Dry age-related macular degeneration (AMD) is a gradual deterioration of the cells of the macula, often over many years. There is no medical treatment for dry AMD but research into dry AMD is happening around the world, including research funded by the Macular Society.
Wet age-related macular degeneration (AMD) is another form of the condition. It is caused by tiny abnormal blood vessels growing into the retina which leak and cause scarring of the macula. A person with wet AMD can lose much of their vision within weeks. There are now treatments for wet AMD which can slow the progress of the condition in most people.
Treatment must be given quickly, before there is permanent scarring to the macula.
Current treatments for wet AMD
Several drugs are used to treat wet AMD. They are known as ‘anti-VEGF’ drugs. VEGF stands for ‘vascular endothelial growth factor’. It is the substance in the body that is responsible for the development of healthy blood vessels. In wet AMD, too much VEGF is produced in the eye, causing the growth of unwanted, unhealthy blood vessels.
Anti-VEGF drugs block the production of VEGF and stop the development of abnormal blood vessels. All the anti-VEGF drugs are given as an injection into the eye. Don’t be alarmed – the injections are much less frightening than they sound.
Lucentis® (medical name ranibizumab) was the first anti-VEGF to be licensed for wet AMD. In accordance with NICE AMD guidelines, all patients receive a standard ‘loading dosage’ at the start of their treatment: normally three or more consecutive monthly injections. There are two licensed drugs available to treat wet AMD: Lucentis® and Eylea®.
After this initial phase, there are a number of treatment regimens that an ophthalmologist can choose. Each regimen has a subtle difference in the frequency of appointments. They also vary as to whether or not you have an injection at every appointment.
The ophthalmologist will tailor treatment to individual patients and how their disease is responding to treatment.
Top tip – We recommend that patients ask their eye doctor, after their original loading dose, what treatment regimen they are being put on. From this, patients will be better able to understand the timescale between injections and feel confident that they are not being overlooked in the clinic appointment system, or missing any treatment.
Eylea® (medical name aflibercept) can be given under different treatment regimens. Firstly the patient will be given three injections, a month apart in accordance with NICE AMD guidelines - the ‘loading dose’. Your hospital doctor will then decide how often treatment is needed. Medical trials suggest that the effects of Eylea® last longer than those of Lucentis® and so people may need fewer injections over time.
A third drug, Avastin® (medical name bevacizumab) may be used in some circumstances. But Avastin® is an anti-VEGF drug used to treat cancer and is not yet licensed for use in the eye.
How is the injection given?
The majority of patients are treated at a hospital in a designated injection room. The eye is examined first to check that an injection is needed. If it is, the procedure may take place on the same day or the person may have to return. In most cases the injections are administered by trained and qualified ophthalmic nurses.
When the injection is given, the patient reclines on a couch. The eye to be treated is held open with a device called a speculum and anaesthetic drops are used to numb it. The patient looks to one side and the injection is given in the opposite corner of the eye.
The patient does not see the needle and the injection only takes a few seconds. While the majority of patients find this a painless procedure some people say the injections are uncomfortable and occasionally painful. Others experience discomfort for a while afterwards. Very occasionally there are more severe reactions.
If you’ve been told you need injections and are worried, you can speak with people who’ve had injections for support and advice. Call our Advice and Information Service for more information and ask about our Treatment Buddy Service.
On rare occasions some people may be offered laser treatment. A light-sensitive drug is injected into the arm. The drug travels to the eye where it is activated by a laser beam, shutting down the abnormal blood vessels. Most people need two to five treatments. The treatment is only suitable for people with particular patterns of damage to the retina. However, as this treatment carries a greater level of risk to the patient, it is not routinely offered.
Researchers all over the world are working hard to find new and improved treatments for AMD. This includes researchers funded by the Macular Society. Among the areas being explored are potential treatments to reduce the inflammation thought to lead to AMD, longer-acting anti-VEGF drugs and eye drops to replace injections.
Treatment for diabetic macular oedema
DMO can be treated if it is caught early. Although treatments cannot restore sight if there is already significant damage to the macula, they can slow the rate of damage and preserve more of your sight for longer.
Anti-VEGF drugs are injected into the eye to stop fluid leaking from the blood vessels. You will usually have a number of injections in the first few months, then more if later check-ups suggest they are needed.
Some people, including those who have had cataract surgery, may be offered a steroid injection instead. A tiny implant is injected into the eye to gradually release the steroid over several months.
If your DMO doesn’t involve the centre of the macula, you may be offered laser treatment. This usually requires one or more visits to an outpatient laser clinic for treatment by an ophthalmologist.
Diabetes is a lifelong condition, so maintaining a healthy lifestyle and monitoring your blood sugar, blood pressure and cholesterol levels is crucial to avoid damage to your eyes.
Treatment for central serous retinopathy
In most cases, the fluid is reabsorbed without any treatment. The majority of people with CSR will regain most or all of the sight they had before. If the fluid is still there after three to six months, you may need treatment to prevent more lasting damage to the macula.
One treatment option uses a laser to seal off the leak, but it cannot be used too close to the centre of the macula, as it can damage your central vision. If this is the case, you may be offered photodynamic therapy. This is where a drug is injected into your bloodstream and activated in the eye using a low-energy laser, which won’t damage the macula. You should also be helped to make any lifestyle changes that might help, such as reducing stress or stopping any drugs which could make the condition worse.
Treatment for macular hole
If you have a macular hole you will undergo vitrectomy surgery to remove the gel from the eye under local anaesthetic. It is successful in repairing macular holes 90 per cent of the time, and nine out of ten people will see their vision improve. A tiny cut is made in the eye and the vitreous gel is replaced with a bubble. To begin with, the bubble will block your sight, but it is naturally absorbed over several weeks.
One common side-effect of this treatment is cataract: within two years of a vitrectomy, most people will need cataract surgery. If you need a vitrectomy, you may be offered cataract surgery at the same time, if you have not already had it.
After surgery, you may be asked to lie face-down for several days (called “posturing”) to help the eye heal properly.
Treatment for myopic macular degeneration
For those who are already short-sighted, little can be done to reduce the risk of maculopathy, although ensuring high blood pressure is controlled is warranted, as high blood pressure is believed to be associated with risk of myopic maculopathy.
The treatment options are similar to those for age-related macular disease (AMD) and depend on the precise cause. For the majority of patients there is no treatment available. Any sudden changes in vision or an increase in 'floaters' should also prompt an urgent check-up visit to the optometrist.
Treatment for punctate inner choroidopathy
Treatments fall into short-term ‘rescue’ and long-term ‘prevention’. Rescue treatments use corticosteroid tablets or injections to suppress the inflammation, or anti-VEGF injections to stop new blood vessels spreading and leaking. Once inflammation is brought under control, preventative treatment may be used to reduce the risk of a future flare-up.
These preventative treatments include immune system-suppressing tablets, or a corticosteroid implant in your eye. If your PIC is mild, you may not be prescribed a preventative therapy, and only take ‘rescue’ medication, if and when needed.
Treatment for retinal vein occlusion
Anti-VEGF injections (Eylea, Lucentis) or steroid implants (Ozurdex) injected into the eye is used to treat RVO. The injections have to be repeated over a period of time to work effectively.
Injection treatment aims to stabilise or improve vision. About 45-55% of patients treated with anti-VEGF injections experience a significant improvement in vision. Steroid implants achieve a significant improvement in vision in up to 30% of patients. 20-30% of patients experience no improvement in vision treatment.
Laser treatment may be used to treat branch retinal vein occlusions.
About 20% of patients with RVO develop abnormal blood vessels that can bleed or increase pressure in the eye, leading to further loss of vision. This can normally be prevented by laser treatment to stabilise and preserve the condition of the eye, but not improve vision.