What is Avastin ? Avastin is an antibody that inhibits the growth of new blood vessels. It blocks the transmitter called VEGF (Vascular Endothelial Growth Factor), which is involved in growth and development of blood vessels. In the eye, Avastin has been found to be useful in treating conditions where VEGF is thought to be involved. These conditions often involve leaking or bleeding blood vessels in the retina. By blocking the action of VEGF, leakage and swelling in the retina can be reduced and even shut down. Avastin was originally developed for use in the treatment of bowel cancer, and has now been shown to have beneficial results relating to the eye.

How is the injection performed ? The injection will be performed in our operation theatre under sterile conditions. You will be taken to the theatre and few anaesthetic drops will be instilled in your eyes. After few minutes, your ophthalmologist will perform the injection. The outside of your eye will first be cleaned with an antiseptic solution. A small needle is inserted through the white part of your eye and the Avastin is injected into the vitreous (the jelly inside the eye). You may experience a sensation of pressure but the injection should not be painful

Are there any side effects ? Some patients experience a stinging sensation after the injection. This is due to the antiseptic solution and should subside quite quickly. Please inform the nurse if you do experience pain so it can be monitored and documented. Most patients do not experience any other pain following the injection.

What are the risks ? Your ophthalmologist will explain the risks involved with the Avastin injection prior to the procedure. Infection, haemorrhage and retinal detachment may occur in less than 1% of patients who have an injection into their eye. Giving 300 times the dose of Avastin we use in the eye and giving it intravenously in patients with cancer being treated with other toxic agents, the following side effects have been noted:

Doubling of the risk of heart attack and strokes

2% gastrointestinal perforation

Hypertension and proteinuria

Nose bleeds and poor wound healing It is possible these systemic side effects could occur in patients being treated with intravitreal Avastin, but common sense would tell us that it is much less likely to occur if we inject a very small amount into the eyeball, as opposed to giving a large dose intravenously. It has to be emphasised that this drug has not been subjected to a controlled trial and we have no long term data as to its beneficial or adverse effect. Reports to date suggest that it has been effective in preserving vision and in some patients improving it. It appears to be relatively safe. Although rare, you must be aware of the following symptoms which may indicate a complication: Severe Pain: This could indicate a rise in intraocular pressure or an infection.

Discharge: A discharge from the eye could indicate an infection. The eye may also appear red and sw-

ollen or you may feel a burning sensation or itchiness in the eye.

ollen or you may feel a burning sensation or itchiness in the eye. Loss of vision: If your vision suddenly deteriorates or you notice a black shadow/curtain progressing o-

ver your visual field, it could indicate a retinal detachment or further progression of your macular condit-

ion. Remember though, it is normal to see a black "blob" immediately after the injection,which will bre-

ak up over the following week. If you experience any of the symptoms listed, or have any other concerns, please contact us.

Post-procedure Care

You will be given a prescription for antibiotic eye drops which must be administered four times a day for one week.

Most patients do not experience any pain other than a slight stinging sensation immediately following the injection. If your eye feels slightly tender or you experience a mild headache you may take a dose of paracetamol. You should not require any stronger pain relief.

You will have a post procedure check up with your ophthalmologist next day and subsequently depending on your medical condition.





Lucentis (Ranibizumab) Information for the Patients

Eye conditions that may benefit from intravitreal Lucentis injection:

Bleeding source (new vessels) and Macular Oedema (swelling around the macula) that affect vision but have not responded adequately to the usual methods.

Wet age related macular degeneration (Wet ARMD)



Choroidal neovascular membranes ( CNVM)



Diabetic retinopathy.



Central retinal vein occlusion (CRVO)



Branch retinal vein occlusion (BRVO)



Proliferative vitreo-retinopathies.



Cystoid macular edema (CME)



New Treatment

Lucentis is a new form of treatment that is available for the treatment of macular degeneration. Until recently, treatments for macular degeneration could slow the progression of the disease and stabilise or reduce the rate of vision loss. Recently, a new treatment has become available that can result in actual improvement of vision.

What are the risks and complications ? Complications after cataract surgery are uncommon, and most can be treated successfully. Cataract surgery risks include:

Inflammation

Infection

Bleeding

Swelling

Retinal detachment

Glaucoma

Secondary cataract

Loss of vision

Your risk of complications is greater if you have another eye disease or a serious medical condition affecting any part of your body. Occasionally, cataract surgery fails to improve vision because of underlying eye damage from other conditions, such as glaucoma or macular degeneration. If possible, it may be beneficial to evaluate and treat other eye problems before making the decision to have cataract surgery.

What is Lucentis ? Lucentis (also known as Ranibizumab) is a form of medical treatment that has been developed to specifically treat the wet type of macular degeneration. Lucentis is made from a human antibody fragment and was developed by Genetec and NovartisThe drug was approved by the US Food and Drugs authorities in June 2006 .

How Does Lucentis Work ? Vascular endothelial growth factor (VEGF) is a naturally occurring molecule that triggers the growth of new blood vessels and leakage of fluids and molecules from blood vessels. VEGF is responsible for the development of new abnormal blood vessels under the retina. Anti-VEGF therapy blocks the effect of new blood vessel growth and leakage. Lucentis is an anti-VEGF. It works by blocking a molecule (known as VEGF-A) that is thought to be the main form of vascular endothelial growth factor (VEGF) involved in the

formation of abnormal new blood vessels as well as leakage from these blood vessels. Consequently Lucentis blocks blood vessel growth and leakage, which if left untreated would lead to progression of macular degeneration and vision loss.



How is Lucentis used ? An anaesthetic is used to numb the eye prior to the treatment. A small device may be used to keep the eyelids open. Lucentis is injected into the eye once every month. However, close monitoring is required for the detection of any signs of disease activity that would determine the need for re-injection. Following the injection of Lucentis, your eyes will monitored to ensure that it is improving the eye condition and is not causing any harmful effects.

What are the risks ? Some patients experience a stinging sensation after the injection. This is due to the antiseptic solution and should subside quite quickly. Please inform the nurse if you do experience pain so it can be monitored and documented. Most patients do not experience any other pain following the injection. Although rare, you must be aware of the following symptoms which may indicate a complication: • Severe Pain: This could indicate a rise in intraocular pressure or an infection. • Discharge: A discharge from the eye could indicate an infection. The eye may also appear red and swollen or you may feel a burning sensation or itchiness in the eye. • Loss of vision: If your vision suddenly deteriorates or you notice a black shadow/curtain progressing over your visual field, it could indicate a retinal detachment or further progression of your macular condition. Remember though, it is normal to see a black "blob" immediately after the injection, which will break up over the following week. If you experience any of the symptoms listed, or have any other concerns, please contact us.



Tests have indicated that following the injection of Lucentis into the eye, small amounts can enter the blood stream. Although the degree of significance of this is not well understood, patients are carefully monitored for signs of side effects. In the clinical trials, non-ocular serious side effects were also infrequent. Possible effects on the body which are found to be rare includes hypertension, myocardial infarction and cerebrovascular events.



Lucentis should be avoided in patients with hypersensitivity and infections associated with the eyes. Other side effects that have not been mentioned may also occur. It is important to contact your doctor about any side effects that seem unusual to you.

Results of Lucentis Treatment

There is no guarantee that this treatment will be beneficial. Results from controlled clinical trials support the use of Lucentis to treat AMD annd vein occlusions. The results have indicated that treatment with Lucentis in the form of monthly injections resulted in stabilised vision or improvement of vision. Approximately 95% of he participants that received a monthly injection of Lucentis maintained their vision, losing less than 15 letters compared to about 60% of patients who were given the control treatment. Also, up to 40% of participants demonstrated an actual improvement in their vision of at least 15 letters (3 lines) on the eye chart.Trials for treatment of AMD have showed a positive outcome with a significant number of patients having a very good chance of stabilising or gaining vision, combined with reassuring safety results.

INTRAVITREAL TRIAMCINOLONE

Ocyanine Green Angiography (ICG)

Triamcinolone is a long acting synthetic corticosteroid. It can be injected intravitreally.Eye conditions that may benefit from intravitreal triamcinolone:

Intraocular inflammations (Uveitis)



Diabetic retinopathy



Central retinal vein occlusion (CRVO)



Branch retinal vein occlusion (BRVO)



Cystoid macular edema (CME)



The advantage is that it is a quick way of stabilising the vision with relative safety. There are, of course, possible complications of any medical procedure. Intravitreal triamcinolone injection is no exception. However, these problems are rarely serious and there are strategies to deal with them if they occur. The biggest problem with intravitreal triamcinolone is that it does not last and its effect usually wears off after three to six months.

Benefits over systemic/oral administration of steroids

Systemic steroids have been associated with high incidence of side effects ,which include weight gain, increased blood pressure, osteoporosis, and development of diabetes and stomach ulcers. The use of very tiny doses of steroid administered to the inside of the eye limits these side effects as the steroid is administered exactly where it is required.

Steroids may also be used by injection around the eye outside the wall of the eye in the orbit or in the fat of the eye socket. However, because the steroid does not gain access to the uvea, their effect is possibly less than if injected into the vitreous jelly. It should be remembered that steroids given by other routes such as tablets or injections around the eye socket may cause similar complications.

How is intravitreal triamcinolone administered ? This procedure may be done under topical anaesthetic (eye drops) in the rooms. A tiny needle is inserted for a few seconds into the white of the eye and the drug is injected into the vitreous jelly. It is slightly painful but no more than having an injection in the arm. The drug is visible to the patient floating around in the patient's field of vision for about three weeks. It then dissolves and it continues to exert its influence for at least that length of time. The patient is at risk of complications from the treatment and these include:

Infection in the eye

Haemorrhage

Retinal detachment

Cataract

Glaucoma Of these, glaucoma is the most likely occurring in large enough numbers to warrant post-operative pressure checks. However, a slight rise in intraocular pressure does not necessary cause the disease of glaucoma and can usually be managed by eye drops to bring the pressure back down again. Only rarely does glaucoma result. Should the patient have bad pain in the eye after the injection, it is imperative that this be reported to the Eye Doctor as quickly as possible, as it might indicate infection.

Eye conditions which may benefit from PDT:

Chronic central serous chorioretinopathy (CSCR)

Polypoidal choroidopathy ( IPCV)

Wet ARMD

Vasoproliferative tumors.

Visudyne therapy is used to treat a condition where abnormal blood vessels grow in the back of the eye causing central vision loss. The medical name for this condition is subfoveal choroidal neovascularisation.

It is a special type of treatment known as photodynamic therapy (or PDT), which uses a combination of a light-activated drug (Visudyne) and a low-energy laser. The laser activates the drug in a specific area of the eye, and this produces a reaction which seals off abnormal bleeding blood vessels. This is beneficial in slowing the progression of the disease.

Previous treatments with laser have been tried for Wet ARMD, with varying success:

1. "Hot" (conventional, or thermal) laser treatment. This involves using laser to burn the abnormal blood vessels, but also destroys the retina over the new vessels. It uses green light of 514-532nm of high intensity and energy. It is still a useful treatment if the abnormal leaking blood vessels are off to one side of the centre of the macula, (extrafoveal) but it damages the retina permanently, so is not used if the area involved is in the centre of the macula, which is called "sub-foveal". There is about a 50% recurrence of the leaking vessel even after this treatment.

2. "Cold" laser. New lasers have been developed which do not burn, or at least they do not burn as badly as the "hot" lasers. The lasers are not really "cold" but it is a useful name to distinguish them. One such laser is used in an experimental technique called Transpupillary Thermotherapy, which is undergoing evaluation. It uses invisible infrared wavelength of 810nm. Although it delivers some heat, this is very mild, about as hot as a warm cup of tea which you have almost finished drinking, 45 degrees Celsius. The energy from the laser is concentrated over the leaking blood vessel, and the patient can generally see as well after the laser as before, unlike the "hot" lasers, which destroy the retina, and cause instant loss of part of the vision. So it can be used for subfoveal lesions without causing instant damage to the sight.

3. Visudyne (verteporfin) is a drug that can be given into the vein of the arm, and used in combination with another kind of "cold" laser, which has a red 689nm wavelength. Visudyne has been extensively tested on patients with AMD (age related macular degeneration), and also on leaking subfoveal or retinal blood vessels from other causes such as myopia (short sightedness), and has been tried in cases due to other inflammatory causes. The results are encouraging and show that the loss of vision may be slowed down. An angiogram of your retinal blood vessels using an injection of a greenish yellow dye called fluorescein will need to be done to enable Dr Rajeev Jain to determine this.

If you are having Visudyne photodynamic treatment, first we calculate the dose that needs to be injected into the blood, through your arm vein. The visudyne flows up to the blood vessels of the eye. We then shine the "cold red laser" at the lesion under the centre of your retina, and this "activates" the drug, causing it to shrink the leaking blood vessel network. Only a drop of local anaesthetic put into your eye and a large contract lens is necessary. We do the whole treatment in the consultation room, it takes about half an hour and then you can go home. When Visudyne is activated with this laser, it causes the adnormal blood vessels of the AMD to close. In this way, further leakage and bleeding is reduced. Unfortunately these blood vessels tend to reopen and further treatments will be necessary, usually at intervals of about 6 – 12 weeks. Visudyne and strong light or sunshine CAUSES SKIN BURNING, or SEVERE

SUNBURN. This can occur for 1-2 days after injection. DO NOT ENTER SUNSHINE OR BRIGHT LIGHTS, such as the dentist's light, or the surgeon's light, or a solarium, or the bright lights of a photographer's studio for two days. COVER YOURSELF with long sleeve clothing, a hat, sunglasses, suncream, gloves etc but if possible STAY INDOORS FOR TWO DAYS. Wearing sunblock does not completely reduce the risk of light sensitivity from this treatment. Wear long pants, a long-sleeved shirt and a hat when you come to our office on the day of treatment. Avoid driving too, because the eyes will be rather blurry for a few hours after the eyedrops we use for the treatment.

Adverse Side Effects

Visudyne can spill into the tissue of the arm during the infusion into the vein. This may cause you to experience some pain where the injection is being made. This is uncommon, but there may be a rash and the skin covering the leak will need to be covered for several days longer to protect it form light, while the photosensitive dye is absorbed by the body. Some patients experience back pain, or felt sick during the injection. These side effects are fairly mild and go away once the injection is stopped. Unfortunately it is possible that decreased vision, bleeding inside the eye, abnormal vision and eye pain and redness, may occur. Some of these may also be due to the AMD (age related macular degeneration) itself. Other side effects have been reported in studies: headaches, dizziness and a drop in blood pressure. It is always your choice whether you want to submit to any therapy. The doctor may advise you that it is likely to help, but in medicine every person reacts slightly differently. If you prefer, we will continue to care for you in other ways, or offer alternatives, or just monitor your progress. If you start with Visudyne therapy, you can also change your mind.

Eye conditions that may benefit from intravitreal ozurdex implant:

Intraocular inflammations (Uveitis)

Diabetic retinopathy

Central retinal vein occlusion (CRVO)

Branch retinal vein occlusion (BRVO)

Cystoid macular edema (CME)

What is a biodegradable implant ? A biodegradable implant is one that doesn't need to be removed after it's done working. OZURDEX® biodegradable implants use advanced NOVADUR® drug delivery technology, in which biodegradable material is combined with the active drug dexamethasone to form a tiny rod-shaped implant. Inside the eye, the implant is slowly dissolved by the vitreous gel that fills the eye, releasing dexamethasone. OZURDEX® is an implant injected into the eye (vitreous) to treat adults with macular edema following branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO) and to treat adults with noninfectious uveitis affecting the posterior segment of the eye.

What are the risks ? Some patients experience a stinging sensation after the injection. This is due to the antiseptic solution and should subside quite quickly. Please inform the nurse if you do experience pain so it can be monitored and documented. Most patients do not experience any other pain following the injection. Although rare, you must be aware of the following symptoms which may indicate a complication: • Severe Pain: This could indicate a rise in intraocular pressure or an infection. • Discharge: A discharge from the eye could indicate an infection. The eye may also appear red and swollen or you may feel a burning sensation or itchiness in the eye. • Loss of vision: If your vision suddenly deteriorates or you notice a black shadow/curtain progressing over your visual field, it could indicate a retinal detachment or further progression of your macular condition. Remember though, it is normal to see a black "blob" immediately after the injection, which will break up over the following week. If you experience any of the symptoms listed, or have any other concerns, please contact us.



Tests have indicated that following the injection of Lucentis into the eye, small amounts can enter the blood stream. Although the degree of significance of this is not well understood, patients are carefully monitored for signs of side effects. In the clinical trials, non-ocular serious side effects were also infrequent. Possible effects on the body which are found to be rare includes hypertension, myocardial infarction and cerebrovascular events.



Lucentis should be avoided in patients with hypersensitivity and infections associated with the eyes. Other side effects that have not been mentioned may also occur. It is important to contact your doctor about any side effects that seem unusual to you.

How does the OZURDEX® intravitreal implant work ? OZURDEX® is a biodegradable implant containing the corticosteroid dexamethasone. Corticosteroids, such as dexamethasone, block chemical pathways that lead to inflammation, leakage from the retinal blood vessels, and edema. OZURDEX® may help reverse some vision loss that may be caused by diabetic retinopathy, retinal vein occlusion or noninfectious posterior segment uveitis.

How is OZURDEX® administered ? The OZURDEX® implant is so tiny that it can be injected into the eye (vitreous) with a procedure in your doctor's office. Each implant is already inside a special applicator device that is needed to perform the insertion. The implant will be injected into the vitreous humor inside your eye. This is known as an intravitreal injection.

What happens during the injection procedure ? You will be awake during the procedure. Your doctor will follow steps that include ensuring the surface of the eye is clean and numbing the surface of the eye to help keep you comfortable. OZURDEX® is injected using a special applicator device that's about the size of a pen. The applicator is designed to help your doctor deliver OZURDEX® to the vitreous where the medication is needed. The injection will be complete within seconds, and the procedure is generally well tolerated by patients.

Will I receive OZURDEX® more than once ? Your doctor may decide to administer OZURDEX® again if he or she believes that you may benefit from another injection.

Is there anyone who should not be given OZURDEX® ? You should not receive OZURDEX® if you have an eye infection in or near your eye (including herpes viral infection of the eye; vaccinia; varicella; mycobacterial infections; and fungal diseases); if you have advanced glaucoma; or if you are allergic to corticosteroids or to any other ingredient of OZURDEX® intravitreal implants.

Are there any risks with intravitreal injections ? Injections into the vitreous in the eye are associated with serious eye infection , eye inflammation, increased eye pressure, and retinal detachments. In the days following an injection with OZURDEX®, patients are at risk for serious eye infection or elevated eye pressure. If your eye becomes red, sensitive to light, painful, or develops a change in vision, you should seek immediate care from your eye doctor. Also, you may experience temporary visual blurring after receiving an injection and should not drive or use machines until this has resolved. These are not the only risks associated with intravitreal injections. If you experience other side effects, you should immediately contact your eye doctor. Your Retina Specialist will discuss the possible risks with you before performing the injection.

What else should I know about safety and follow-up ? Corticosteroids, such as OZURDEX® intravitreal implants, can cause the fluid pressure inside the eye (intraocular pressure) to increase. This is not something you can feel. So, following the injection, your doctor should monitor your eye pressure. If you experience this side effect, treatment such as medicated eyedrops or surgery may be required to lower the pressure. Some patients who receive OZURDEX® intravitreal implants may develop cataracts or their existing cataracts may worsen. These are not the only risks associated with intravitreal injections. If you experience other side effects, you should immediately contact your eye doctor. It's important to remember that not treating macular edema may lead to irreversible vision loss. You should discuss this issue with your doctor.

What happens during the injection procedure ? You will be awake during the procedure. Your doctor will follow steps that include ensuring the surface of the eye is clean and numbing the surface of the eye to help keep you comfortable. OZURDEX® is injected using a special applicator device that's about the size of a pen. The applicator is designed to help your doctor deliver OZURDEX® to the vitreous where the medication is needed. The injection will be complete within seconds, and the procedure is generally well tolerated by patients.

What is a laser ? A laser beam is made of light of the same color (wavelength) and the light is synchronized so the beam is very focused (coherent). Lasers are useful in treating retinal diseases. Anything you can see inside the eye you can treat with a laser. Laser treatments fall into two major categories: laser used to seal up leaking blood vessels and lasers used to create an adhesion to tack down the retina The laser light can be focused onto the retina, selectively treating the desired area while leaving the surrounding tissues untouched. The absorbed energy creates a microscopic spot to destroy lesions or weld tissues together.

Who needs laser surgery ? Lasers were first used to treat eye diseases in the early 1970's and have become the standard of care for previously untreatable disorders. For many patients, laser can preserve or prevent vision loss if given in a timely fashion. Your eye will almost always look and feel normal with retinal diseases, even when there is hemorrhaging and leakage in the back of your eye. Your sight may also be normal for a while despite the presence of potentially blinding eye problems. The only way to tell if you need laser surgery is to have a careful, dilated retinal examination, often followed by special testing including OCT scanning and fluorescein angiography FFA (a photographic test that evaluates the eye's circulation). Lasers are commonly used to treat the following eye conditions: Diabetic Retinopathy.

Vascular Occlussions.

Retinal tears/ holes and lattices ( Barrage Laser).

Proliferative Retinopathy.

And Others

Diabetic Retinopathy

Diabetes causes circulation problems throughout the body, including the eyes, nerves, and kidneys. The retinal blood vessels are usually like pipes, bringing blood into and out of the back of the eye. In diabetes, however, the vessels may leak, causing the retina to swell and not work properly (diabetic macular edema). Vision is affected when the swelling involves the central vision area. Laser surgery can seal the leaks, thereby preventing further vision loss.

Some patients will have new retinal blood vessels grow to replace some which have closed from the diabetes (proliferative diabetic retinopathy). While this sounds good, these new blood vessels can cause blindness from bleeding and scarring. Laser treatment can often prevent severe vision loss by making these new vessels disappear.

Retinal vein occlusions. The small blood vessels that drain blood from the retina (retinal veins) can sometimes become blocked as part of the aging process. This is more common in patients with diabetes or high blood pressure. A retinal vein occlusion can cause the retina to swell with fluid and blood, blurring central and peripheral vision. Other times, new blood vessels may grow and cause pain with very high pressure inside the eye (neovascular glaucoma). Laser treatment can help reduce this swelling or cause the new blood vessels to disappear.

Retinal breaks and detachment. The retina lines the back of the eye like wallpaper. Retinal tears or rips can occur as part of an aging phenomenon, or following cataract surgery or eye injury. Patients will often see cobweb-like floaters or light flashes when a retinal tear develops. Liquid that normally fills the central portion of the eye (the vitreous) can leak beneath the tear, lifting the retina away from the eye wall. This is called a retinal detachment, which can cause blindness if left untreated. Laser surgery around retinal tears is often able to weld the retina to the underlying eye wall. This can prevent or limit retinal detachment.

Central serous chorioretinopathy (CSC). CSC consists of one or more "blisters" of fluid (serous detachment) beneath the macula. It can cause central blurriness, distortion, abnormal color vision, blind spots, and temporary farsightedness. Although the vast majority of cases will resolve spontaneously, laser photocoagulation is sometimes necessary for persistent lesions.

Ocular tumors. Some patients will have non-cancerous leaking vascular tumors that can cause the retina to swell and not function properly. Laser surgery can destroy these tumors and allow the swelling to go away.

What happens during my surgery ? There are no special preparations before eye laser treatment. You should eat normally and take your regularly prescribed medications before surgery. Retinal laser surgery is performed as an outpatient procedure. Eye drops will be given to dilate the pupil and numb the eye. The treatment is performed while you are seated in a chair, similar to the one used for regular eye examinations. You will remain awake and comfortable. Treatment is usually painless, although some patients may require a numbing injection for discomfort or sensitivity to the laser light.

The laser treatment usually takes less than 30 minutes to complete, and you can go home immediately following surgery. Arrangements for transportation should be made in advance since you may not be able to drive right away.

What are the restrictions and side effects after laser ? There are virtually no restrictions following retinal laser surgery, and you should be able to resume your normal activities and work schedule the following day. Possible complications of laser treatment include temporary burns to the cornea and rarely lens changes. Occasionally an inflammatory reaction which can cause water logging to the sensitive part of the vision and iritis, both can be treated by tablets or drops. A bleed can occur before or after treatment in eyes that require green laser, these usually settle down without treatment. Very rarely scar tissue can form which might be massive and cause loss of vision (others). Unfortunately, sometimes a continuous deterioration of vision can occur despite (rather than due to) laser treatment, due to poor blood flow to the eye nerve or to the seeing part of the retina (macula). Most patients notice no vision changes following their laser surgery, although there may be some temporary blurring for several weeks to months. In addition, depending on the condition being treated, some may notice a permanent blind spot or decrease in peripheral and night vision.