www.diabeticretinopathy.org.uk

Anti-VEGF injections for diabetic retinopathy Lucentis, Avastin, & Eyelea ...a leaflet for patients

 

David Kinshuck

 

 

Anti-VEGF drugs: introduction

macular oedema

Macular oedema shown in green by the arrow. Macular oedema affects the centre of the retina which is responsible for sharp vision, see

The front of the eye is on the left, and the retina is shown in red

Lucentis, Avastin and Eyelea are anti-growth factor drugs (anti-VEGF). The drugs are given as injections into the vitreous cavity of your eye. Lucentis, Avastin, & Eyelea= Ranibizumab, Bevacizumab, Aflibercept

The drugs are used to reduce

  1. macular oedema, that is fluid at the back of the eye, occurs in diabetes, retinal vein occlusion. (Often abbrevaiated as DMO or DME, hat is diabetic macular oedema)
  2. reduce retinal new vessel growth in these conditions 
  3. to reduce new vessel growth on the iris (rubeotic glaucoma)
  4. See
  5. The drugs are also used to treat ARMD, but that is not discussed here.

 

avastin injection to reduce macular oedema

injection in a very clean room.

 

The drugs are given as an injection usually in a clean minor surgery room. The injection procedure itself takes seconds and is usually feels like a tiny prick. You can go home later that day...this is a 'day case' procedure. Repeated injections are safe

In the UK Avastin is not licenced, but it is the commonest drug used round the world.

If the macular oedema is greater than 400µ, the NHS funds treatment NICE.

 

 

Leakage.....macular oedema

Diabetes and other conditions damage blood vessels in the retina, and the damaged blood vessels then start to leak. The leakage makes the retina waterlogged, a bit like a sponge, as in the diagram above. This is part of 'diabetic maculopathy' (DME) or 'macular oedema' in retinal vein occlusion. animationText

The macula is the central area of the retina, responsible for your central or 'sharp' vision used for reading & watching TV.... our sharp & detailed vision. When the macula is swollen (oedema) the sight is reduced, and people cannot see details like faces and writing on TV, and bus numbers.

The retinal damage releases a chemical, VEGF (VEGF= vascular endothelial growth factor). The VEGF then causes adjacent retina to leak or grow 'new blood vessels' as below.

Anti-VEGFs block the effect of VEGF by binding to the VEGF receptors on the cells in the retina. This then reduces the leakage, and the sight may improve. See the evidence, also, DRRN, Byeon, India

 

Macular oedema (DME) and response to Anti-VEGF treatment

Anti-VEGF treatment will reduce  DME (diabetic macular oedema). They are unlikely to improve sight if there is no oedema. Rarely patients will notice a deterioration in vision,, due to more macular ischaemia.

The Anti-VEGFs are given by injection into the vitreous cavity of the eyeball details. The drugs last 4-8 weeks. There are different protocols.

New blood vessel growth

A second effect of the VEGF is to make tiny blood vessels grow. These are called 'new' blood vessels, and an ophthalmologists calls these 'new vessels' see animation . This is proliferative retinopathy.

These new vessels are very delicate and very easily bleed, and this blood can damage your eye badly. This is 'proliferative retinopathy'. If the blood spreads in front of the retina, scar tissue can grow. The scar tissue can then shrink and pull the retina off, causing blindness.

New blood vessel growth must be stopped. Laser is the main treatment, but Lucentis and Avastin are new treatments that will generally be used IN ADDITION to laser. See the evidence also . Minella. Tonella. May work instead of laser DRCRnet 16.

 

Rubeotic glaucoma

When the blood vessels grow in the 'drainage meshwork, the aqueous humour produced in the eye cannot drain away. This leads to a very high pressure in the eye, called rubeotic glaucoma. Avastin is an excellent treatment for this, but the effect may be temporary. Rubeotic glaucoma is described in detail here with an animation here. See the evidence.   Laser is usually needed as soon as the pressure has dropped.

normal aqueous flow

 

normal flow of aqueous humour

 

new vessels in trabecular meshwork

drain blocked by 'new' blood vessels' aqueous trapped in eye, and this puts the pressure up

 

The procedure

Risks etc

Hours

The injection will put the eye pressure up for a few hours. It is therefore riskier is you have glaucoma, but this is generally not a major problem. There should not be much pain. You may see the drug floating around your eye for the next few hours.

 

Night

Days

About 1/1000 people will develop a serious eye infection: symptoms

An infection... common symptoms   Eye 12  

  1. blurred vision........96%
  2. pain/photophobia...73%
  3. redness ...............50%
  4. floaters................25%
  5. lid swelling ...........10%
  6. discharge .............10%

Months..sight

The drugs will reduce the retinopathy, both the leakage and new vessel growth. Anti-VEGF may hasten vitreomacular traction Eye 17.

Pregnancy

Please tell your doctor is you are pregnant, and try and avoid getting pregnant for the 6 weeks following the injection. This is a new drug and is probably UNWISE IN PREGNANCY. In any respect, pregnancy makes active diabetic retinopathy MUCH worse. Retina 2012

Retinal tears

There is a 1% risk of a retinal tear after this injection. Please seek attention (within 24 hours....the next day is usually OK) from an ophthalmologist if you develop the symptoms of a tear, that is (all of a sudden) a sudden shower of floaters and flashes of light. These may happen in the months after the injection.

 

Anticoagulants ...extra precautions

Treatment is safe continuing the anticoagulants.

 

Remember the 'targets' for good control

By keeping to these levels as much as possible (or lower still) you will be doing your best to stop your eyes getting worse. Occasionally by sticking to these targets your retinopathy will improve, even without laser. Review BMJ17   

 

lifestyle

blood pressure

HbA1c

sudden decrease in HbA1c

cholesterol and statins

smoking

insulin

education

Diabetes education courses

sleep apnoea etc

glucose level

Glitazones

hypoglycaemia

neuropathy

issues

compliance

type 2 at diagnosis