. Relatives should be checked for macular degeneration, as well.

By Scott E Pautler, MD

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.

Copyright  © 2021-2022 Designs Unlimited of Florida.  All Rights Reserved.

Pain After Eye Injections

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Why are eye injections given?

There are many conditions, which threaten loss of vision, that are treated by injecting various medications into the eye. The eye conditions include macular degeneration, diabetic retinopathy, retinal vein occlusion, uveitis, and others.  The injections may be given into the tissues outside the eyeball (subtenon’s injections) or into the eyeball (intravitreal injections).  It is very important to avoid pain as these injections may need to be given repeatedly over time.

Why do I have pain after eye injections?

Although pain during eye injections can usually be minimized with anesthetics given before the injection, sometimes there is pain for hours after the injection.  There are many reasons why this may occur:

1.) The antibiotic (betadine) may irritate the eye for hours after it has been applied to the eye.

2.) The eye may become dried out after the injection due to insufficient blinking.

3.) The eye may be accidentally scratched by rubbing the eye while it is still anesthetized.  

4.) The drug that is injected into the eye may cause an inflammatory reaction.

5.) Rarely, a severe infection called endophthalmitis may occur after injection into the eyeball.  

What can be done to prevent pain after injections?

The key to eliminating pain after eye injections is to identify the underlying cause. This may take some detective work.  Although betadine is given at the time of injection to prevent infection, only a small dose is needed.  If a large amount of betadine is used or if the betadine has not been thoroughly rinsed off the eye, it may cause blurred vision, persistent burning, itching, and/or a scratchy sensation like sand in the eye (called a foreign body sensation).  Therefore, it is important for the eye doctor or technician to completely rinse the betadine off the eye after an eye injection in order to avoid pain later.

Sometimes, the surface of the eye may become dry after an injection because the patient does not blink frequently enough or not completely enough.  This often happens as a result of the anesthetic used in preparation for the injection.  After the injection is over, the anesthetic may continue to work for 15-30 minutes.  During that time, the patient does not have the normal sensation necessary to indicate that it is time to blink.  If the eye does not blink often enough, the surface may dry out and cause blurred vision, pain or foreign body sensation.  Therefore, the patient may need to purposefully blink frequently or simply rest the eye closed for a while after an eye injection in order to prevent drying.  Similarly, if a patient does not close the eye completely with each blink, part of the eye can become dry.  In some cases, it may be necessary to forcibly close the eyes with each blink in order to be sure the lids close completely.

At times a patient may unknowingly rub and scratch the eye after an injection because of persistent numbing after an injection.  Therefore, it is very important to avoid touching the eye for 15-30 minutes after an injection.  If the eye needs to be dried off, a clean tissue may be used with a gently damping or blotting motion in the corner of the eye where the lids come together at the bridge of the nose.  It is best not to move the tissue left and right or up and down in a rubbing fashion.  Once the eye becomes dry or irritated for any reason listed above, it may take 1-2 days for the pain to go away and the eye to return to normal. 

Rarely, a drug that is injected into the eye can cause an inflammation that causes pain or blurred vision.  The doctor makes this diagnosis by examining the eye under the biomicroscope (called a slit lamp).  If a medication is determined to be the cause of inflammation, it is treated with prescription eye drops and the offending drug is not used again in that patient in the future. 

Infection is an extremely rare cause of pain after an eye injection.  In about one in several thousand injections, germs may enter the eye through the needle tract after an eye injection.  This rare infection is called endophthalmitis (pronounced like “end-off-thal-my-tiss”).  Symptoms usually start with pain, redness, and loss of vision several days to a few weeks after an injection.  There is no perfect way to prevent endophthalmitis.  The doctor uses techniques like applying betadine before the injection.  The patient tries to avoid contaminating the eye by avoiding exposure the unclean areas (like a barnyard) and avoid rubbing the eyes after injection.  Endophthalmitis is very serious and may result in permanent loss of vision.  Therefore, any patient having deep aching pain, increasing redness, and loss of vision starting several days or weeks after an eye injection should notify their eye doctor for prompt evaluation.  

What can be done to make the eye feel better?

If the cause of the pain and irritation is from betadine, drying, or rubbing the eye, the best treatment is lubrication.  Lubricants are available over-the-counter in the form of eye drops, eye gels, and eye ointments (see examples at the end of this article).  The thicker the lubricant, the better the relief of pain and discomfort.  However, gels and ointments may be difficult to place into the eye and they tend to make the vision blurry for several minutes or more.  Lubricants may be used as often as needed.  Resting the eyes closed may also provide relief.  Cold compresses help many patients.  Over-the-counter pain medications like ibuprofen and/or Tylenol may be helpful.  Prescription pain medications are rarely needed and may cause undesirable side effects.

If the cause of the pain and irritation is from a drug reaction or from infection inside the eye, the doctor will prescribe special anti-inflammatory eye drops.  If the eye exam shows infection, antibiotic injections must be given into the eye and surgery in the operating room may be necessary. 

If pain keeps occurring after eye injections despite taking the measures listed above, sometimes prescription eye medication can help. Non-steroid (NSAID) eyes drops or steroid/antibiotic ointments may help prevent the pain. Most instances of pain after eye injections may be avoidable. Please talk with your eye doctor to help resolve the problem in order to undergo treatment without pain.

Check the current price of Systane Gel on Amazon.

Gels are easier to apply than ointments and may be used immediately after an eye injection to prevent eye pain and they may be used later to soothe eye discomfort.

Check the current price of Lacri-Lube on Amazon.

Ointments are more difficult to place in the eye. However, they provide longer duration of action. They may be used immediately after an eye injection to prevent eye pain and they may be used later to soothe eye discomfort.

By Scott E. Pautler, MD

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.

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