Age-Related Macular Degeneration Current Treatments and Future Therapies

Thank you so much. It really
is a pleasure to join all of you tonight
on this balmy, summer evening in Palo Alto
at the Hoover Pavilion. I think today's topic
is very important. It's age-related macular
degeneration, an eye condition that probably affects someone
you know.

It's a rapidly increasing eye condition
because our population is living longer. And
it's a disease of aging. What are the key take-home points
of my discussion today? First, I want to share with you some
of the known risk factors for developing age-related macular
degeneration, such as age, genetics, and race. Second, we're gonna go over a simple
classification of age-related macular degeneration, so
you understand what your potential diagnosis is if
you go to an eye doctor, and they tell you you have
a certain stage of AMD.

Third, we're gonna talk about
how untreated wet macular degeneration results in loss
of your central vision. And that's why it's important
to get diagnosed early and get effective treatments
when recommended. Finally, we'll go over how to
obtain a diagnosis and treatment in order to
preserve your vision and your quality of life. The eye
and the sense of vision is so important to all of us.

When
we encounter the outside world to see the beautiful flowers,
to see our friends, or to read books,
we depend on our vision. And many studies have shown that
people value their vision as one of the most important
factors of their health. Let's briefly review the eye
anatomy. The eye is a small, but very complex and
important structure.

In fact, the retina, which is the thin
layer of tissue that lines the back wall of the eye,
is a part of the brain. The front part of
their eye is the clear part called the cornea. And
then the colored part of our eye, the iris, gives you
either blue-colored eyes, brown, or hazel-colored eyes.
Behind the iris sits the lens of the eye.
With aging, you can develop cloudiness of the lens, which
is called a cataract. And maybe some of you know people
or even yourself who've obtain cataract surgery in order
to remove that cloudy lens.

Behind the lens is the
posterior segment of the eye. And there lies the retina,
that thin film of tissue that coats the back wall of
the eye. This is the area that can be affected by
macular degeneration. Age-related macular
degeneration is the leading cause of blindness in people
over 50 years of age in developed countries.

That
means in the United States age-related macular
degeneration is the leading cause of blindness in people
age 50 years and older. 80% Of affected people have the dry
form of macular degeneration. 20% Of the people affected
have the wet form. One might ask, what's the
difference between dry and wet macular degeneration? We'll
review that in just a few minutes.

First, let's briefly
discuss the risk factors for developing age-related
macular degeneration. Numerous scientific studies
have shown that genetics can pay a key role in
the development of AMD. In addition, if you're of
Caucasian ethnicity, you have a higher risk for potentially
developing age-related macular degeneration than someone of
a different ethnicity. And finally, increasing age is
also an important risk factor because we see this condition
in people who are usually 50 years of age or older.
Let's look at the genetics.

What have we learned
over the past five years? When scientists like
myself conducted research on large groups of people,
we found that it's a certain genetic
marker increases your risk for developing age-related
macular degeneration. In fact, that marker is
called complement factor H. And there's a specific
polymorphism that is change in that gene that puts you
at a higher risk for developing macular
degeneration. Complement factor H is
located on chromosome 1.

And an alteration in this
leads to an up-regulation of inflammation, which we thinks
leads and plays a role in the development of age-related
macular degeneration. Patients who are homozygous,
that is, have two affected copies for this risk allele
can have a 7-fold increase risk of developing age-related
macular degeneration. That's significant. What are some modifiable
risk factors for the development of age-related
macular degeneration? As I said, first, our genes,
we can't change that.

That's what we were born with.
Our age, we can't change that too. Our ethnicity, that's
something that we are also born with. But there are some
modifiable risk factors, lifestyles that we can alter
that can decrease our risks. One of the modifiable
risk factors is smoking.

We've learned through numerous
medical conditions that smoking is very dangerous. It
not only increases the risk of lung cancer, but
it also increases the risk of developing age-related
macular degeneration. So the number one thing we
tell patients if we know that they're still active smokers
is we need to have smoking cessation, to learn to
stop smoking. In addition, some studies have also
indicated that an increase in the waist-to-hip ratio
can also increase the risk of macular degeneration,
which means obesity is also a modifiable risk factor.
If we're overweight, it's better to try to
lose that extra weight, not have an elevated
body mass index, because being overweight can
cause numerous problems and can also increase the risk
of age-related macular degeneration.

When you're
concerned about your eye, who do you go to?
>> Ophthamologist. >> Exactly, an ophthalmologist is
an eye medical doctor. The ophthalmologist went
to medical school, is specifically board certified
and trained to evaluate and treat eye diseases. And an
ophthalmologists is trained to do eye surgery when necessary.
When one has a problem in the retina, the tissue in
the back part of the eye And has age related
macular degeneration.

There's a specific type of
ophthalmologist, a retina specialist, who has performed
additional fellowship training to specialize
in the management and treatment of retinal diseases, of which age-related macular
degeneration is one of them. I am a board-certified
ophthalmologist who has done additional subspecialty
training in diseases of the retina. And a retina
specialist is the ideal type of eye doctor you should
see if you're concerned about age-related macular
degeneration. How do we detect AMD? First, when you go to
your ophthalmologist or retina specialist, we do a
careful and thorough eye exam.

This involves first
checking your vision, checking your eye pressure,
and then administering topical drops onto your eye in
order to dilate the pupil. This allows the doctor
to view the retina, which is hidden in the back
part of the eye. When I try to examine the retina, I do
several different procedures. One of which is putting
the patient in a slit lamp microscope, and we use various
handheld lenses to give us a more magnified view of
the retina, in order to see if there is age-related
macular degeneration present.

What is age-related
macular degeneration? In order just, just understand
this pathogenic state, we first have to look at
the normal retina. The retina is in the back part of the eye
and it's a complex tissue. It has different
cellular layers to it. And underneath the retina
is a basement membrane and a tissue called the RPE, the
retinal pigment epithelium.

All of these layers have to be
healthy in order for you to have ideal perfect vision.
In the initial stages of age related macular degeneration,
one develops Drusen which are these yellow aging
deposits beneath the retina. They appear as these little
yellow dots on examination, that are deep to the retina.
When we look at the histopathology of an eye
with age related macular degeneration, we see that
the normal basement membrane becomes thickened. And
these drusen become apparent. When I'm examining
a patient I'm looking for these signs of drusen because
if they're present then this person likely has age
related macular degeneration.

Now, let's review
the classification of AMD. When someone is seen and only
has a few or no small drusen, we classify them as having no
signs of age-related macular degeneration. When someone
has many small-sized drusen, and we define small as
less than 63 microns. 63 Microns is very tiny, we
could only see that under high magnification in a trained
ophthalmologist eyes.

But if you have many small or
a few medium sized, medium are between 63 and
125 microns, then you have signs of early age related
macular degeneration. If one has many
medium size drusen or one large drusen then we put
you in the category of having intermediate age-related
macular degeneration. And if we see other signs,
such as atrophy of the retina or the retinal
pigment epithelium, then you have advanced age-related
macular degeneration. Or if we see bleeding and swelling in the back of the
eye, then you might have wet macular degeneration, which
also puts you in the category of having advanced age-related
macular degeneration.

Advanced AMD, when untreated, will lead to irreversible
loss of your central vision. We wanna prevent that.
Why do we classify macular degeneration? Because
they use different stages, have different prognosis. If one has early age-related
macular degeneration, you have a very low risk,
of losing your central vision in the next five to ten years.
If you are diagnosed with intermediate age-related
macular degeneration, your risk of developing
severe vision loss or advanced macular degeneration
could be 12% in the next 5 years. What do we do
to decrease your risk? One thing we've learned
over the past ten years is micronutrient
supplementation with certain antioxidant
vitamins can be beneficial.

The National Eye Institute
conducted a large, randomized clinical trial involving
thousands of patients with different stages of macular
degeneration. And they found that taking a combination
of these antioxidants, provided some benefit. This
medication which is available over the counter contains
Vitamin C, E, Zinc, Copper, Beta-carotene or lutein and zeaxanthine. Why does it
contain these antioxidants? Scientists hypothesize
thought that because macular degeneration
is a disease of aging, there must be oxidative damage
that occurs in the body and in they eye that contributes
to the formation of AMD.

So over a decade ago, they
tested different antioxidant vitamins in people with
macular degeneration. And lo and behold, they found
that if you had intermediate macular degeneration,
by taking these vitamins, you could decrease your risk
of progression. If we look at this figure, it tells us
a little bit about the result. People who were taking
placebo, that is, the pill without any
antioxidants in it, they had a 28% risk over a 5 year
period of developing advanced macular degeneration.

But when
you took these supplements, your risk decreased to 20%
over the next 5 years, represented by the light blue
line. So there was a small risk reduction in patients
who had intermediate macular degeneration if they took
these supplements everyday. That's become a standard
of care now. If I encounter a patient and I diagnose
them with intermediate macular degeneration, I will
gladly recommend that they take these supplements for
the rest of their life.

Because it will help decrease
the risk a tiny bit, and every little bit helps. How
often should you be examined for macular degeneration?
If you have very early signs, then probably once
a year is sufficient. If you have intermediate
macular degeneration, then at least every six months
with a retina specialist, or more often if you have
new symptoms. Now let's discuss advanced macular
degeneration.

Remember, I mentioned that advanced
AMD leads to severe vision loss if untreated. The most
common cause of severe vision loss is the untreated wet
form of macular degeneration. What are the symptoms?
One might feel that they have reduction
in their central vision or a dark spot, a scotoma in
their central field of view. Sometimes patients complain
of distortion, that is, their friend's face
looks irregular or warped, or there's decreased
contrast sensitivity.

That is, you can't read things
or discern different colors if there's not appropriate light.
Or some people even have a reduction in their color
vision. These could all be signs of the development
of wet age-related macular degeneration. What is wet
macular degeneration? It's the development of
abnormal blood vessels, called choroidal neovascularization,
underneath the retina in an area it should never
develop in. When these abnormal blood vessels sprout
up, they distort the retina, they damage the retina,
they can bleed.

And that's why someone gets a reduction
in their central vision. When I examine a patient and
I see clinical signs of hemorrhage underneath
the retina. Or swelling within the retina,
with the presence of fluid. Or elevation of the retinal
pigment epithelium, which is the layer of tissue
underneath the retina.

That is very suspicious for the development of wet macular
degeneration. How do I. Confirm the diagnosis? After a
careful clinical examination, I'll obtain additional
in-office imaging studies. I often obtain retinal photos,
so color photographs of
the back of the eye, so I can follow the eye over
time, and see subtle changes.

In addition, there's
a non-invasive imaging test, called optical coherence
tomography, OCT. Which is a wonderful,
very fast, non-invasive imaging test, which gives
us a two-dimensional cross-sectional view of
the retina. In this picture, the retina is elevated,
represented by the green line. The red line underneath is the
retinal pigment epithelium.

And instead of being flat and
horizontal, it's elevated, because there's
choroidal neovascularization growing underneath. Another
important test that we do in our clinic is called
fluorescein angiography. An intravenous vegetable dye
is injected in your arm vein, and our photographers
take pictures as the dye goes through
the retinal blood circulation, to outline the blood vessels
in the back of the eye. In this fluorescein
angiogram picture, this eye has wet macular
degeneration.

The bright area represents abnormal blood
vessels that are leaking. These blood vessels
shouldn't be there, and because they're right in
the center of the retina, they're causing reduction in
someone's central field of view. It's important to obtain
a fluorescein angiogram because it tells us where the
abnormal blood vessels are. We can quantify
the size of them, and follow them over time to
understand how they respond to our treatment.

Another
new imaging tool that is available to us at Stanford is
called OCT angiography. This new imaging technique provides
complimentary information, and it's unique because it allows
us to visualize blood vessels without having to put
in intravenous dye. It's a non-invasive imaging
technique based on OCT, but it takes it a step further.
It allows us to visualize normal and abnormal blood
vessels. We can see here, highlighted by the yellow
arrow, this is an area of abnormal choroidal
neovascularization, abnormal wet AMD growing
underneath the retina.

This is another photograph,
showing a color photograph of the retina on
the top. And then the OCT. Angiogram outlining
the retinal blood vessels that are present, and some of
the abnormal blood vessels on the screen left.
Is there a treatment for wet macular degeneration?
Fortunately, there is, over the past decade, we have
developed effective treatments to halt the swelling and
bleeding that's associated with wet macular degeneration.
How did we develop this? We discovered that when an eye
has wet macular degeneration, there's elevated levels of
a certain protein in the eye. This protein is called
vascular endothelial growth factor, or
VEGF for abbreviation.

This is elevated in this
abnormal condition, so scientists like
myself thought, why don't we develop some type
of therapy that blocks this abnormal protein? All of us
need some level of VEGF, but when we have too much, it
causes damage, so we want to cut down that elevated level.
We need to block excess levels of VEGF in order to treat
this condition. Therefore, clinician scientists
developed a treatment, a medication that's
administered in the clinic, as an injection under
topical anesthetic. And it delivers a medicine,
a protein, that locks high levels of VEGF.
It might sound scary to you, I don't want an injection
of medicine into my eye. But this is done in the office
under topical anesthesia, and actually can be a very
comfortable procedure.

It's effective because it delivers
the medicine right into the area where it's needed
without having the medicine go throughout your entire body.
This is a photograph of an eye that's receiving an injection
of a VEGF blocker in clinic. These medicines have been
used since the year 2005. And they'd been proven in
multiple randomized clinical trials to be an effective and
safe treatment for wet macular degeneration.
These injections are given every one to two months,
depending on whether or not the wet macular
degeneration is still active in you eye. Why do they have
to be given so often? Because the medicine only lasts one
to two months in the eye.

Once the medicine wears off, sometimes those abnormal blood
vessels want to grow again and wreak havoc again. That's why
patients need to come back to their retina specialist
every one to two months for reevaluation. And if
the disease is still active, we would recommend another
treatment. You might ask, how many injections on
average does someone need when they're first diagnosed
with wet macular degeneration? If we look at one of our
landmark clinical trials, it lists among these hundreds of
study participants the mean, or the average, number of
treatments through 24 months, two years of being in
this clinical trial.

And we can see when patients were
treated on an as needed basis, they needed about seven
injections the first year. And then over a 2 year period,
they needed about 12 to 14 if, when they were treated every
time the disease was active. So it's not a tremendous
amount of injections. The majority of injections are
necessary in the first year, when the disease is
most active.

But it's important whenever
we detect swelling or bleeding to administer a
treatment. Because without it, those abnormal blood vessels
continue to grow. And when they grow to a large,
large size, they're harder to treat.
Let's look at one of the visual acuity results
from these landmark studies. This graph illustrates the
mean change in visual acuity, from baseline which
as 0.0 All the way to 2 years.

And
we can see that on average, patients gained about five to
eight letters on the visual acuity chart if they
followed up routinely and received the necessary
treatment over a two year period. These treatments
can improve your vision if you follow up diligently
and receive adequate care. If patients are under-treated,
or they're lost to follow up, then they don't obtain these
visual acuity benefits. Let's look at a case.
This is a 68 year old man with a history of dry
macular degeneration, who came to me complaining
of new decreased vision in his left eye.

Previously
the vision was close to 20/20, which is perfect vision.
But now, it dropped to 20/60. On examination I saw drusen
and I saw elevation and swelling within the retina.
So I initially obtained two tests. The top of the screen
shows the fluorescein angiogram. That intravenous
dye test accompanied by the photography of the
retina.

And it shows in that center that ring of abnormal
blood vessels, confirming that diagnosis of wet macular
degeneration. On the bottom, I preformed OCT which gives
us that cross-sectional two-dimensional view
of the retina. And it shows that the retina is
elevated. That huge elevation which normally shouldn't be
present.

This confirms this patient has new onset wet
macular degeneration. That's the diagnosis,
what do you recommend? The number one treatment
is the administration of the eye injection of
the medicine that blocks VEGF. And that's what I recommended
in this particular case. After the first treatment,
there still is elevation.

And we know that most patients
need on average about eight treatments over the first
year. So I resumed additional treatments. And after
multiple, multiple treatments, we can see that there is
flattening of that elevation and a reduction of
the swelling. The therapy is working.

There is still active
wet macular degeneration. So we still need to
continue treatment. But we can see without
this medication we wouldn't have seen that
reduction in the swelling. What happens if you
don't treat wet macular degeneration?
Well, unfortunately those abnormal blood vessels
continue to grow.

And over time scar tissue grows,
that's a bad side. If you have scar tissue in the
retina, unfortunately there is no effective treatment to
remove scar tissue. And that area with the scar
will not improve. And your vision will have a permanent
reduction in that area.

That's why it's important to diagnose
wet macular degeneration as soon as possible and
to receive therapy to prevent scar tissue formation.
I mentioned earlier there's two forms of advanced
macular degeneration. The first is wet
macular degeneration, the second is an advanced dry
form of macular degeneration called geographic atrophy.
Geographic atrophy is the name we use when there's dry
macular degeneration that's accompanied by thinning of the
retina, atrophy of the retina, and loss of pigmentation. That
can cause irreversible vision loss. The retina has to be
of normal thickness for one to have perfect vision.
If the retina is too thick, swollen, your vision
decreases.

If it's to thin, if there's atrophy,
your vision is decreased too. Just like the muscle
in your body. If you have muscle atrophy,
that muscle is weak. So that's why there's two forms of
advanced macular degeneration, the geographic atrophy or
the wet macular degeneration.

Geographic atrophy sometimes
it's difficult and challenging to diagnose
because we're looking for subtle signs of atrophy
in the retina and loss of pigmentation. We have
special photography machines called fundus autofluorescence
which allow us to take this special black and white
photograph. If there's a loss of pigment it appears
as a large black spot. This person has an advanced
form of geographic atrophy because there's this large
piece of tissue missing.

Loss of the pigment, loss
of the retina in that area causing atrophy which is
picked up in this special imaging device. Unfortunately,
at this time, there is no effective treatment for
geographic atrophy. Right now, we are conducting clinical
trials at Stanford and throughout the world, looking
at novel treatments to test for treatment of geographic
atrophy. It's also important if you have geographic atrophy
to still follow-up with your retina specialist because
eyes with this advanced form of macular degeneration could
still develop wet macular degeneration too.

Even though
we can't treat the atrophy, if one develops wet
macular degeneration, we still wanna treat that to
minimize vision loss from that form of advanced macular
degeneration. What are some new treatments on the horizon
for wet macular degeneration? Although those injections to
block VEGF are very effective, we want even better therapies,
because we know some people don't necessarily
gain ten letters of vision when they're treated
with these eye shots. So we're looking at new medicines
with longer duration of action that might allow patients to
come in every three months to the eye doctor,
rather than every month. We're also evaluating stem
cell therapy to see if that would provide benefit
in macular degeneration.

And we're also looking at
gene therapy to see if that would be beneficial.
All of these new exciting clinical trials are being
conducted at multiple clinical centers throughout
the United States and also at the Byers Eye Institute at
Stanford University. In summary, tonight I think we've
discussed some many important aspects of age-related
macular degeneration. We reviewed the risk factors,
such as age, genetics, race, smoking, obesity. We learned
the classification of early, intermediate, and
advanced age-related macular degeneration.

We also
discussed that untreated wet macular degeneration
causes severe vision loss. And that's why it's important
to receive early diagnosis because we have
effective treatments. And we need to follow up closely
with our retina specialists and ophthalmologists to
obtain early diagnosis and treatment if we want to
prevent vision loss. I'm very fortunate to
work with outstanding colleagues at the Byers Eye
Institute which is located at 2452 Watson Court, off of
101 and Embarcadero road.

We have a full service
comprehensive eye clinic that can properly diagnose
all eye conditions. We specialize in macular
degeneration, and have all the state of
the art treatments and diagnostic tools available. I encourage you, all of you,
to have your eye examination with your local
ophthalmologist or with one of our ophthalmologists at the
Byers Eye Institute. Because early detection and treatment
is so vital to keeping and preserving your eye sight.
Thank you very much for allowing me to share this
information with you tonight.

And I'm happy to answer any
questions you might have. >> [APPLAUSE] >> Great we have a question in the back.
>> At what stage do you start recommending the injections?
>> The question is at what stage do we recommend those eye injections.
Those eye injections are only effective to treat wet macular
degeneration. So one must have a diagnosis of wet age-related
macular degeneration in order to receive benefit from these
injections. If you have dry or intermediate macular
degeneration, those injections
are not effective.

Yes, this lady first.
>> How does blood pressure come into effect with macular
degeneration, the wet kind? >> The question is, does blood pressure play
a role in the development of macular degeneration,
especially the wet form? Right now blood pressure is
not a proven risk factor for developing macular
degeneration. High blood pressure, however,
can damage the blood vessels in the retina, and
also lead to vision loss through a different mechanism.
So it's important if you have hypertension to keep it
under control, because high blood pressure can damage your
eyes in ways different than macular degeneration can.
>> Thank you.
>> Yes, question here first.
>> Can you have macular degeneration that
isn't age-related? >> The question is, can you have macular
degeneration that is not age-related. Yes you can.
Macular degeneration can be a general term.
And in tonight's talk, we were specifically dealing
with age-related macular degeneration. But
I do encounter in my clinic, people who are younger,
who are 30 or 40, who have changes in their macular due
to another condition.

But it causes degenerative changes
as well that's not related to this type of genetic
predisposition or age. And some of those have
effective therapies, but they need to be diagnosed.
Other question? The gentleman, on that side?
>> If you have it in one eye, are you probably gonna get
it in the other eye too? >> The question is, if you have
age-related macular degeneration in one eye will
you develop in the fellow eye. Most likely yes, age-related
macular degeneration is usually a symmetric condition.
So when I encounter a patient, usually they have
signs of drusen, those yellow aging deposits
in both eyes. One eye may be a little bit more severe,
more advanced than the other.

If one develops wet macular
degeneration in one eye, the risk in the fellow
eye also increases, that's why it's important to
see you retina specialist often. Question, the gentleman
here with the tie? >> Have you seen anyone radically change their
diet and cause reversal? >> The question is, can you cause reversal of
macular degeneration by radically changing your diet?
That's a great suggestion. But unfortunately, dietary changes
only help a little bit. They will not reverse.

What's
already happened. So it's not sufficient enough just to
change your diet. You know, a lot of these risk factors
as I mentioned, genetics, ethnicity, age, even if you
change your diet, you can't modify those risk factors.
And those are stronger risk factors to the development
of macular degeneration. Yes, this lady here.
>> The dry early stage, if one sees an opthamologist
every year, is it still necessary to see
a retina specialist as well? >> Yes, the question is, if you have the early stage
of macular degeneration and you're already seeing
an ophthamologist, is it necessary to see
a retina specialist? I think if you only have early signs
of macular degeneration and you've been seen by
an opthamalogist that, that is probably sufficient.
If you have intermediate or wet macular degeneration,
then I would say it would be very important to
see a retina specialist to confirm the diagnosis.
And then, if you have wet macular degeneration
to obtain treatment.

Yes?
>> [INAUDIBLE] they took down a circular recently
regarding the supplements. [INAUDIBLE] >> Yep, the question is, if you're taking
a certain vitamins, will it interfere with these
micronutrients tested in the age related eye disease? Multivitamin. And we found
that taking that combination was safe and didn't provide
any additional harm. So, You have the intermediate or
advanced form.

Gentleman over there?
>> You mentioned both the possible weight related,
as well as vitamin related benefits. To what degree could
exercise benefit or prevent the onset of adva, age related
macular degeneration and how would the mechanism
work for these? >> Yes, the question is, will exercising, keeping
healthy, reduce the risk of developing macular
degeneration? Right now there's no current evidence to
suggest that exercise alone would reduce the risk of
macular degeneration. Certainly exercise,
I think, is very beneficial to the body. And would help
decrease that modifiable risk factor of that increased
waist to hip ratio, the body mass index.

So
I think exercise is good for your general health and
probably helps keep, you know,
your your blood pressure, your cholesterol, all these
signs that if abnormal can lead to more inflammatory
damage in your body. Certainly that could contribute to some
of the oxidative damage that could occur in macular
degeneration. So keeping a good weight,
being healthy, makes sense. Good, yes sir?
>> Yes, I have like a two part question.
>> Sure.

>> But the first part is, with what's the progress
with respect to the stem cell research?
And how, how far have they gone-
>> Yeah. >> And to what extent? So that's my first question.
>> Great, the question is, how far has stem cell
research progressed? Right now, stem cell research
is still in its early stages, so it's not widespread yet. There are complications with
conducting stem cell research. First, the source of the stem
cells and are they safe to use in human eyes?
So it's still in its infancy, but we are hopeful that there
might be breakthroughs with stem cells especially to
regenerate tissue that's atrophied.

So we're hopeful.
>> Okay, this is the second question. With respect to
what the individual can do. >> Yes. >> Is it possible to introduce things
like eye exercise or even where you rotate the eye
or you exercise your own eye? And possibly
lubricants using heat, cold, lubrication, lotion,
whatever that would take? >> Yes, the question is, are there eye exercises,
or creams, or lotions that you could do
to your eye that would help decrease the risk of macular
degeneration? Unfortunately, there are no eye exercises or topical ointments that
are effective.

In the past, we've reserved some eye
exercises to adults who have a misalignment of their eye
muscles, where they need to kind of refocus their line of
sight to prevent their eye muscles from being misaligned.
Eye exercises have not been proven to help
in macular degeneration. In addition, topical ointments
also have not been proven to be of benefit in macular
degeneration. Question from the gentleman to the right.
>> What is the probability rate of dry macular
degeneration advancing to wet macular degeneration?
>> Yes, yes. The question is,
what is the risk, or the rate of dry macular
degeneration progressing to wet macular degeneration? It's
hard to give a general rate, because it depends on
the clinical features we see on examination.

For
example, I mentioned drusen, those yellow aging deposits.
If one has large drusen, so the larger the drusen
the slightly increased risk of progression of the macular
degeneration. In addition, if the back of the eye has
a lot of pigmentary changes, hyper and hypo-pigmentation,
that also increases the risk. And as we mentioned, if you
have wet macular degeneration in one eye, the fellow eye,
even though it has dry macular degeneration, the risk
increases of developing wet. So it's an individualized
number that can only be given when you're sitting in
front of me in the clinic and I'm evaluating both eyes, and determining those
individual risk factors you have.

Yes sir?
>> [COUGH] In my treatment of my case-
>> Yes, yes. >> Which is wet AMD, the vitreal injections
cause tremendous pressure in the eyeball.
Is, can that be avoided by another treatment other
than the injections? Or can it be [INAUDIBLE]?
>> Yes, this question was, in his particular case, thank
you for sharing it with us, he has wet macular degeneration
and he's been receiving those intravitreal injections to his
eye. When he receives these medications, he feels
an elevated pressure sensation in the eye that's very
uncomfortable. And he's wondering if there's
any way to avoid that.

There are multiple techniques
to administering the eye injections. And
sometimes depending on which technique is used one might
feel more pressure or a little bit more
uncomfortable sensation. I try my best in my patients to be
very gentle, very attentive, to provide very sufficient
amounts of topic anesthetic. So that they're
very comfortable, as comfortable as they can be.
So I would just recommend that you speak to your retina
specialists and convey those symptoms you're having and
be honest with them.

So they can try to work
with you to try to make it a more comfortable experience.
But right now, there's no other way of administering
those medications other than that in office injection.
A question in the back, the back row?
>> I have a [INAUDIBLE] macular degeneration and
I have I think three different types
of eye drops. And I I have a thicker
cornea than average and so I wonder when
putting in the drops, can you give some advice
[INAUDIBLE] penetrate through the cornea
which takes time. And I wonder if
you can give some advice on how to take
the drops and the intervals between them etc.
>> This gentleman told us that he has macular degeneration,
but he's also taking three types of eye drops. And he is
wondering what's the best way to administer these eye drops.
First of all the eye drops you were taking probably
are not a treatment for the macular degeneration.

It
might be for another condition you have sir, is that correct?
>> No it's macular degeneration.
It's [INAUDIBLE] and [INAUDIBLE]
>> Yeah the drops that you mentioned, and I'll repeat
the name brimonidine. That's a treatment for
elevated eye pressure, or a condition called glaucoma.
Which is a distinct entity from age
related macular degeneration. Because right now there's
no effective eye drop that treats macular
degeneration. The eye drops, in your case, are to
treat high eye pressure, which is a different
condition.

The treatment that you're undergoing for
your high eye pressure, the best way to administer the
drops is to tilt your head up, use one hand to pull
down the lower lid. The lower lid acts like
an envelope, and you can drop the eye medication into
the little lower lid envelope, rather than needing to drop it
right in the center surface of the eye. That's the best way
of preventing that eye drop from rolling down your
cheek and then not really going to the area. But
the eye drops you're on is for probably a condition
called glaucoma and not age related macular
degeneration.

Yes, there's a question in the back.
>> Yes, I don't have MA, but how often should I have mine?
>> The question is, how often should she have an
eye exam if she does not have age related macular
degeneration? The American Academy of
Ophthalmology recommends that everyone who is older,
usually 40 years of age or older, have an eye exam
at least once a year And depending on what your
ophthalmologist finds, you might need to be
seen more frequently. But that's important,
because besides looking for age related macular
degeneration, you could have other
eye conditions. If you had diabetes, you could
have diabetic eye disease. You could have cataracts,
you could have glaucoma.

There are many different conditions
that can arise in the eyes and early detection is
very important. Yes, maybe the gentleman
in the middle, hi. >> When treating the wet macular degeneration
with injections, there was an indication
that with time the number of injections
per year go down, do we ever get to zero?
>> The question is, in the studies it seemed
to indicate that if you're receiving those injections for
wet macular degeneration, the number of treatments
decrease over time. And will there ever be a need for
no injections.

We followed patients for
over a decade now and there are some patients who after
several years of treatment their wet macular degeneration
becomes inactive. But there are also many patients
where they have kind of a waxing waning horse. Where
it becomes a little inactive for a few months but then it
might become active again. So there are many patients who
need chronic evaluation and chronic treatment.

Maybe not
every month and maybe every three or four months they come
in because their duration of disease is inactive for
longer periods of time. But they do have these little
recurrences. A question in the far back there?
>> Is there a difference in outcome between the off-label
[INAUDIBLE] and the [INAUDIBLE]
>> Yes, the question, the question is, is there a difference between
these anti [INAUDIBLE] agents because there are some that
are on label or FDA approved. And there's one that's off
label or that's in use but not FDA approved.

Currently
there are three different anti-VEGF agents that can
be injected into the eye. Fortunately the bottom
line is all of them are very effective. So
you can't go wrong with either of those three choices. Two
of them are FDA approved and one of them is not.

Now in
medicine, there a lot of treatments and medicines are
available that are off label, that is they were developed
from one indication. But physicians found out that they
work for another disease, and they're effective. So there
are many medications that you might be on right now that
are off label. So for most of my patients I'll say that
any three of those medications are very effective.
And there has only been no real definitive
data to suggest that in age-related macular
degeneration, one is clearly superior than the other.
In some individual cases patients respond better to one
medicine than the other.

So it's an individualized
approach that we have to take. Yes, the gentleman
in the back. >> So my understanding, correct me if I'm wrong,
is that you can only differentiate between
the wet and the dry types of macular degeneration when
you get to the advanced stage. So that the early and
the intermediate, you can't tell the difference?
Is that correct? >> The question is, can we distinguish between
the early, intermediate, and advanced forms of macular
degeneration? Fortunately, we can and only a trained
ophthalmologist or retina specialist can do that
because a lot of that is based on clinical examination
skills with ancillary imaging tests
to confirm it.

So yes, when I see patients,
I can diagnose them with early macular degeneration or
intermediate or advanced, depending on what I see on
clinical examination. And depending on that diagnosis,
it will affect my recommendation on when
they should return to see me. If they have early
macular degeneration, I'll say you could
come back in a year. If they had intermediate,
I'll recommend six months.

If they have wet, then I'm
treating them that day and then having them come back
in a month. Question, sir, yes.
>> Are there any, specifically Internet
mediated clinical studies or trials in any language or
country that you know about would lead to advances
in age related macular degeneration benefits?
>> The question is, is there any thing on the
Internet that would be helpful in advancing research
knowledge of macular degeneration? Many
of you are Internet savvy, of course, we're living in
Silicon Valley. And there's so much, when we use a search
engine like Google and we look up age related
macular degeneration, there are gonna be thousands,
thousands of references you could look at. But
be careful of what you read.

Because not everything
that's on the Internet has been approved or reviewed
by the American Academy of Ophthalmology, or the American
Society of Retina Specialists. So you have to be careful
of what you read. As you said, there's a lot
of fake news out there. And there's a lot, [LAUGH] so
apt in this time, day and age.

And there are a lot of people
who are taking advantage of patients who are desperate
for medical cures. If you see an ad on the
Internet that says stem cell therapy effective for macular
degeneration, fly here and pay, you know, x amount of
money. I would tell you, please do not do that for your
safety. Because if it's an FDA.

Approved treatment, your
insurance will pay for it. You shouldn't have to
pay out of pocket. And there currently is no
effective stem cell therapy. So I think you have to discuss
with your ophthalmologist or retina specialist, and
reliable reading aids.

Many of them are on
the American Academy of Ophthalmology website. I would recommend that.
>> I think we're right at 8 o'clock, so.
>> Great. >> Thank you very much. >> I thank you all for coming tonight.

I really
enjoyed discussing this important topic
with all of you. I hope you learned something
tonight. I'd be happy to talk with you at a future
date. Enjoy your evening.

Thank you very much.
>> [APPLAUSE].

Labels: CURRENT

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