Dry Macular Degeneration There is no treatment for dry Age-Related Macular Degeneration (Dry AMD), but there are ways to slow the progression for some individuals.  The Age-Related Eye Disease Study (AREDS) showed that people with intermediate stage dry AMD could reduce their risk of progressing to advanced AMD by about 25% by taking a special high-dose formula of supplements, sold without a prescription.

The specific formulation of vitamins  known as the AREDS formula: (Zinc 80 mg, Vitamin C 500 mg, Vitamin E 400 IU, Beta-Carotene 15 mg, and Copper 2 mg) is readily available over-the-counter sold by many manufacturers.  Vitamin supplements are not cures for AMD, nor can they restore vision already lost from AMD.  For dry AMD taking a multivitamin with LUTEIN, eating 3 servings of fruit a day, avoiding snack foods, smoking, and sunlight, and eating fish, spinach, and collard greens has been found helpful.

We strongly encourage you to talk to your doctor about the risks and benefits of these dietary supplements before taking them.  High-dose vitamins, even when sold without a prescription, may present a risk for some people.  

Smokers taking beta-carotene may increase their risk of lung cancer.  High Dose Vitamin E (400 IU) has been linked to 5% higher death rates, bleeding, suppressing the body’s antioxidants and reducing the effect of cholesterol lowering medications.

Expert publication by Dr. Frenkel:

• Katz, RS, Vogel, R, McLeod, K and Fenretinide Study Group
  A Phase II Multicenter, Double-Masked, Placebo-Controlled, Dose-Comparison Study of the Safety and Efficacy of Fenretinide in the Treatment of Geographic Atrophy in Subjects with Age-Related Macular Degeneration: Preliminary Demographic Data and Reasons for Screen Failure
  Invest. Ophthalmol. Vis. Sci. 2009 50: E-Abstract 4918.

Wet Macular Degeneration Treating Exudative Macular Degeneration (Wet AMD) has evolved over the years from a destructive treatment that damaged the area it was attempting to treat to a truly revolutionary therapy that for the first time allows ophthalmologists to halt the progression of the disease without damaging the cells of the macula that are responsible for seeing.

In years past, a thermal “hot” laser therapy destroyed abnormal blood vessels by “burning” it with a high-energy laser.  Scar tissue formed where treatment occurred, creating a permanent blind spot that might be noticeable in your vision.

Photodynamic therapy (PDT) “cool” laser came along thereafter and involved the use of a combination of a medication injected into the arm and a lower-power “cool” laser.  The laser activated the drug, which destroyed the abnormal blood vessels. While it was initially accepted as a better option than thermal laser, it still caused scar tissue. 

In December 2004, the first in a new class of medications Anti-VEGF, became available for the treatment of wet AMD.  The first in it's drug was Macugen, followed by Avastin, and now Lucentis.  These are the first non-destructive treatments for wet AMD.  Rather than using a laser, these medications are injected directly into the eye.  In wet AMD, a protein called VEGF (vascular endothelial  growth factor) causes growth of abnormal blood vessels in the eye, which lead to vision loss.  These drugs block VEGF, therefore halting the growth of abnormal blood vessels.

Avastin approved by FDA in Feb 2004 for the treatment of colon cancer, but is used “off-label” in the eye since Nov 2005. 

Lucentis was approved by FDA in July 2006 and has had promising results.  

Our Wet Macular Degeneration Treatment Strategies

All treatment plans are individualized to each patient to give them the maximum quality of life.    Many factors are taken into account such as:

• How bad is your disease?
• How much difficulty are you having with your vision?
• Is there scar tissue in the center of the macula?
• How conservative or aggressive do you want your treatment to be?
• How difficult is it for you to get into the office?
• What other medical problems do you have? Have you ever had a stroke or heart attack?  If so how recently?  How long might you live?  What is your quality of life?
• Did someone in your family have wet macular degeneration, and if so how did they do? 
• Do you have 2,1, or 0 good eyes?  It makes a difference in what we recommend for you.  For example if one eye is very good and the other has scarring in the center of the macula and has had poor vision for a long time we tend to be less aggressive with the poor eye—but we will never deny you treatment.
• We rarely use laser as it destroys the retina and has a high rate of recurrence of disease
• We usually recommend: Lucentis– (FDA approved) or Avastin or Macugen (FDA approved)
• Monthly treatments are required for certain patients and are more likely to be given if you only have one good eye.
• Treat and Extend philosophy attempts to minimize the number of treatments you receive as long as we can keep your macula dry. We space out your treatments as long as possible.
• As needed philosophy treats you only when you are wet.
• Regular Dose is usually used but some patients don’t respond to it.
• Higher dose is considered in those who stay wet.
• More frequent dose is also considered in those who stay wet.
• We may suggest you go into a clinical trial to get a drug that is only available that way.  Some examples are:
• A new form of Lucentis is being evaluated

• In the VEGF Trap Eye clinical study for wet age-related macular degeneration (AMD) patients gained more vision back when treated monthly with the stronger dose of VEGF Trap than did patients treated with the current standard using Lucentis. Patients treated with the stronger dose required half as many treatments as did the Lucentis patients to maintain their vision.

• Combination therapy

  • Macusight: a drug used in combination with Lucentis
  • Posurdex: also used with Lucentis

Dr. Frenkel teaches other doctors to give Macular Degeneration Treatments safely!

Just published in the Journal of Clinical Ophthalmology, Dr. Frenkel’s article- “A protocol for the retina surgeon’s safe initial intravitreal injections”- provides a comprehensive guide for doctors to inject patients safely. Through the analysis and vast understanding of current methods, Dr. Frenkel provides full explanations on crucial steps that doctors should implement during their procedures. By following this protocol, injections may be performed very safely and with a very low risk of complications.

“The contribution of the paper lies upon its understanding and explaining the crucial steps implemented during the procedure.”

The results in this article not only give confidence to other retinal surgeons, it also encourages all patients who receive these treatments.

Expert publications by Dr. Frenkel:

• Houle, L and Frenkel, REP and Toler, AR: Incidents of Transient NLP Following Macugen Treatment in Patients with Glaucoma and Glaucoma Suspects, Investigative Ophthalmology and Visual Science, 2006. E-Abstract 4276.
• Toler, AR and Frenkel, REP: IOP Effects of Macugen in Glaucoma Patients, Investigative Ophthalmology and Visual Science, 2006. E-Abstract 432.
• Schoenholtz, S, Frenkel, REP, Toler, AR, and Frenkel, MPC. Should We Be Concerned With Post-Injection IOP Spikes From Lucentis? Invest. Ophthalmol. Vis. Sci. 2007 48: E-Abstract 1268.
• Toler, AR, Frenkel, REP, Mani, L., and Frenkel, MPC. Is IOP a Concern Post-Injection of Macugen, Avastin, or Lucentis? Invest. Ophthalmol. Vis. Sci. 2007 48: E-Abstract 74.
• Giuliano, A. . Frenkel, REP, Avery, R, Thomas, G, Toler, AR, and Frenkel, MPC. Contralateral Effect from Intravitreal Avastin for the Treatment of Wet AMD. Invest. Ophthalmol. Vis. Sci. 2007 48: E-Abstract 3365.
• Frenkel, REP, Toler, AR, Mani, L and Frenkel, MPC. IOP Effects of Pegaptanib (Macugen) Injections in Patients With and Without Glaucoma. American Journal of Ophthalmology, Vol 143, June 2007
• Frenkel, REP, Toler, A.:  IOP Spikes Following Anti-VEGF Injections. EuroTimes, September 2007.
• Frenkel, REP, Toler, AR, Mani, L and Frenkel, MPC. IOP Effects of Pegaptanib (Macugen) Injections in Patients With and Without Glaucoma, American Journal of   Ophthalmology, Vol 145, January 2008
• R.E. Frenkel, L. Mani, A. Reyes., Complications of a Surgeon’s Initial Intravitreal Injections, Investigative Ophthalmology and Visual Science, 2008, E-Abstract 253.
• Frenkel, MPC, Frenkel, REP, and Haji, S. The Effect of Prophylactic Use of IOP Lowering Medication on IOP Spikes after Intravitreal Injections. Invest. Ophthalmol. Vis. Sci. 2009 50: E-Abstract 5020.
• Heier, JS and CLEAR-IT 2 Investigators CLEAR-IT 2: Phase 2, Randomized, Controlled Dose-and Interval-Ranging Study of Intravitreal VEGF Trap Eye in Patients With Neovascular Age-Related Macular Degeneration: Predictive Factors for Visual Acuity Outcome at One Year Invest. Ophthalmol. Vis. Sci. 2009 50: E-Abstract 1255.
• Do, DV, and CLEAR-IT 2 Investigators VEGF Trap-Eye Vision-Specific Quality of Life Through 52 Weeks in Patients With Neovascular AMD in CLEAR-IT 2: A Phase 2 Clinical Trial Invest. Ophthalmol. Vis. Sci. 2009 50: E-Abstract 1887.
• Haji, S, Frenkel, R. Phakic Eyes Have a Higher Risk of Developing Immediate IOP Spikes After Intravitreal (IVT) Injection of Anti-VEGF Drugs. Invest. Ophthalmol. Vis. Sci. 2010: E-Abstract 5124. 
• Frenkel, MP, Haji, S, Frenkel, REP, The Effect of Acute IOP Rise on Retinal Capillary Blood Flow, Invest. Ophthalmol. Vis. Sci. 2010 E-Abstract 5123.
• Ronald E. P. Frenkel, MD, FACS, Melvin La, Max P.C. Frenkel, Angela Reyes, BS, A Protocol for the Retina Surgeon’s Safe Initial Intravitreal Injections, In press 2010, Journal of Clinical Ophthalmology

Study: Aspirin prophylaxis has no effect on AMD development

Prophylactic aspirin therapy appears to have no effect on development of new-onset age-related macular degeneration.

Click here to view the full article!

East Florida Eye Institute currently offers the following to treat Wet AMD:

Intraocular injections

Avastin- Avastin is the first U.S. Food and Drug Administration (FDA) approved therapy designed to inhibit angiogenesis, the process by which new blood vessels develop. Avastin was not initially developed to treat your eye condition.  However, ophthalmologists are using Avastin to treat AMD and similar conditions since research indicates that VEGF is one of the causes for the growth of the abnormal vessels that cause these conditions.  Some patients treated with AvastinTM had less fluid and more normal-appearing maculas, and their vision improved.  Avastin is also used, therefore, to treat macular edema, or swelling of the macula. 

Lucentis- Now, there is new hope for many who once faced certain blindness. Lucentis is a prescription medicine for the treatment of patients with Wet Age-Related Macular Degeneration (AMD) and Macular Edema following Retinal Vein Occlusion (RVO). 


Lucentis in clinical trials has been shown to stop and, in many cases, reverse at least some vision loss in most people with advanced AMD. These positive findings clearly make Lucentis by far the most effective FDA-approved treatment currently available for more damaging forms of AMD.

      Proposed Mechanism of Action:

      Lucentis was designed to bind and inhibit vascular endothelial growth factor , a protein believed to play a critical role in the formation of new blood vessels and the likiness of the vessels.

      In wet AMD, blood vessels grow under the retina and leak blood and fluid, causing rapid damage to the macula, the portion of the eye responsible for fine, detailed central vision. In RVO, formation of new blood vessels and likiness can lead to macular edema, the swelling and thickening of the macula.

Clinical Trial: Genentech Study--Harbor- The HARBOR trial is the latest Lucentis trial from Genentech. This trial will be studying how effective different doses of Lucentis are on Wet AMD.

Click here for more information on clinical trials now enrolling for the treatment of Macular Degeneration.

What if AMD cannot be treated?

Normal Amsler Grid	Amsler Grid of Patient with AMD

Diabetic Retinopathy Treatment

Careful observation of the diabetic patient on a regular basis by an eye doctor is crucial in detecting Diabetic changes.  There often is no decrease in vision, though damage from diabetes may be occurring.

As with many diseases, the best treatment is prevention.  Strict control of your blood sugar will significantly reduce the long-term risk of vision loss from diabetic retinopathy.  Laser surgery is often recommended for people with Diabetic Macular Edema, Proliferative Diabetic Retinopathy, and Neovascular Glaucoma.

Laser surgery for Macular Edema

In Laser surgery for Macular Edema, the laser is focused on the damaged retina near the macula to decrease fluid leakage.  Some may see laser spots near the center of their vision following treatment; usually fade with time, but may not disappear.  It is uncommon for people who have blurred vision from macular edema to recover normal vision, although some may experience partial improvement.  The main goal of treatment is to prevent further loss of vision.

Laser surgery for Proliferative Diabetic Retinopathy

In Laser surgery for Proliferative Diabetic Retinopathy, the laser is focused on all parts of the retina except the macula.  This “pan retinal” photocoagulation treatment causes abnormal new vessels to shrink; often prevents them from growing again.  Treatment decreases the chance that vitreous bleeding or retinal distortion will occur.  Multiple laser treatments over time are sometimes necessary.

Laser panretinal photocoagulation  (PRP)  treatment (arrows show laser spots on the retina)

Vitrectomy Surgery

Vitrectomy Surgery for advanced Proliferative Diabetic Retinopathy is needed when the vitreous (white, gel-like substance in middle of eye) fills with blood.  Performed in the operating room, this microsurgical procedure involves removing the blood-filled vitreous and replacing it with a clear solution.  This invasive surgery often prevents further bleeding by removing abnormal vessels that caused bleeding, by additionally treating the eye with laser treatment.

New Treatments

For certain patients, Anti-VEGF treatment (Avastin and Lucentis) is a new choice in controlling Macular Edema, and Proliferative Daiabetic Retinopathy.  Call our office to find out if this treatment option may be right for you.

Dry Eye Disease Treatment

Treatment is based on the cause and severity of the disease ad is customized on a patient by patient basis.  Treatment is targeted at: supplementing the tears, conserving the tears, preventing evaporation of tears, and increasing production of tears. Artificial Tears lubricate the eyes and help replace the natural moisture layer of the tear film.  They are available without a prescription in several different variations; preserved (in a bottle) – not recommended more than 4x a day, non-preserved (in a vial) - can be used as often as necessary and ointments – used mainly at night and which may cause temporary blurred vision Artificial tears lubricate the eye, but they lack the complex mixture of proteins, mucins, and other factors found in normal health tears and are useful for temporary relief. Punctal plugs conserve your own tears and make artificial tears last longer on the eye so that they do not drain out of the eye through small channels into the nasal cavity.

At East Florida Eye Institute we are currently enrolling patients into a clinical trial investigating a new medication for Moderate to Severe Dry Eyes.  Benefits to you are access to new medications, free study related eye exam and medication and you are able to contribute to the advancement of new treatments.  Click on our Current Research and Clinical Trial page for more information. Above all dry eye should not interfere with your lifestyle.  Don’t suffer from chronic dry eye one more day!  Ask about treatment options right for you available at EFEI.

Cataract Treatment

More than 1.4 million people in the U.S. have cataract surgery each year.  More than 95% of cataract surgeries are performed with no complications and improved vision.   You and your ophthalmologist should decide together when cataract surgery is appropriate for you.  Cataract Surgery is usually an Outpatient procedure, performed with local (a numbing block) or topical anesthesia (eye drops) and some sedation through an IV in your hand or arm.

Cataract Surgery A small incision is made close to the edge of the cornea.  A tiny, high-frequency ultrasound instrument is inserted that breaks up center of the lens.  Broken-up cloudy lens material is removed through the incision. An Intraocular lens (IOL) implant is inserted into your eye to replace the cloudy lens. The IOL is customized for your eye; restores focusing power.  The IOL usually placed behind the iris (posterior chamber lens), but sometimes placed in front of iris (anterior chamber lens).

Most cataract surgical procedures are performed without complications and result in immediate improvement in vision.  You will apply eye drops for several weeks following surgery to reduce the possibility of infection and/or inflammation in the eye.  You may need an eyeglass prescription to obtain your clearest vision following surgery.

In a number of cases, the natural capsule supporting IOL can become cloudy after cataract surgery.  A Posterior Capsulotomy, (laser surgery done in the office) can be performed to open  cloudy capsule and restore clear vision. This procedure is normally done in a surgery center but we are able to perform this procedure directly in our office.

Yag Capsulotomy 

 

Lens Implants for Astigmatism

The AcrySof® Toric IOL

Astigmatism is an optical condition that can blur vision at both distance and near. Until recently, patients with significant amounts of astigmatism were forced to still depend on glasses or contacts after cataract surgery or refractive lens exchange surgery to improve their vision.

The AcrySof® Toric Intraocular Lens has advanced technology that can eliminate the cataracts that cloud your vision and correct the astigmatism that distorts your vision all at the same time. In a recent FDA study 97% of patients were able to eliminate the need for glasses to see in the distance and achieved 20/25 or better. Patients enjoy activities like sports, driving, or watching T.V. and movies without the need for contacts or glasses.

 Lens Implants for Night Driving

The TECNIS® Aspheric IOL 

The new TECNIS® IOL provides patients with youthful, clear and crisp vision using wavefront lens technology. It corrects the optical imbalances that reduce contrast in our vision as we age. The major benefit of the lens is the increased contrast of vision in low-light situations such as night driving and the reduction of glare during the day. The functional improvement in night vision makes night driving safer because traffic hazards can be identified more easily.

Multifocal Lens Implants
TECNIS ™ Multifocal and Crystalens®

The TECNIS ™ MF, and Crystalens® implants are multifocal premium intraocular lenses that we recommend for many of our patients who are undergoing cataract surgery. We also recommend these lenses for those who suffer from presbyopia (the need to wear reading glasses), and who want to eliminate wearing contact lenses and glasses. Though they work in different ways, these implants give patients freedom from glasses by correcting both distance and near vision at the same time.

THE TECNIS ™ Multifocal The unique design of this implant reduces optical distortions by using Wavefront technology and optics that make it possible for patients to have reading and distance vision in any light condition. The range of vision includes reading, intermediate, and distance vision. The results are superior to a standard monofocal lens. 94% of patients that have had the lens implanted would choose the lens again!

  

 

The Crystalens® Crystalens, is a revolutionary new breakthrough in vision enhancement. It is the first and only intraocular lens (IOL) replacement that focuses like the eye's natural lens, allowing for continuous vision up close, far away and all distances in between. By using the eye's muscle to move the lens backwards and forwards naturally in response to the brain's desire to see at different distances, Crystalens® enables the eye to focus continuously and seamlessly through a range of distances. Patients experience the same vision they had when they were younger, for most without the inconvenience of corrective lenses. Crystalens® corrects distance vision while reducing your dependence on reading glasses. Past Instructor, American Academy of Ophthalmology, Combined Management of Chronic Open-Angle Glaucoma and Cataract. Expert Teaching experience and publications by Dr. Frenkel: Difluprednate ophthalmic emulsion 0.05% for postoperative inflammation and pain, Michael S. Korenfeld, MD, Steven M. Silverstein, MD, David L. Cooke, MD,  Roger Vogel, MD, Robert S. Crockett, PhD,and the Difluprednate Ophthalmic Emulsion 0.05%, as part of the (Durezol) Study Group, Journal of Cataract and Refractive Surgery, January, 2009, pps 27-34.