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.
  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.  VEGF levels drop after the injection.

In the US the term 'IVT' means intravitreal 'treatment', which might be triamcinolone, Lucentis, Avastin, or Eylea. This page refers to Lucentis, Avastin, or Eylea, anti-VEGF drugs.

In the UK Avastin is not licenced, which means that has not yet been approved by the NHS, but it is the commonest drug used round the world.

If the macular oedema is greater than 400µ, the NHS pays for treatment NICE. Avastin is much, much cheaper, is rarely funded by the NHS, but should be approved by NICE. NICE have refused to consider Avastin, as the drug company has not carried out much research etc. Avastin is marginally less powerful Jama 16 .

 

Leakage.....macular oedema

Diabetes and the 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

 

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

 

Iodine allergy

 

After the injection

By one month the drugs should be working. Many people will notice some improvement in vision. Generally this improvement is temporary, and the injection may be offered again months later. The macular oedema reduces, with a maximum reduction at 2 weeks, and starts to wear off after 3 months (see). It gives a chance for laser treatment and lower blood pressure etc  to have their effect. Further injections are usually needed, but as this treatment is new there is no definite treatment plan available.

 

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. The day after the injection your eye should be comfortable, there should be very little pain. If your eye starts to get red, with misty vision (there may be no pain), perhaps 2-5 days after the injection, you should suspect an infection and attend your eye department urgently. In Birmingham this is the Birmingham and Midland Eye Centre Casualty at the
Birmingham & Midland Eye Centre, City Hospital, Dudley Road, Birmingham B18 7QH
Tel: 0121-554 3801. Avastin, infection..preventing.

A scratchy after injentiosn is normal; a painful achy eye may be infected.

Check pressure 4, 8, & 16 weeks after injection EJO15 .


 

Symptoms of infection

These are the common symptoms that patients notice   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. Laser...if it has not been carried out already will be needed, on many occasion. Rarely the drugs will cause some loss of sight...there is no detailed information as to the exact risk. Unlike a steroid, there should be no long term pressure effects.

Years

IVL or IVA may hasten cataract development or to 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

You should remind your ophthalmic team you use anticoagulants and ask for specific advice. Treatment is safe continuing the anticoagulents (Retina 2010).  Epidemiology 2010

 

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

smoking

insulin

education

sleep apnoea

glucose level

Glitazones

hypoglycaemia

neuropathy

issues

compliance

type 2 at diagnosis