NEWS & EVENTS
Retinal Review, Issue 09
CASE NUMBER 9
A 71 year old woman was referred for macular degeneration. Past medical history is significant for thyroid disease and hyperlipidemia. Past ocular history is significant for macular degeneration for which she has used ocular vitamins for three years. Visual acuity measured 20/20- in both eyes. Applanation tensions were normal. The anterior segments were normal as well. There were mild cataracts in both eyes. The vitreous cavities were clear. Examination of the fundi was significant for unusual peripapillary atrophy. There were mild atrophic changes in each macula. There was no evidence of exudation. Photography and fluorescein angiography were performed. The testing confirmed mild atrophy but no evidence of exudation. Interestingly there were radiating streaks of RPE disease around each optic nerve.
The patient was diagnosed with dry AMD. She was also told that she had angioid streaks. These linear RPE defects typically radiate from the optic nerve. They can be found in patients with underlying medical conditions such as sickle cell disease, Ehler’s Danlos syndrome, pseudoxanthoma elasticum, and Paget’s disease. Our patient had none of the above. She was asked to use weekly amsler grid testing and to continue her ocular vitamins.
She returned a few months later complaining of vision loss OS. Vision measured OD: 20/25 and OS: 20/80. Subretinal hemorrhage and exudation were noted in the left eye. She was diagnosed with exudative AMD.
Treatment options for exudative AMD include laser photocoagulation, photodynamic therapy (“cold laser”), observation, and antiVEGF injections. Our patient had a subfoveal choroidal neovascular membrane (CNVM). The best treatment for this condition is antiVEGF injections. There are several different antiVEGF options. The first available medication was Macugen. Macugen injections were usually successful in stabilizing vision but rarely improved vision. The next available agents were Avastin and Lucentis. Both not only stabilize vision in the majority of cases, but 30 to 40% of patients experience some degree of visual improvement. A new agent, Eylea, was just introduced to the market and results initially seem comparable to Avastin and Lucentis. The decision as to which antiVEGF medication is most appropriate for the patient is complex due to financial and insurance issues. Because the results are comparable, they are all acceptable choices. We chose to initiate treatment with Avastin. The patients are given monthly injections until the hemorrhage and exudation resolve. Often 6 to 8 initial injections are required. After the macula stabilizes, the patients are put on a maintenance course involving frequent examinations and “booster” injections. It is unclear at this stage how often to give booster injections; however, it is clear that without maintaining some sort of reinjection course most patients will have recurrent exudation. Our patient returned after two injections with significant improvement. The macula was improved and the vision had improved to 20/40 in the left eye.
The patient then had a typical course of improvement and recurrence. The following photos will highlight her subsequent course. To date she has received a total of 12 Avastin injections. Vision ranges between 20/50 and 20/70. She will require ongoing monitoring and periodic treatments to maintain stability.