Macular degeneration , Macular oedema

Age-related macular degeneration (AMD) is a painless eye condition that leads to the gradual loss of central vision. Central vision is used to see what is directly in front of you, during activities such as reading or watching television for example. The central vision becomes increasingly blurred leading to symptoms including: 1. difficulty reading printed or written text (because it appears blurry) colours appear less vibrant difficulty recognising people's faces AMD usually affects both eyes, but the speed at which it progresses can vary from eye to eye. Read more about the symptoms of age-related macular degeneration. What causes AMD? Macular degeneration develops when the macula (the part of the eye responsible for central vision) is unable to function as effectively as it used to. It is still unclear what causes the macula to become damaged, but getting older, smoking and a family history of AMD are known to increase the risk of developing the condition. Macular degeneration does not affect the peripheral vision (outer vision), which means it will not cause complete blindness. There are two main types of AMD:

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Dry AMD
9. Dry AMD develops when the cells of the macula become damaged due to lack of nutrients and a build-up of waste products called drusens. It is the

most common and least serious type of AMD accounting for around 9 out of 10 cases. 10. The loss of vision is gradual, occurring over many years. However, an estimated 1 in 10 people with dry AMD will then go on to develop wet AMD.

Wet AMD
11. Wet AMD develops when abnormal blood vessels form underneath the macula and damage its cells (doctors sometimes refer to wet AMD as neovascular AMD). Wet AMD is more serious and without treatment, vision can deteriorate within days. Treatment There is currently no cure for dry AMD so treatment is mostly based on helping a person make the most of their remaining vision, such as using magnifying lenses to help make reading easier. There is also limited evidence that eating a diet high in leafy green vegetables and fresh fruit can slow the progression of dry AMD. Wet MD can be treated with a medication called ranibizumab, which helps prevent further blood vessels developing. In some cases laser surgery can also be used to destroy abnormal blood vessels. Treatment for wet AMD does not always lead to improved vision, but can prevent vision from worsening. The sooner treatment is started the greater the chance of success.

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When to seek medical advice

20. If you notice problems with your vision, such as blurring.

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If your vision suddenly gets worse or you notice blind spots in your field of vision,

Who is affected
22. AMD is the leading cause of visual impairment in the UK, with 462,000 people experiencing some degree of AMD. For reasons that are unclear AMD tends to be more common in women than men. White people and people of Chinese ethnicity are more likely to get AMD than other ethnic groups As would be expected by its name, age is one of the most important risk factors for AMD. It is estimated that around 1 in 500 people aged 55-64 have AMD. This rises to 1 in 8 people aged 85 or over.

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Reducing your risk

The best ways you can reduce your risk of getting AMD, or your AMD becoming worse, are: 26. 27. 28. 29. quit smoking if you are a smoker moderate your consumption of alcohol eat a healthy diet high with at least five portions of fruit and vegetables a day try to achieve or maintain a healthy weight

Treatment of Macular degeneration

Lucentis injection
Lucentis, also known as ranibizumab, is recommended for impaired sight in some patients with diabetic macular edema.

NICE, which advises the state-run National Health Service on which treatments represent value for money, rejected Lucentis in 2011 because the drug didnt provide enough benefit to justify the cost. Diabetic macular edema is caused by leaky blood vessels in the eye. Lucentis, an injection, prevents the buildup of a protein called vascular endothelial growth factor that contributes to the leakage. NICE already recommends Lucentis for a separate eye condition, wet age-related macular degeneration. The drug costs 742.17 pounds ($1,210.18) for each injection, according to NICE. Lucentis is given monthly until a patients vision is stable over three consecutive months, and treatment may resume if sight later becomes impaired, the agency said. Novartis will reduce the price, and the size of the discount is confidential, NICE said. The Basel, Switzerland- based company also provided updated analyses showing the drug was more effective in patients with a central retinal thickness greater than 400 micrometers.

Administration
The drug is injected intravitreally (into the vitreous humour of the eye) once a month. If monthly injections are not feasible, the regimen may be reduced to 1 injection every 3 months after the first 4 months. However, dosing every 3 months is linked to a loss of approximately 5 letters (1 line) in visual acuity for the following 9 months as compared with dosing on a monthly basis. Large phase 3 clinical trials which randomized patients with wet macular degeneration showed that 95% of ranibizumab-treated patients maintained visual acuity compared with 62% of those administered placebo (P < .01) at 1 year; moreover, up to 40% demonstrated an improvement in vision of at least 3 lines. Vision maintenance and loss were defined as a loss of less than 15 letters and a gain of 15 or more letters in visual acuity, respectively, as measured using the Early Treatment of Diabetic Retinopathy eye chart.

What are the side effects?

A number of side effects that could be associated with Lucentis include: 1. Eye pain 2. Redness or blood spots in the white of the eye 3. Specks or floaters in the vision 4. Cataracts 5. Increased pressure in the eye 6. Sensation of a presence in the eye 7. Blurred vision 8. Headache 9. Bronchitis The most common side effects in clinical trials were conjunctival hemorrhage, eye pain, vitreous floaters, increased intraocular pressure, and intraocular inflammation. Although there is a theoretical risk for arterial thromboembolic events in patients receiving VEGF-inhibitors by intravitreal injection, the observed incidence rate was low (< 4%) and similar to that seen in patients randomized to placebo. Serious adverse events related to the injection procedure occurred with an incidence rate of less than 1% and included endophthalmitis, retinal detachment, and traumatic cataracts. Other serious ocular adverse events observed among ranibizumab-treated patients (incidence rate < 1%) included intraocular inflammation and blindness.

Is there an alternative drug?

Avastin, trade name of the drug bevacizumab, is a drug that has helped to treat cancers. It works in a similar way as Lucentis in that it helps to inhibit the growth of new blood vessels. Avastin is notably cheaper than Lucentis, but the drug has yet to be tested enough to be approved for use against diabetic madular oedema. A complication is that both Avastin and Lucentis are made by Novartis. With Lucentis bringing higher profits, Novartis has no financial incentive to spend money licensing Avastin for use in DMO.

Why, if they are so similar and made by the same company are the costs so different? The answer is actually quite complicated. In reality, a dose of Avastin for its true indication (cancer) is about $3,000. What happens is that when it is used for treatment of retinal conditions, a compounding pharmacy prepares and aliquots the doses for eye injections (50-60 doses in one vial of Avastin). That is why the cost for a dose for eye treatments goes down. Therefore, Avastin is an anomaly that is quite unique in medicine. A small study showed no superior effect of ranibizumab versus bevacizumab in direct comparison The trial showed that the two drugs "had equivalent effects on visual acuity when administered according to the same schedule

Marketing
On November 3, 2010, The New York Times reported that Genentech began offering secret rebates to about 300 ophthalmologists in an apparent inducement to get them to use more ranibizumab rather than their less expensive bevacizumab. This may have been in anticipation of the results of the CATT clinical trial, which was sponsored by the National Eye Institute, and compared the relative safety and efficacy of ranibizumab and bevacizumab in treating AMD. Some retina specialists consider the tactic bribery.