Vitreous cavity drug injections for fundoplication have become more popular recently, and they do have some efficacy, changing some of our traditional thinking about treatment. Recently, patients have been asking questions about vitreous cavity drug injections, and I have focused my answers as follows.
1. What diseases are treated by vitreous cavity injection (intraocular injection).
A: The main mechanism of the drugs currently used for vitreous cavity injection is that in some listed macular diseases such as age-related macular degeneration, the growth of neovascularization in the eye (choroid and retina) is caused by various reasons, and the neovascularization is very brittle and easily bleeds, leaks, and edema, which eventually leads to scar formation and causes blindness. Anti-neoangiogenic drugs are meant to stop the growth of neovascularization, reduce leakage, and reduce edema, thus stabilizing or improving visual acuity. Anti-angiogenic drugs are currently used in a wide range of applications for.
(1) macular edema caused by various reasons (including diabetic macular edema, macular edema caused by various diseases such as post-cataract surgery or post-uveitis;)
(2) Choroidal neovascular membrane formation from various causes (including age-related macular degeneration, highly myopic macular degeneration, mid-bleed, etc.)
(3) retinal neovascularization (e.g., retinal neovascularization or microangiopathy caused by diabetic retinopathy, venous obstruction, retinal perivasculitis, Coats’ disease, choroidal osteoma, choroidal hemangioma, etc.)
(4) Retinal vein obstruction.
(5) Neovascular glaucoma and other diseases.
2.What are the drugs used?
A: At present, the main drug is ranibizumab (Lucentis), which has been marketed in China.
Lucentis has been marketed in the United States in 2006 and was named one of the top ten health news in the United States that year. It is a vascular endothelial growth factor (VEGF) fragment antibody that can inhibit multiple VEGF isoforms, and many clinical trials have demonstrated its very exciting therapeutic effect in the treatment of age-related macular degeneration. It has been approved by the state and is now available for use in China.
This table above shows that, overall, vision can improve after the injection, but this is an average, and specifically for individuals, there are actually no improvement or even vision loss. It depends on the condition, if it is already atrophied or scarred, the effect will not be good.
Ranibizumab, the current indication is still age-related macular degeneration, and clinical trials concerning the treatment of diabetic macular edema, pathological myopia, retinal vein obstruction and other diseases will be conducted in the near future. Therefore, currently used to treat these diseases principle listed beyond the scope of the instructions used, but these indications have been approved in foreign countries (China always do things a few steps slower), a large number of clinical applications to prove its efficacy is very good, and there is no other way to have such a good effect, patient friends in the use of this drug to understand this, if you can not understand, to the doctor!
As macular degeneration or diabetic macular edema or venous obstruction, is a chronic disease, the current treatment can not be cured, anti-VEGF drug treatment, in general, is to control the development of the disease, the need for multiple treatments, foreign recommended monthly injections, about 12 times a year, the actual domestic clinical, generally first 3 times, later according to the need to decide whether the need for injection again, this point must This point must be clear, anti-VEGF drug treatment is never a “one-shot”.
Avastin is approved by the FDA for the treatment of rectal tumors and other malignant tumors, but because Avastin is a full-length antibody to vascular endothelial growth factor, its mechanism of treating tumors is to “starve” the tumor, allowing the blood vessels supplying the tumor to shrink, so that the tumor may shrink without blood supply. Since its composition is similar to Lucentis, it has been used to treat macular degeneration and other intraocular neovascularization disorders with good results. Its biggest advantage is that it is much cheaper in price. However, since the drug has no indication for intraocular injection, it is generally not allowed to be used in large, strictly regulated hospitals to treat eye diseases.
Triamcinolone acetonide is a hormone, which can assist in the treatment of intraocular neovascularization and reduce macular edema, but the side effects are cataract and hormonal glaucoma, especially the incidence of glaucoma may be more than 20%, and sometimes surgery is required to control intraocular pressure.
3.What are the side effects and complications of intraocular injection?
A: At present, there is really no particularly good treatment for intraocular neovascularization. The anti-angiogenic drugs mentioned above are one of the best treatments available (in addition to photodynamic therapy). However, any treatment has its limitations. The biggest risk of intraocular injections is the complications associated with the injections, such as: intraocular infections, hemorrhage, and retinal detachment. In addition, complications such as retinal pigment epithelial tears have also been reported. One of the most important complications is intraocular infection, which can have unimaginable consequences with the possibility of blindness. The incidence of infection has been reported from abroad to be about 0.1%. The side effects of the drug itself are not significant. It is generally not recommended to inject anti-angiogenic drugs to pregnant women.
4.Preparation for injection and how to inject?
A: First of all, we should let the doctor determine the need before treatment, and secondly, we should find out what kind of drugs are injected. It is important to understand that anti-neovascular drugs are not currently covered by medical insurance in China, so the cost is not reimbursable. It is important to understand the risks of the injections, and to understand that neither macular degeneration, diabetic retinopathy, nor venous obstruction can be treated successfully in one visit, and multiple injections are required. Sign a consent form for the procedure before the injections are administered. If you have any doubts, do not rush to inject blindly, and it is not too late to figure out before proceeding with the treatment.
Antibiotic eye drops should be administered 3 days before the proposed injection. If you cannot administer eye drops 3 days in advance, you should order eye drops intensively, such as once every 5 minutes, and only then should you inject.
It is best to be accompanied on the day of injection, and it is generally not recommended to inject both eyes at the same time.
On the day of surgery, after registration, payment and signature, you will enter the operating room. In the operating room, the eye is first disinfected, surface anesthetic is ordered, and the drug is injected into the eye at 3.5 mm from the corneal edge.
5. What should I do after surgery?
A: You can open the gauze on the night of surgery, order 3-4 times of antibiotic eye drops before going to bed, and do not wash your face that night. From the first day after surgery, order eye drops for at least 3 consecutive days, at least 4 times a day. Usually you can resume your normal life or work on the second day after surgery. However, if you have obvious eye pain, obvious blurred vision, red and congested eyes, you should contact your doctor immediately or visit the ophthalmology department of your local hospital, mainly to know if there is any infection occurring, and never delay!
6.How many times do I need to inject in general?
A: There is no fixed number of times. Generally, the number of times of treatment for “medium infiltration” will be less, but generally it should be 2-3 times. For macular degeneration, venous obstruction, macular edema of diabetic retinopathy, several times of treatment are usually needed. Overseas it is once a month, and the most has been injected more than 90 times. We have also injected more than 20 times here, mainly depending on the fundus, OCT and fundoscopic imaging. The more injections, the greater the risk, which is the downside of this treatment. There are studies on extended-release devices, but they are far from clinical use.
7.What is the relationship between intraocular injection of anti-angiogenic drugs and photodynamic therapy (PDT)?
A: Photodynamic therapy has been used in China for 7-8 years, and we at Union Hospital are one of the first units to carry out the treatment and have rich experience in treatment. pDT was the only treatment for intraocular neovascularization 3 years ago, and it is indeed effective in closing the neovascularization (see separate article for details) and stabilizing vision. Another great benefit is that there are basically no side effects or complications, the downside is that it is more expensive, about 17,000 RMB to do once. The biggest advantage of intraocular injection is that it is much cheaper and very effective, but the risk is much greater, the most fear is infection, but the incidence is not very high. At present, we promote “combination therapy”, which is PDT combined with intraocular injection for the treatment of intraocular neovascular disease (especially polypoid choroidal vasculopathy), with the aim of achieving better efficacy while reducing the number of PDT or intraocular injections, reducing costs, alleviating the burden of multiple trips to the hospital for families, and most importantly, reducing side effects and the risk of intraocular injections.
Combination therapy is usually done once with PDT, 1 intraocular drug injection within 3 days before or after PDT, followed by a review in 4-6 weeks, and more than 1-5 intravitreal injections as needed, as appropriate.
8.Postoperative situation
(1) Flocculent floaters in front of the eyes immediately after surgery: it may be drugs floating inside the vitreous, do not be nervous.
(2) After the surgery, when you look in the mirror at home, your eyes bleed a lot and even turn purple: this may be a small blood vessel bleeding when injecting, this is not terrible, usually about 10 days to absorb.
(3) the day of surgery go back to the eye is very painful, the eye can not move, a lot of tears, foreign body feeling: may be the role of disinfectant, if indeed the pain can not be tolerated, then need to come to the hospital to see; such as still tolerable, generally the next day can be relieved.
9.I have had several injections and even combined with photodynamic therapy, how come my vision still hasn’t returned to normal, and there are deformation and darkening or improper color?
A: Macula is the most important part of our eye vision, the division of our central vision, color vision and shape vision, so once the macula is diseased, it will affect the visual function very seriously. Sometimes, because the time is too long, the nerve tissue has irreversible damage, or although the lesion is well, no bleeding and edema, that is, we are medically cured, but the scar is left in the center of the macula, so the vision will definitely not be as good as if there was no disease, and there may be visual distortion, which is one of the disadvantages of macular disorders. Moreover, the cause of most macular lesions is not yet known, and the current treatment is still treating the symptoms, so there is a possibility of recurrence. Therefore, I hope the patients can not be too idealistic, everyone’s condition is different, the current science can not reach the degree that can make everyone very satisfied, the condition can not deteriorate sharply, or there is a certain improvement, you should be happy, life should maintain an optimistic state of mind.
10.Young macular degeneration (Stargardt’s disease) and retinitis pigmentosa cannot be treated with anti-angiogenic drugs?
A: No, unless there is neovascular growth. These two diseases depend on future gene therapy, or stem cell therapy, there is no special method.
11.How to treat dry macular degeneration?
A: There is no special treatment method. Suggestions: eat more vegetables and fruits, quit smoking, maintain proper weight, control blood pressure and blood lipids; wear sunglasses when you go out in the sun; supplement lutein-like drugs, but this is a health care drug, available in pharmacies, need to be taken for a long time.
12, other reminders to pay attention to the following issues.
(1) The cause of some fundus disorders like age-related macular degeneration is still unclear, and some of them are clear, such as highly myopic macular degeneration, but there is no way to eliminate it. Therefore, it is not surprising that one treatment is often not enough to solve the problem, because the root of the disease is still there, so multiple treatments are needed, but it is better than no treatment at all. If the lesion is too long, if the damage to the retina is too great, or if there is scarring, or if the macula has undergone atrophic changes, it will be more difficult to restore vision. There are some hospitals or drugs that claim to be able to cure macular degeneration, but I personally think they are not credible.
(2) There are many online treatments for macular degeneration, such as photodynamic therapy, Lucentis and Avastin, so you can read them before going to the hospital and do a little homework so that you will not be too blind.