In wet age-related macular degeneration (AMD), abnormal blood vessels grow under the retina and leak blood and fluid. This causes rapid damage to the macula, the portion of the eye responsible for fine, detailed central vision. Avastin (bevacizumab) is an antibody that inhibits VEGF-A, a protein which plays a critical role in the formation of new blood vessels. It was developed for use in cancer and is registered in New Zealand as a cancer treatment. It is very closely related to Lucentis, a medication shown to be extremely effective for AMD and macular oedema from diabetic retinopathy and retinal vein occlusions in clinical trials. A number of trials have shown that Avastin and Lucentis have very similar effectiveness in treating wet AMD.

Cataracts are the most common age-related occurrence in eyes. The lens becomes thicker and stiffer and appears yellow and cloudy. Eventually it may turn white, changing the colour of the pupil. A cataract may cause your vision to become fuzzy in a progressive fashion and may also be the cause of disabling glare. Once a cataract affects vision too much, a cataract removal operation is generally advised. This decision is usually made in consultation with an eye specialist. The operation is almost always done under local anaesthetic. Once the cataract has been removed an artificial lens is put in to replace it. It is relatively short in duration and an overnight stay in hospital is not required. Post-operative care consists of eye drops and a check at 1-2 days then after 2-4 weeks.

This is a complication of diabetes and is caused by small blood vessel damage within the retina of the eye. It commonly affects both eyes and may cause permanent loss of vision. Macular oedema is sometimes also present with diabetic retinopathy. Macular oedema is when fluid leaks into the retina and causes swelling and blurred vision. This may occur at any stage of diabetic retinopathy, but is more common as the disease progresses. There are often no symptoms in the early stages but as the condition progresses vision may begin to become impaired. Often visual loss may be sudden and without warning. This is why it is imperative that at-risk diabetics have frequent eye checks. Poorly controlled diabetes and pregnancy in diabetes are risk factors for developing this condition. Often, first-stage diabetic retinopathy requires no active treatment on the eye but requires stabilisation of diabetes and regular eye examinations. With progressive retinopathy, treatments with either laser or injections may be required. Severe disease with extensive haemorrhage may require a procedure known as a vitrectomy where blood is surgically removed from the eye.

Ophthalmic electrodiagnostic tests provide information about the function of the visual system from the retina at the back of the eye, through the visual pathways to the visual centre in the brain. This information helps the ophthalmologist make a diagnosis and recommend treatment for patients with retinal and visual pathway disorders. Tests take between 30 and 60 minutes. Many people will need a combination of electrodiagnostic tests to give complete information about their visual problem. Electroretinogram (ERG) The electroretinogram is an electrodiagnostic test for evaluating the function of the retina. Electrodes are place on the skin around the eye and a soft gold foil electrode is placed over the lower lid so that it is in contact with the cornea through the tear film. The ERG responses to flashes of light give the ophthalmologist information about any retinal abnormalities. If the flashes of light are changed to a flickering pattern on a TV monitor screen, the resulting ERG waveform gives information about macular disease. Electro-oculogram (EOG) The electro-oculogram tests abnormalities of the outermost layer of the retina, the retinal pigment epithelium, allowing the early diagnosis of some inherited macular diseases such as Bests disease. Cortical Visual Evoked Potential (VEP) The cortical visual evoked potential provides information about the health and function of the visual pathways from the optic nerve as it leaves the back of the eye, to the visual centre in the brain.

This intravitreal injection can be used for (wet) neovascular age related macular degeneration, visual impairment due to diabetic macular oedema, visual impairment due to macular oedema secondary to retinal vein occlusion (branch or central) and visual impairment due to myopic choroidal neovascularisation. Eylea is similar to Avastin and Lucentis but works slightly differently to them. It binds to VEGF significantly more strongly than both Avastin and Lucentis, and also binds placental growth factor (another factor involved in the development of abnormal blood vessels). The medication is delivered by injection into the vitreous jelly which fills the eye. The injections need to be repeated monthly for the first three months, following which the frequency may be reduced, although close monitoring of the eye will still be required, and further injections are likely. It is longer acting and only needs to be injected every two to three months rather than monthly in some cases. It is registered for use in the eye and funded on special authority in selected cases. More information about Eylea is available on the following website: http://www.eylea.com/international/

Fluorescein angiography is a procedure where dye is injected into a vein in your hand or arm and a series of photographs are taken of the back of the eye. This gives important information about the blood vessels and is vital in the diagnosis and management of many eye conditions. After the procedure you will notice a yellow discolouration of your skin and urine for 24 - 48 hours. A few people may notice transient nausea or allergic reactions, but serious ill effects are very rare.

We are the only unit in Auckland with specialists in Ocular Genetics, Electrophysiology, and inherited Retinal Dystrophies. We undertake a comprehensive consultation, including family history and imaging, often with electrophysiology testing, and genetic testing using next generation sequencing technology can be initiated at Retina Specialists. Associate Professor Andrea Vincent is a consultant ophthalmologist in ocular genetics at the Eye Department Greenlane Hospital Te Toka Tumai, Auckland, Te Whatu Ora, and Associate Professor Vincent leads the research team in Ocular Genetics in the University of Auckland and has established the Database of Inherited Retinal and Optic Nerve Disease.

Glaucoma is a group of diseases that can damage the eye’s optic nerve and may result in vision loss and blindness. Multiple factors are often important in causing glaucoma, but it is most commonly related to in an increase in pressure in the eye. Symptoms are generally absent until the condition has progressed to an advanced stage. Very occasionally, a rarer form of glaucoma can develop suddenly and symptoms may then include: headaches and aches around the affected eye, seeing halos around lights, sensitivity to light, blurred vision, nausea and vomiting. You may be more likely to develop glaucoma if you: have someone else in your family with glaucoma already have high pressure in your eye have experienced injury to your eye have or have had certain other eye problems have migraine or circulation problems. Glaucoma is more common in people over 50 years of age. Diagnosis usually comes after consultation with an eye doctor. Signs of glaucoma may also be picked up at an optometrist’s eye examination. The following tests are used to diagnose and monitor glaucoma: Tonometry – measures eye pressure. It is often the first screening test for glaucoma. The eyes are numbed with eye drops and then examined. Dilated eye exam - this is done with an ophthalmoscope (which is a medical instrument that allows the doctor to look through the pupil to the back of the eye).The retina and optic nerve are then examined for any sign of damage. Visual acuity test – test to check distance vision using an eye chart. Visual field test – test to measure side (peripheral) vision. Pachymetry – test to measure the thickness of the cornea. Many other new techniques are emerging to help identify the likelihood of glaucoma and help determine its rate of worsening. Although glaucoma cannot be cured, early treatment can prevent further worsening of the condition and vision loss. Regular eye examinations will need to be continued life-long. Eye drops to decrease eye pressure are the most common early treatment. Surgery may be required, especially if medications are not taking adequate effect. Laser trabeculoplasty, in which a surgeon uses a laser to help the fluid drain from the eye, may be considered in some cases, but has limited effectiveness. More commonly, a trabeculectomy may be performed when other methods have failed to adequately control pressure. This is a medium length operation that makes a new opening for fluid to drain from the eye.

In wet age-related macular degeneration (AMD), abnormal blood vessels grow under the retina and leak blood and fluid. This causes rapid damage to the macula, the portion of the eye responsible for fine, detailed central vision. Lucentis (ranibizumab) is a drug that closes down these blood vessels by inhibiting VEGF-A, a protein that is believed to play a critical role in the formation of new blood vessels. In clinical trials on patients with wet AMD, it was found to prevent further visual loss in 90 - 95% of patients. Up to a third of patients in the trials also experienced an increase in their vision following treatment – something not seen before in the treatment of AMD. In addition, Lucentis has been shown to be effective in improving vision in diabetic macular oedema and macular oedema resulting from retinal vein occlusions. The medication is delivered by injection into the vitreous jelly which fills the eye. The injections need to be repeated monthly for the first 3 months, following which the frequency may be reduced, although close monitoring of the eye will still be required, and further injections are likely. More information about Lucentis is available on the following website: www.gene.com/gene/products/information/tgr/lucentis

Photodynamic therapy uses a light-activated dye (Verteporfin) and a special non-thermal laser. The dye is injected into your arm and concentrates in abnormal blood vessels within the eye. When the laser is shone at the abnormal blood vessels, the dye is activated and the abnormal blood vessels are destroyed, leaving the overlying retina undamaged. Initially photodynamic therapy was used for age-related macular degeneration, but it is less commonly used for this now. However, it is still useful in the management of other eye conditions such as central serous chorioretinopathy. The procedure takes about 20 minutes and may need to be repeated. PDT is relatively painless and you are advised to wear dark glasses and stay indoors for 48 hours after the procedure.

These conditions cause distance blur. In myopia, the eye has a resting focus at a near distance so that people will be able to see objects clearly at some point close to them, whilst the distance is blurry. Hyperopia also causes distance blur but often does not become noticeable until the eye loses its ability to change focus, frequently in middle age. The loss of focus for near distance (presbyopia or “aged sight”) is also related to a decreased ability to change focus but only affects reading. Astigmatism causes an image to be blurry at all distances, but does not affect clarity of images unless it is severe. An optometrist or ophthalmologist can test for these conditions. Treatment is usually glasses or contact lenses which are only obtainable through an optometrist or dispensing optician. Laser surgery and other corrective surgical techniques can also be used to change the focus of the eye to give clarity of sight in suitable patients.

This is when the retina detaches, meaning it is lifted or separated from its normal position within the eye. An acute retinal detachment requires urgent assessment and appropriate treatment. Unless prompt and effective treatment is given, some forms of retinal detachment may lead to irreversible blindness. Signs and symptoms include: a sudden or gradual increase in floaters, deterioration in vision, cobwebs or specks with the visual field, light flashes in the eye or the appearance of curtains over the visual field. You are more likely to have a retinal detachment if you are very short-sighted or have had an injury or previous surgery to the eye. For minor detachments, a laser or freeze treatment (cryopexy) are used. Both therapies re-attach the retina. For major detachment, surgery will be necessary. A band is often put around the back of the eye to prevent further detachment. Surgical treatment is usually a vitrectomy, where the jelly (vitreous) is removed from the eye. This often involves a hospital stay. It can take several months post-surgery to see the final visual result.

A weakness in one or more of the muscles of the eye will cause the eye to turn or move away from the normal focusing position. This is commonly known as a squint. A squint can be corrected by surgery, or by using glasses. Rarely, children may grow out of a squint. Surgical correction of squint usually involves a general anaesthetic. In the procedure, the muscles involved are repositioned to correct the alignment. It is important to recognise and treat a squint as, if left uncorrected, it can result in permanent impairment of vision.

Vabysmo (faricimab) is the first bispecific antibody designed for the eye. It targets and inhibits two signalling pathways linked to several vision-threatening retinal conditions by neutralising angiopoietin-2 (Ang-2) and vascular endothelial growth factor-A (VEGF-A). Ang-2 and VEGF-A contribute to vision loss by destabilising blood vessels, causing new leaky blood vessels to form and increasing inflammation. By blocking both pathways involving Ang-2 and VEGF-A, Vabysmo is designed to stabilise blood vessels. This intravitreal injection can be used for (wet) neovascular age related macular degeneration, visual impairment due to diabetic macular oedema, visual impairment due to macular oedema secondary to retinal vein occlusion (branch or central) and visual impairment due to myopic choroidal neovascularisation. Faricimab is like Eylea but works slightly differently to it. Certain proteins in higher-than-normal levels can cause the growth of abnormal blood vessels or cause damage to the normal vessels at the back of the eye. These abnormal vessels can leak fluid into the eye causing swelling and vision loss. By blocking these proteins Faricimab helps reduce the leakage and thereby might maintain, or may even improve, your vision. Your condition will be regularly monitored by your doctor to make sure the treatment is working properly. The medication is delivered by injection into the vitreous jelly which fills the eye. The injections need to be repeated monthly initially, the doctors will try to treat and extend which may allow for the frequency to be reduced, although close monitoring of the eye will still be required, and further injections are likely. It is registered for use in the eye but is not currently funded by Pharmac. More information about Vabysmo is available on the following website: https://www.roche.com/solutions/pharma/productid-0a6b3497-d8a2-4a5f-a2d4-b0ffa5769fea

Many patients will benefit from Eylea therapy but do not qualify based on the Pharmac criteria. One major group is patients with retinal vein occlusion who do not respond to Avastin. Otherwise, patients with neovascular AMD or diabetic maculopathy who are on frequent Avastin injections and wish to have less frequent injections will also benefit from Eylea but are not funded. The generic name of Zaltrap is ziv-aflibercept. It is the active ingredient of Eylea (i.e. aflibercept) in a different buffer. It is available as a large vial for intravenous use for oncology patients, but in New Zealand, it is repackaged into individual syringes for intravitreal injections by compounding pharmacies. If Avastin does not adequately control the disease process, Zaltrap is a reasonable second-line option if Eylea is not funded. However, one should always use Eylea ahead of Zaltrap, as Eylea is designed explicitly for intravitreal use, and there is a wealth of evidence behind its safety and efficacy. In New Zealand, one should always start with Avastin therapy for diabetic macular oedema and neovascular AMD, the Pharmac prerequisite for Eylea funding. The medication is delivered by injection into the vitreous jelly which fills the eye. The injections need to be repeated monthly initially, the doctors will try to treat and extend which may allow for the frequency to be reduced, although close monitoring of the eye will still be required, and further injections are likely. More information about Eylea is available on the following website: https://www.leosheck.co.nz/post/what-is-zaltrap