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Home>Patient Education>Age–Related Macular Degeneration>Treatment & Research

Treatment & Research

Visudyne Photodynamic Therapy

Since the year 2000, photodynamic therapy has been used to treat some forms of wet macular degeneration. This treatment couples a laser with a light–sensitive drug to destroy leaking blood vessels in the retina.

To begin the treatment, a special light–sensitive drug is infused into a vein in the arm and allowed to circulate throughout the body. In the bloodstream, the drug attaches itself to molecules of low–density lipoprotein, or LDL.

Inside the retina, the abnormal blood vessels attract and absorb LDL. Since the drug is attached to the LDLs, it also accumulates inside the abnormal vessels. With time, the drug is cleared from the normal nearby blood vessels.

Next, eye drops will be used to numb the eye, and a special contact lens is placed on the eye to focus the laser. At this point, low intensity laser energy is directed through the contact lens, onto the area of choroidal neovascularization (CNV).

The laser energy activates the drug concentrated in the abnormal blood vessels, causing them to close and stop growing. Using this low–intensity laser spares the overlying retina from damage. In some cases your ophthalmologist may also inject a steroid into the treated eye. The steroid reduces inflammation and swelling.

Usually, the whole procedure takes less than 30 minutes. When you go home afterwards, and for the next 5 days, you do have to be careful not to expose yourself to direct sunlight or other bright lights as the drug is cleared from your system.

Several sessions of photodynamic therapy are typically required to control the neovascular growth. It is common for patients to have three or four treatments in the first year and two treatments the second year. Your ophthalmologist will use angiograms and/or OCT imaging of your retina to determine if additional treatments might be beneficial. The goal of treatment is to stabilize your vision. Your ophthalmologist will discuss the risks, benefits, limitations and alternatives for your particular case.

www.Visudyne.com

Pharmacologic (Drug) Therapy

Macugen

Macugen is the first drug therapy for wet macular degeneration, approved late in 2004. Treatment with Macugen aims to block the stimulus of blood vessel growth in order to stabilize vision.

In wet macular degeneration, new blood vessels grow in the choroid layer underneath the retina. Growth of these new, leaky vessels is stimulated by proteins known as Vascular Endothelial Growth Factor, or VEGF.

To control the growth of the leaky blood vessels, a drug called Macugen is injected directly into the vitreous body of the eye. The drug then diffuses throughout the retina and choroid. Your ophthalmologist will take precautions to minimize the risks of injection.

Inside the eye, Macugen binds strongly to the abnormal VEGF proteins it comes in contact with. This prevents the VEGF molecules from stimulating further blood vessel growth and leakage.

Over a period of weeks, Macugen is slowly absorbed into the circulatory system, and excreted from the body. In order to keep an adequate amount of medicine in the eye, injections are repeated every 6 weeks. Initial studies show that a course of therapy of one or two years may be necessary to stabilize vision in most patients.

www.Macugen.com

Lucentis

Lucentis is another drug that blocks VEGF. It was in the late stages of testing in 2005 and will likely be available for the treatment of patients in 2006.

Like Macugen, treatment with Lucentis involves injecting the drug into the vitreous body of the eye. As it diffuses throughout the back of the eye, the drug comes in contact with VEGF proteins in the damaged area of the retina and choroid. Lucentis binds to the VEGF proteins, preventing them from stimulating further blood vessel growth and leakage.

In the early stages of treatment, injections are repeated every 4 weeks. The optimal timing of subsequent treatments is still under investigation. Lucentis is the first drug to offer hope of improvement in vision for some patients while stabilizing vision in the majority of patients.

Other drugs which target the production of VEGF, the circulation of VEGF, or the receptor for VEGF are currently under investigation in preliminary clinical trials. Research is also underway to develop better methods of delivering drugs to the eye to reduce the need for frequent injections.

Lucentis and Avastin

Before the approval of Lucentis, retinal specialists had started using a related drug called Avastin (bevacizumab) which was not approved for ocular use but was available for cancer treatment and was chemically related to Lucentis (both drugs are made by the same company Genentech). The results that retinal specialists have seen with Avastin (which is now in use worldwide for AMD) appear to be similar to the results seen with Lucentis. There has been a great deal of media attention to both of these drugs because although they may both help in AMD, they have very different costs. Lucentis is expensive and Avastin is very inexpensive. Both drugs are now covered by insurance plans for the treatment of wet AMD. However, only Lucentis has been approved for use in this indication (so far). The National Eye Institute has initiated a study which will compare these two drugs to each other which should help retinal specialists advise patients in an informed way.

There are potential risks and benefits of these varied drug options which a retinal specialist would discuss with an AMD patient before helping him or her to decide which treatment is best for his condition.

This is an exciting and hopeful time for patients and their doctors. Macular degeneration is now receiving the attention it has long–deserved. With a vast amount of ongoing research, we expect to see continued progress in treating this disease in coming years.

www.Lucentis.com

Laser Treatment

One treatment for wet macular degeneration uses a thermal laser to coagulate the CNV and stop it from spreading. In some cases, the area of involvement may be too extensive to treat. Your doctor will discuss with you the risks, benefits, limitations and alternatives in your particular case.

Laser treatment for wet macular degeneration is done on an outpatient basis with local anesthesia (eye drops). To begin the procedure, the patient is seated at a special slit lamp. A lens is placed on the eye to give your ophthalmologist a magnified view of the retina. Next, your ophthalmologist will aim the laser directly at the CNV beneath your retina. Only minimal discomfort is felt as several small pulses of laser light are directed at the CNV.

The laser light passes through the tissues of the retina where the light is absorbed by the CNV and pigmented tissues beneath the retina (RPE and choroid). The absorption of laser energy produces heat which burns the CNV and some of the surrounding retinal tissues, causing a small scar to form. After treatment, the scarred area will appear as a permanent blind spot in your vision.

It is important to realize that laser treatment generally doesn’t improve your vision. Laser treatment is a compromise: a small portion of retina is sacrificed in order to prevent damage to a much larger area which would occur if the CNV were allowed to continue growing. When laser treatment is successful, the scar produced by the laser is smaller than the scar that would have resulted if the CNV had been left untreated.

Even if successful, laser treatment treats the CNV but not the underlying disease process of macular degeneration. It is not uncommon for CNV to come back in the future. Following laser treatment, is often necessary to use angiography to detect any recurrences of CNV. If new CNV is found, your eye doctor may recommend additional treatment to preserve your remaining vision.

Experimental Treatments

Although there are now effective treatments for macular degeneration, there is no cure for the chronic disease process. For this reason and for the hope of better visual results for the patient, many new methods of treatment are being developed and tested. A wide variety of therapies are being considered, including:

• Retaane (drug therapy)
• off–label drugs
• rheopheresis
• low dose radiation therapy
• submacular surgery
• RPE transplantation
• macular translocation surgery
• laser treatment of drusen
• artificial vision

We will briefly discuss each of these experimental treatments.

Retaane

If you look under the retina in an eye with wet macular degeneration, you will see new, leaky blood vessels growing in the choroid layer.

To control the growth of these new blood vessels, a drug called Retaane is deposited behind the eye. In this procedure, a curved cannula is slid alongside the eye until the end is resting directly underneath the macula.

The drug is deposited behind the eye, where it is slowly absorbed into the tissues of the retina.

Inside the choroid and retina, Retaane slows the growth of abnormal vessels seen in wet macular degeneration. It helps to keep the tiniest blood vessels of the retina, the capillaries, from breaking down. When these capillaries remain intact and healthy, neovascularization does not occur.

Treatment with Retaane is typically repeated after six months to maintain therapeutic levels of the drug in the retina. In 2006, this drug was in the late stages of testing.

Off–Label Drugs

The term “off–label” means using drugs for a purpose for which they were not originally approved. For example, aspirin is used to prevent heart attacks and for blood thinning even though the FDA label did not initially list these specific reasons. Now these reasons have been added to the list of indications.

Physicians may use any available drug to treat macular degeneration, including drugs approved for other reasons. Steroids injected into the eye and Avastin injected into the eye are examples of offlabel uses of medications. Your doctor may discuss these drugs as part of treatment.

Rheopheresis

Rheopheresis attempts to remove abnormal circulating proteins from the bloodstream. In this procedure, blood is removed from the veins in the arm and filtered with a machine to remove heavy proteins. The rest of the blood is returned to the bloodstream. This treatment is under investigation in a number of research centers. A small study has indicated there may be some beneficial effects. Larger, controlled trials are ongoing.

Low Dose Radiation Therapy

Radiation therapy for wet macular degeneration is under investigation in a number of research centers. Because growing blood vessels are sensitive to radiation, it has been suggested that radiation may stop or slow choroidal neovascularization.

Implantable Miniature Telescope (IMT)

The implantable miniature telescope is a surgical device currently in late stage trials. It magnifies the central visual images on a larger retinal area than normal to improve vision and the quality of life for patients who have lost significant vision. After surgical implantation, patients undergo a visual rehabilitation program.

Submacular Surgery

Submacular surgery attempts to remove abnormal blood vessels (CNV) and/or blood from under the retina.

To begin the surgery, a technique called a vitrectomy is performed. In a vitrectomy, microsurgical instruments are used to remove the vitreous gel from the eye, and replace the gel with a saline solution.

Next, a small incision is made in the retina to gain access to the sub–retinal space. Using fine microsurgical instruments, the surgeon will pull the neovascular vessels out from under the retina and remove them from the eye.

Early results using this technique have been somewhat disappointing. Vision is rarely significantly improved and the blood vessels may grow back.

RPE Transplantation

In many cases of macular degeneration, it appears that the retinal pigment epithelium, or RPE layer, is the first component of the retina to fail. RPE transplantation attempts to replace diseased RPE tissues with healthy RPE cells.

First, a vitrectomy is performed to remove the vitreous gel from the eye. Then, a small incision is made in the retina to gain access to the sub-retinal space. At this point, RPE cells are injected under the retina.

As time passes and the retina heals, it is hoped that these transplanted RPE cells will arrange themselves properly to replace lost or diseased RPE.

This technique is still highly experimental. Although RPE cells can be implanted successfully, the cells may not form the necessary connections with their neighboring cells and tissues. Additionally, rejection of these cells by the body is possible.

Macular Translocation Surgery

Macular translocation is an experimental surgical technique. This technique aims to move the macula when it overlies diseased sub–retinal tissues.

First, a vitrectomy is performed to remove the vitreous gel from the eye. Then, a flap of retina is detached from the underlying tissues, cut, and rotated into a new position. The rotated retina is reattached to an area of healthier sub–retinal tissue.

At this time, this experimental technique is associated with a high percentage of serious complications.

Laser Treatment of Drusen

Most people with macular degeneration have some drusen, yellow deposits underneath the retina. Some studies have found that low intensity laser treatment causes drusen to shrink and even disappear in some people.

Although this low intensity laser treatment can make the drusen disappear, there is no scientific proof so far that this treatment is beneficial.

These experimental treatments are being studied by numerous researchers around the world. It is hoped that some of these procedures will lead to more effective treatment of macular degeneration in the near future.

Artificial Vision

Because macular degeneration results in impaired functioning of the retina, researchers are attempting to bypass the retina using electronics or silicon chips to send signals to the brain to improve vision. Typically, surgery is required to implant the device into position. This type of technology is many years away from helping people with macular degeneration, but it may offer hope for improved visual function in the future.