AMD (Age-Related Macular Degeneration) is a common age-related condition that affects the macula. There are two forms of AMD: dry AMD and wet AMD, also referred to as neovascular AMD. Wet AMD is much more common. It is caused by the deterioration of the nerve tissue needed for central vision. In the course of AMD, vision is usually slowly deteriorating. Until now, no treatment for this disease has been developed. However, taking vitamins and taking care of general health can slow down the process.
Neovascular or wet AMD is much less common, but its course may be more serious. In some cases, the disease may progress so fast that the vision is lost within a few days. In neovascular AMD, a choroidal neovascular membrane grows underneath the retina, damaging the cells responsible for vision. Injections of medicines (Avastin, Lucentis, Eylea) is the only method of treatment. If there is a risk of suffering from AMD, a comprehensive eye exam should be performed regularly, ideally several times a year. Since an ordinary eye exam may not be sufficient, it is necessary to perform an OCT (optical coherent tomography) examination in order to establish the right diagnosis.
In our Clinic, we conduct a full diagnostic procedure for both dry and wet AMD and we use all the available anti-VEGF medication. Dr Agnieszka Nowosielska was among the first ophthalmologists in Poland to start treating AMD with injections, starting already in 2006. Over the last 11 years, she has performed more than 11 000 injections. Such a broad clinical experience enabled her to develop an innovative regimen of medicine administration that guarantees the highest effectiveness. Anti-VEGF medication is used in many countries around the world. In the United States, patients diagnosed with neovascular AMD receive injections every four weeks, regardless of their eye condition. In practice, some patients receive more injections than they need. In the Clinic of dr Nowosielska, a regimen of anti-VEGF medication administration as well as an adequate dose are established depending on the individual needs of every patient. It is aimed at achieving the best results, that is, at restoring visual acuity, with as few injections as possible. It should be remembered that AMD requires a life-long treatment. Reducing the number of injections to a necessary minimum allows to reduce the risk of suffering from adverse events related to this kind of treatment.
Epiretinal membrane is a tissue that covers the central part of the retina. It may cause blurring and distortion to the vision. Patients with epiretinal membrane should undergo a surgical procedure called vitrectomy. After the surgery, vision always improves, however, the sooner the surgery is performed, the better the results will be.
Diabetic eye diseases do not cause any pain, but they can affect the vision; therefore, patients diagnosed with diabetes should have their eyes tested regularly, regardless of whether they have any problems with vision or not. In order to detect diabetic eye disease, it is necessary to perform a standard eye exam together with additional examinations, such as optical coherent tomography (OCT) and fluorescein angiography (FA). Treatment options for diabetes include laser eye treatment, injections and, in some cases, surgical procedures. In our Clinic, we perform retinal photocoagulation and administer anti-VEGF medication or steroids. Under justified circumstances, patients with diabetes can be subjected to a vitrectomy. Treatment for diabetes is always carried out individually and tailored to specific patient’s needs. It is also important to carry out an ophthalmic treatment in combination with a standard treatment for diabetes.
In the case of major changes induced by diabetes, a surgical procedure called vitrectomy is the most effective method of treatment. It involves removing pathological changes from the retina and the vitreous body. This procedure always improves patient’s eye condition. During one surgery, it is possible to perform laser eye treatment, remove diabetic membranes as well as to administer anti-VEGF medication and steroids. If all these procedures were carried out during one out-patient consultation, it would last much longer and it would cost more. Surgery guarantees the improvement in vision, but it is necessary to wait several weeks, sometimes even months, to appreciate its full effects. The improvement in vision after the surgery depends on the general condition of the patients and the degree of control over diabetes.
Glaucoma is a condition associated with increased eye pressure that causes a progressive damage to the optic nerve. Two types of glaucoma are usually distinguished: angle-closure glaucoma and open angle glaucoma, also referred to as primary glaucoma. In the case of angle-closure glaucoma, the eye pressure raises as a result of the characteristics of the anatomy of the eye, in particular, the angle. The second type of glaucoma, open angle glaucoma, may be due to raised eye pressure or poor general circulation. Diagnostic procedure for glaucoma involves an examination of the optic nerve. In order to assess if the optic nerve works correctly, a visual field exam, an optic nerve head tomography (HRT) and a nerve fibre analysis (GDX) are performed. Such examination should be repeated twice a year. Treatment for glaucoma consists mainly of lowering the eye pressure by administrating special eye-drops. In some cases, it may be necessary to perform a laser treatment or a surgery. Attention should be given to patients who have been receiving eye-drops for glaucoma for a prolonged time. After many years of receiving eye-drops containing preservatives, patients complain of stinging, burning and eye pain, that is, the dry eye syndrome. Unfortunately, in the case of a long-term treatment for glaucoma, it is not possible to avoid this problem. However, patients can use moisturizing eye-drops to relieve the symptoms.
Neovascular glaucoma is a serious condition, which develops as a result of a serious retinal ischemia. It may occur as a consequence of retinal vein occlusion, diabetes and, on occasions, central retinal artery occlusion. In glaucoma, abnormal blood vessels grow inside the eye causing damage to its natural structures. They may cause haemorrhages but, above all, they lead to increased eye pressure. It is very difficult to control raised eye pressure using eye-drops. It may cause acute pain. In some cases, it is so serious that it may lead to the removal of the eyeball. Treatment for neovascular glaucoma is very complicated, but it can be successful if applied early. We can talk about the success of the treatment, if the eye and the basic vision are maintained. Neovascular glaucoma most frequently causes a serious damage to the vision. When treating neovascular glaucoma, it is essential not only to control the eye pressure, but also to determine and treat its underlying causes. Every effort should be made to avoid a situation when the disease develops in both eyes.
Retinal detachment is a very serious condition that requires an immediate surgery. It occurs when the retina is lifted from its normal position and starts moving in the inside of the eye. Treatment for retinal detachment consists of placing the retina in its location and reattaching it with laser. It is considered that the treatment is going to be successful if the surgery is performed within 24 hours. In Poland, it is still considered to be a success if a surgery is performed within a week. A limited access to ophthalmologists leads to a late diagnosis of the problem. As a consequence, patients are subjected to the surgery too late and the results are worse that they might have been. An early treatment carried out by an experienced surgeon gives a chance to restore normal vision.
Macular hole refers to a break in the central part of the retina – the most important part of the eye. It always leads to loss of vision. In one out of five patients, such a hole may occur in both eyes. In order to check if we are dealing with this condition, an optical coherent tomography (OCT) should be performed. Vitrectomy remains the only available method of treatment. It should be performed as soon as possible. The sooner it is performed, the bigger the chance to restore vision will be. It is not true that there is no point in treating older or bigger macular holes. A surgical technique used by dr Nowosielska ensures success in 90% of the cases. Patients usually have to wait a couple of months for the vision to improve, but the sooner the surgery is performed, the more rapid the recovery will be.
This type of haemorrhage may occur in the course of different eye diseases. Most frequently, it is due to neovascular AMD, diabetes or retinal vein occlusion. Haemorrhage to the retina is always an indication of a disease that should be treated as soon as possible. Unfortunately, patients are frequently informed that they have to wait until the blood is absorbed. Nothing could be further from the truth! If the blood is left to be absorbed, especially in a large amount, a “scab” may be formed, causing a permanent damage to the retina and consequently, hampering the vision forever. Surgical procedures, such as removing the blood from the eye, are normally used in the case of haemorrhages, especially the intense ones. Treatment should be started as soon as possible in order to save the vision.
PATIENTS SHOULD NOT REFRAIN FROM THE TREATMENT UNTIL THE HAEMORRHAGE IS ABSORBED, BECAUSE ONCE IT HAPPENS, IT IS TOO LATE TO RESTORE VISION!
Haemorrhage to the vitreous body is always an indication of a disease. If it occurs, a diagnostic procedure should be performed urgently in order to determine the causes of the haemorrhage to the inside of the eye. Therefore, a consultation with an ophthalmologist and a specialised examination, in this case an ultrasound examination, are needed. It is also important to start a treatment as soon as possible. Properly selected medication, in form of eye-drops or tablets, is used to treat small haemorrhages. They are normally self-limitating, but it is important to make sure that they are not a symptom of any serious disease. In the case of intense haemorrhage, the blood is removed from the eye surgically. In some cases, for example when a retinal detachment is suspected, a procedure should be performed immediately.
Cataract refers to the clouding of the lens, which leads to vision deterioration. This disease is usually observed in elder people, in particular in patients after the age of 60, but there are cases of congenital cataract. In the course of the disease, the lens loses its transparency and, as a consequence, the patients sees as if they were looking through a dirty glass. Cataract can develop slowly, causing a progressive vision deterioration, or progress very fast.
If the eye is affected by any other diseases, apart from cataract, we can talk about complicated cataract. Most frequently, this kind of cataract coexists with different types of glaucoma. Complicated cataract often occurs in patients with far-sightedness. The bigger the lens is, the more complicated the surgery gets. Another type of complicated cataract is subluxated cataract, in which suspensory ligaments of the lens (a mechanism that normally holds the lens in place inside the eye) do not work properly. In such cases, it may not be possible to insert a standard lens. If so, a special one, which can be attached to the eye, must be ordered.
Vein occlusions are always caused by systemic diseases, such as hypertension, atherosclerosis or diabetes. In young patients (aged from 35 to 50 years) they may be due to inflammatory diseases, for example, vasculitis. Vein occlusions are formed as a consequence of changes in the arteries, similarly as in the case of a heart attack or a stroke. The fact that a vein occlusion is formed in the eye is a coincidence. For that reason, it is necessary to consult an internist and a cardiologist in order to treat this disease. Retinal vein occlusion always leads to vision deterioration. The degree of the damage depends on the size of the occlusion. In order to save the vision, an ophthalmic treatment should be carried out in combination with general treatment and it should include: laser treatment, anti-VEGF injections and steroids. A surgical treatment (vitrectomy) may be necessary in some cases. In most cases, it is possible to achieve improvement in vision, but it is not possible to restore vision in 100%.
Exams and Procedures
Anti-VEGF treatment consists of administrating anti-VEGF medication into the eyeball. Anti-VEGF stands for anti-vascular endothelial growth factor – a substance that blocks vascular endothelial growth factor. Avastin (bevacizumab) was the first medicine of this group in the world. It was registered by FDA (Food and Drug Administration – an institution that authorizes placing food and medicines on the market in the United States) as a medicine administrated intravenously and indicated to treat cancer of the colon. Avastin is indicated to treat cancer because, like other anti-VEGF medication, it blocks the growth of new blood vessels, thus preventing cancer from developing by causing lack of blood supply. Similarly, when the growth of new blood vessels is blocked, diseases such as neovascular AMD cannot progress. Research has demonstrated that in neovascular AMD, diabetic macular oedema or macular oedema in the course of retinal vein occlusion, the level of VEGF in the eye is increased. This is the reason why anti-VEGF medication is successfully used to treat those diseases. Currently, it is the most common method of treatment. When talking about intraocular injections, patients usually refer to anti-VEGF medication. There are three anti-VEGF medicines used in the treatment for neovascular AMD available on the market. They include: Avastin (bevacizumab), Lucentis (ranibizumabum) and Eylea (aflibercept). In anti-VEGF treatment, the outset of the treatment as well as the frequency of drugs administration are of vital importance. An inadequate regimen of treatment may lead to its ineffectiveness.
Avastin (bevacizumab) was the first anti-VEGF medication registered in the world. It has been used in ophthalmology since the turn of the years 2005 and 2006. Philip Rosenfeld from Badcom Palmer University in Florida was the first person who thought that Avastin could be used in the treatment for neovascular AMD. He correctly assumed that if Avastin could stop the growth of cancerous tumour by blocking the growth of its blood vessels, it could be as effective in the case of neovascular AMD, a disease caused by the uncontrolled growth of new blood vessels underneath the retina. The first attempts to use Avastin consisted in administrating the dose that were used in oncology intravenously. Currently, a significantly reduced dose (4000 times smaller) is used and administrated directly into the eye instead of into the vein. This prevents patient from suffering from adverse events. Avastin is owned by the company Genentech.
Lucentis (ranibizumab) was especially designed and registered to treat wet AMD. From the chemical point of view, it is a derivative of Avastin. It was produced by Genentech. After the success of Avastin, the company wanted to introduce a medicine developed specifically for ophthalmic use. The mechanism of action and adverse events of Lucentis and Avastin are similar. Clinical trials CATT/IVAN that have been carried out demonstrated that the effectiveness of Avastin and Lucentis is also akin. The same applies to the adverse events. The effectiveness of treatments is usually related to the regimen of treatment and the experience of a doctor who performs it.
Eylea (aflibercept) is the most recent medicine that we use to treat wet AMD. Eylea is produced by Bayer. It is also a cancer medicine, which was tried out in ophthalmology. It turned out that it achieved very good results in retinal oedema and neovascular AMD. The mechanism of action of Eylea is slightly different from that of Avastin or Lucentis and some patients react better to the treatment
Minor changes around the eyes and on the eyelids, which are not dangerous from the medical point of view, but may cause inconvenience to patients. The procedure of the removal of warts and atheroma is painless, as it is performed under local anaesthesia. In some cases, it may be necessary to use stitches, which are removed after 7 days.
Endoscopic cyclophotocoagulation (ECP) is an endoscopic treatment applied in very advanced glaucoma in order to save the eye and the vision. ECP is carried out in order to reduce the amount of water produced inside the eye thus, lowering the eye pressure. This technique is more precise and safer than others, such as laser cyclophotocoagulation or cryotheraphy of the ciliary body, which cause an irrevocable damage to the eye.
Fluorescein angiography is an examination of the blood vessels of the eye. In order to carry out this examination, a fluorescent dye is injected into the bloodstream. It passes through the blood vessels. Then, photos of the fundus of the eye are taken. The pupils are dilated with special eye-drops prior to the examination. The whole procedure usually lasts for about 1,5-2 hours with some breaks. Before the examination, patients are recommended not to have copious meals, because some of them may experience nausea and vomiting as a result of dye injection. After the examination, the skin, the conjunctiva and the mucous eye-membranes are yellow, the same with the urine of the patient. In some cases, an allergic reaction to the dye may be developed.
Gonioscopy is an examination of the angle which is responsible for the drainage of fluids out of the eye, and consequently, for maintaining an adequate eye pressure. Gonioscopy is typically performed in the case of glaucoma, intraocular hypertension or eye traumas, but it can be also carried out in any other case if it can help to make a diagnosis. Gonioscopy is performed using a special device under anaesthesia administrated in the form of eye-drops. Patient’s vision may be blurred for a couple of hours after the procedure.
Chalazion is a small lump that appears on the eyelid after a stye. It usually is not absorbed spontaneously; therefore, it has to be removed surgically. Removal of a chalazion is performed under local anaesthesia. No scares are left once the chalazion is removed.
HRT examination is an optic nerve head assessment. In the course of the examination, the optic nerve head and the optic nerve pit are measured with an analyser. As the device is equipped with a database, so called “norms”, the result can be compared to the norms. This is the basis for diagnosing patient for glaucoma.
Intravitreous injections are injections into the eyeball. They consists of introducing an exact necessary amount of medicine directly into the eye. In the case of neovascular AMD, diabetes or retinal vein occlusion, anti-VEGF medication is administrated, in the case of diabetes – steroids and in the case of intraocular inflammation – antibiotics.
Iridotomy is a laser procedure performed in angle closure glaucoma. In the case of this disease, eye fluids cannot flow freely inside the eye and may get trapped in some parts of the eye. Then, the eye pressure increases leading to an episode of acute glaucoma. Such episode is not only very painful, but is can also cause a permanent damage to the vision. In order to avoid it, a hole in the iris, the coloured part of the eye, should be made with laser. The hole is small and thus invisible. It is normally made in the part of the iris covered by the upper eyelid. It allows the water to flow inside the eye freely and thus, it reduces the eye pressure.
During the cataract surgery, an artificial lens in inserted into a special bag, which stays inside the eye permanently. It is a component of the lens and receives the name of posterior lens capsule. In 50-80% of the patients, the posterior lens capsule may be losing its transparency over time, becoming whitish, as matt glass. It leads to vision deterioration. It may resemble a recurrence of the cataract. A laser treatment involving the “cleaning” of the posterior lens capsule is then necessary. It leads to the improvement in vision, which can become as good as it was immediately after the cataract surgery. This procedure is performed only once in the patient’s life, because the problem does not recur.
Xanthelasma are yellowish plaques that occur on the eyelids. They normally indicate that the level of cholesterol or fats in the system is too high. Removal of xanthelasma is performed under local anaesthesia. After the surgery, stitches are used and then, removed after 7 days.
Laser treatment is used to treat a number of retinal diseases. Laser is frequently used in the case of changes that can lead to retinal detachment, that is, in peripheral retinal changes. Laser treatment consists of "welding" the retina to the surface so that it remains in place. An ophthalmologist specialised in treatment for retinal diseases should decide on using laser treatment.
Optical coherence tomography of the fundus of the eye (OCT) is an examination applied in the diagnostic procedure for retinal diseases, such as Age-Related Macular Detachment, diabetic maculopathy, macular oedema or macular holes. The examination shows an anatomy of the eye in details. It is a non-invasive procedure. Eye dilating eye-drops are normally used before the examination, so patients may complain of deteriorated vision and sensitivity to light for about 4 hours after the procedure. OCT examination also allows to assess the optic nerve head, similarly to HRT or GDX examinations, as well as to examine the anterior segment, the angle, and the anterior surface of the eye.
Perimetry, that is, a visual field exam, is one of the baseline eye examinations. It measures the area of the eyesight of the patient. It also assesses the optic nerve head. It is baseline examination in the case of glaucoma, but it is also widely used in the diseases of the nervous system.
Pan-retinal photocoagulation is a type of laser treatment performed when the retina is damaged by diseases such as diabetes or retinal vein occlusion. If the retina is damaged by these diseases, it can emit some poisonous substances into the eye, leading to its further damage. In order to stop this process, photocoagulation of the retina has to be performed. This kind of laser can be used only in the parts of the eye that are not responsible for vision. It cannot be used, for example, in the macula. It is usually necessary to repeat the procedure. After PRP, some patients may complain of lower contrast.
It is a laser procedure applied in the case of glaucoma. It is aimed at lowering the eye pressure. It is usually performed in both eyes at once. SLT normally allows for lowering the eye pressure by about 20%. The procedure can be repeated if, after some time, the eye pressure keeps increasing. It is a painless procedure.
Steroids are widely used in medicine due to their strong anti-inflammatory and anti-swelling properties. They also block the process of cell division. Currently, in ophthalmology, steroids are mainly administrated locally, that is exactly where they are needed, in order to achieve better medical results and avoid systemic complications. Generally, steroids are administrated if the defects in the eye are caused by systemic changes. It is because steroids have been reported to have numerous adverse events, such as diabetes, gastric ulcers or mood disorders.
The eye diseases that can be treated with steroids include uveitis (inflammation of the middle layer of the eye), diabetic macular oedema or retinal vein occlusion. Among the most common medicines from this group, there are: Triamcinolone, Ozurdex and Illuvien. All steroids have similar, local adverse events. They include glaucoma and cataract. Secondary glaucoma (raised eye pressure) occurs in 25-30% of cases, in which steroids are administrated into the eye. Raised eye pressure is usually temporary; it drops once an adequate medicine is administrated. A very small proportion of patients requires glaucoma surgery. Steroids may also speed up the process of cataract progression. However, it should be remembered that steroids are often used to treat uveitis or diabetes and these are the diseases that may speed up the process of cataract progression themselves. For that reason, cataract is considered to be an unpleasant, but easy to remove complication. If steroids are used in patients after cataract surgery, such problem does not exist.
Triamcinolone is a derivative of prednizolon. Triamcinolone has strong anti-inflammatory and anti-swelling action and blocks the process of cell division. In ophthalmology, it was among the first medicines to be administrated directly into the eye. It is administrated into the eye "off label" (for an unapproved route of administration), because it is registered as a medicine to be administrated intramuscularly. It is a very cheap and effective medicine. Its effects in the eye can last for about 4-6 months. Following this period, treatment usually has to be repeated. Triamcinolone is administrated into the eye in the form of suspension, so dark floaters may appear in the visual field during the first days after the injection. They disappear after a few days.
Ozurdex is a derivate of dexamethazon. It is an implant designed especially to be injected into the eye. It looks like a piece of white pencil load. Unlike Triamcinolone, it is does not cause floaters in the visual field after the injection. Its effects in the eye can last for about 4-6 months.
Illuvien is another implant with steroid medicine registered to inject into the eye. It has been originally created for patients with uveitis, but it can also be used to treat diabetic macular oedema. Its effects in the eye can last even up to 2 years! That is why it is very convenient in application. In Poland it is barely used.
Tonometry is performed to measure the eye pressure. It is one of the basic examinations in ophthalmology. It is especially important in the diagnostic procedure for advanced glaucoma. There are several techniques of performing tonometry including the contact ones and the non-contact ones. In the case of non-contact tonometry, the eye is anaesthetised with special eye-drops.
It is a surgical operation aimed at lowering the eye pressure in patients with glaucoma. It consists of creating a special drainage canal from the inside of the eye. An experienced surgeon is able to create a drainage canal adapted to the patient’s needs.
Ultrasound biomicroscopy is a technique primarily used for imaging the anterior segment of the eye using ultrasounds. It is used to assess the retina or the angle, among others. It can be very useful in the diagnostic procedure for glaucoma or when assessing tumour or other changes, for example, in the iris. UBM examination can be also used to assess the location of the lens in sublaxated glaucoma. The procedure is performed under anaesthesia administrated in the form of eye-drops.
Ultrasound examination (USG) of the eye allows to assess the condition of the orbit, the eye muscles and, in particular, the eyeball. This examination is particularly useful if it is not possible to look into the inside of the eye because of reduced transparency of the lens or of the vitreous body. It can happen in advanced cataract, which makes it impossible to look into the eye or in the case of an intense haemorrhage that covers the fundus of the eye. Ultrasound examination can be also performed in any other case if it is recommended by an ophthalmologist. It is a painless procedure.
Vitrectomy is a procedure in which an ophthalmic surgeon accesses the inside of the eye. It is performed to treat retinal detachment, macular holes, epimacular membranes, diabetes, haemorrhage to the vitreous body, macular oedema, inflammations, retinal vein occlusion; it is also performed in the case of more complicated cataract surgeries. Every vitrectomy is different, as there are no two identical eyes. In the course of the surgery, it may be necessary to carry out a number of procedures, including membrane removal, membrane staining or photocoagulation. In vitrectomy, there are never two identical cases and it can be successful only when it is tailored to the patient’s individual circumstances. For that reason, vitrectomy is a surgery that requires broad experience from a surgeon. After the surgery, a special substance, such as gas bubble or silicone oil, is inserted into the eye in order to unfold the retina. These substances normally cause vision deterioration, but they are removed at a later date and the vision improves.
The vitrectomy technique was developed in the United States over 40 years ago. In Poland it is performed by a small group of ophthalmologists; therefore, the majority of doctors who work in ophthalmic clinics in Poland have little experience using this method. As recently as 15 years ago, vitrectomy was performed only in very difficult cases or as the last resort. Given that the experience of the surgeons, as well as the technique itself were not as developed as today, it was performed only when other treatments were not effective. Today the situation has changed. Thanks to both the experience of the surgeon and the technological progress, vitrectomy is now a safe, reproducible method that offers a chance to restore vision. In view of the experience gained in the recent years, many conditions may be successfully treated by performing a vitrectomy. However, a frequent mistake is to perform it at the last possible moment. According to dr Nowosielska, patients should be referred to vitrectomy earlier than it happens now. Vitrectomy, when performed by an experienced surgeon, is not a means of last resort.
Scharioth macular lens is dedicated to patients with AMD or other macular diseases, who are not able to read small print. It consists of inserting into the eye a lens that acts as a magnifier in the eye so that the image is magnified and thus, more visible. The lens is inserted only into one of the eyes. As a consequence, one eye fares better in reading and the other one in distant vision. The lens can be implanted even if the vision is very poor as long as a cataract surgery has been performed before. This procedures is not aimed at treating the disease that causes vision impairment, but at helping the patient to carry out daily activities. In most cases, it is necessary to carry out a further treatment for the main eye disease that the patient suffers from.