Treatments for Macular Degeneration

Dry Macular Degeneration Treatments

There were two very large studies by the National Eye Institute involving multiple locations and universities around the United States which were called Age-Related Eye Disease Studies (AREDS and AREDS 2). The first AREDS 5-year study was completed in 2001. The studies found that taking certain supplements can slow the progression rate of macular degeneration.

  • AREDS 1 Formula
  • Vitamin C – 500mg
  • Vitamin E – 400 IU
  • Beta-carotene – 15mg
  • Zinc – 80mg
  • Cupric oxide – 2mg
  • AREDS 2 Formula
  • Vitamin C – 500mg
  • Vitamin E – 400 IU
  • Zinc – 25mg
  • Copper – 2mg
  • Omega-3 fatty acids – 1000mg
  • Lutein – 10mg
  • Zeaxanthin – 2mg

No beta-carotene (beta-carotene has been shown to increase the risk of lung cancer in current and former smokers)

These formulas resulted in a decrease of 25 percent or more in certain groups of individuals over 5 years in the progression of macular degeneration.

Other Things that Reduce the Risk

  • Exercise
  • No smoking
  • Healthy diet that includes lots of green vegetables and fish
  • Try to stay away from packaged foods as most contain omega-6 fatty acids
  • Maintain good health such as control blood pressure
  • If you take a multivitamin you should still take an AREDS formula supplement
  • Wear sunglasses

Genetic Testing for Macular Degeneration

Some recent studies have shown that certain genotypes will benefit from AREDS supplements and others could be harmed. These are only a couple studies related to a portion of the AREDS research. NEI investigators have completed thorough and comprehensive analyses of the complete AREDS study information and those findings support the use of AREDS supplements in all tested genotypes. Based on all the data, the American Academy of Ophthalmology does not support the use of genetic testing to guide the treatment of macular degeneration.

Treatments for Wet Macular Degeneration

Wet macular degeneration without treatment almost always results in severe vision loss. Not that long ago there was no hope. The only treatment available was laser treatment to the underlying abnormal blood vessels. This laser destroyed the blood vessels but also damaged the surrounding retinal tissue. It did decrease the risk of losing vision but also could cause a loss of vision from the treatment. This type of laser treatment is not used today in the treatment of wet macular degeneration. As stated before, abnormal blood vessels growing under the macula is what causes wet macular degeneration. A chemical called vascular endothelial growth factor causes the abnormal vessels to grow. Today, people can maintain their vision with the advent of anti-vascular endothelial growth factor (anti-VEGF) injections. The anti-VEGF injections inside the eye causes the blood vessels to shrink and in many cases the vessels go away. There are several anti-VEGF drugs, but the three most common are Lucentis, Eylea, and Avastin. Macugen is not used very often. The differences between the drugs is considered insignificant by many eye doctors. The injections are usually given once a month in the beginning and some times can be decreased once the blood vessels have been completely treated. These injections are the mainstay of the treatment of wet macular degeneration.

Lucentis (Ranibizumab)

Lucentis received FDA approval in 2006 developed by Genentech. One study showed that the vision was stabilized or improved in 95 percent of patients. The injections of the medications are injected into the back of the eye usually on a monthly basis in the beginning.

Lucentis (Ranibizumab)

Eylea (Aflibercept)

Eylea is manufactured by Regeneron Pharmaceuticals Inc… There may be some advantage of using Eylea as it may needed to injected every 2 months instead of every month.


Avastin (Bevacizumab)

Lucentis and Eylea have received FDA approval for the treatment of wet macular degeneration. Avastin was FDA approved as a treatment of colon cancer in 2004 and has been used by eye doctors to treat wet macular degeneration “off-label”. Many eye doctors use the drug instead of the other FDA approved drugs for wet macular degeneration. There is a big controversy as Avastin is not FDA approved for wet macular degeneration but the results of using Avastin is very similar to the other drugs. Eylea and Lucentis costs between $1,700.00 to $2,000.00 per injection or treatment. Avastin costs approximately $50.00 per injection. The controversy is using a drug “off-label” verses an FDA approved drug. Price can be a significant factor in treating patients. The manufacturers of Lucentis and Eylea do offer some assistance for some patients in need.

Avastin (Bevacizumab)

Side Effects of the Anti-VEGF Treatments

You should not have an injection if there is an eye infection present or an infection near the eye.

Common Side Effects

  • Redness of the eye
  • Hemorrhage on the surface of the eye
  • Eye pain
  • Cataract
  • Floaters in the vision

Less Common Side Effects

  • Eye inflammation
  • Retinal detachment
  • Eye infection
  • Increased eye pressure right after the injection or may occur after repeated injections
  • Risk of blood clots leading to a heart attack or stroke

Other Possible Treatments for Wet Macular Degeneration

Photodynamic Therapy (PDT) with Visudyne™

PDT is a two-step treatment protocol in which a drug called Visudyne is injected intravenously and then a non-thermal laser light is projected into the eye. The Visudyne drug is activated by the laser light. The Visudyne drug causes selective shrinkage or destruction of the leaking abnormal vessels and leaves the normal vessels intact. This procedure may be used in combination with Anti-VEGF injections.

Macular Translocation Surgery

Macular translocation surgery involves lifting up the retina in the macula and moving it slightly to a new location with underlying normal tissue. It has shown to be useful in some people if done early during the onset of wet macular degeneration. It is unlikely to become a standard treatment for wet macular degeneration.

IRay Radiotherapy System

The IRay Radiotherapy System uses three low-energy beams of x-ray radiation. The small 3.5mm beams are delivered one after the other through three different locations on sclera or white portion of the eye at the 5,6, and 7 o-clock positions on the eye. The low energy beams mean a longer duration of time and the necessity of keeping the eye absolutely still during the treatment. Each of the three beams may last as long as 4 minutes. A special contact lens is placed on the eye with a very small post attached to the front of the contact that is attached to the machine. This keeps the eye in proper alignment. The results of a recent study showed that there was a 45 percent reduction in Anti-VEGF injections to keep the macula stable. Fifty percent of patients only required one injection in two years following the treatment. Twenty three percent required no injections. At the time of the writing, the IRay Radiotherapy System is only available in England and Switzerland.

SalutarisMD Treatment

SalutarisMD treatment is a radiation-based treatment for wet macular degeneration. A very small curved instrument that contains a tiny amount of radioactive strontium 90 sealed in the tip of the instrument is used for the treatment. The eye is dilated and the eye is anesthetized. The eye doctor passes the instrument around the eye between the eye muscles to the back of the eye. There is a fiber optic light on the tip of the instrument for guidance. The tip of the instrument is placed up against the back of the eye in the area of the macula. A five- or six-minute dose of beta radiation is applied to the macula. At the time of this writing, the treatment is still under investigation in the United States.

Submacular Surgery

In patients that have a large hemorrhage under their macula, the eye doctor may choose to operate on the eye to remove the blood under the macula. This large amount of blood will most likely result in significant scarring in the macula. The surgery needs to be done very soon after the hemorrhage has occurred. This procedure is not performed often in the United States today.

Research on New Treatments for Macular Degeneration

Complement Inhibitors

There is a class of drugs called complement inhibitors. These types of drugs are under investigation for the treatment of macular degeneration. There is a connection between the immune system and macular degeneration. The complement cascade is composed of a group of proteins present in our blood. The retina can activate this complement system resulting in inflammation and death of cells in the retina. Some of the studies have failed to show any improvement in the treatment of advanced dry macular degeneration. A recent study has reported phase II trials which show significant slowing of the progression of advance dry macular degeneration. The drug inhibits the activation of C3. The drug is injected into the back of the eye monthly. These complement drugs are also being tested in wet macular degeneration.

Stem Cell Transplantation for Macular Degeneration

Early Detection of Macular Degeneration

Most people have had macular degeneration for several years before it is diagnosed. It is believed that the sooner it is detected the better. Night vision and the ability of the eye to adapt from light to dark is diminished in people with macular degeneration. Therefore, measuring dark adaptation can allow the eye doctor to diagnose macular degeneration early in the disease process. MacuLogix received FDA approval for their device called AdaptDx Dark Adaptometer.
The instrument is like a stress test for the retina. The patient places their chin on the chin rest in front of the instrument. The lights are turned off and the patient stares into the instrument. The patient holds a response button in their hand and stares at a red light in the instrument. There is a bright flash of light to simulate daylight and the instrument returns to darkness. A green light is now shown below the red dot. The patient presses the button when they can see the green light. The test is repeated with the green light becoming dimmer and dimmer until the patient is unable to see the green light.

The responses are compared to healthy normal responses. The test can not only diagnose the early stages of macular degeneration but may be used to monitor the course of the degeneration. At this time, there are no treatments for dry macular degeneration. The only thing you can do are lifestyle changes such as losing weight, exercise, no smoking, healthy diet with eating fish more often, and taking an AREDS formula supplement.

Implantable Telescope

In 2012, VisionCare with its CentraSight treatment program received FDA approval for its implantable telescope to be used during cataract surgery. The implant is indicated for people having cataract surgery who have advanced dry macular degeneration. It is not for people who have already had cataract surgery. This tiny implantable miniature telescope magnifies the image and reduces the relative size of the blind area from the macular degeneration.

CentraSight Implantable Telescope

CentraSight Implantable Telescope

Clinical Trials for Advanced Dry Macular Degeneration

Cell-Based Treatment

The cells used in the treatment are taken from umbilical cord tissue which is called palucorcel. Palucorcel is not stem cell therapy. Palucorcel was developed from umbilical cord tissue from several years ago. A single umbilical cord can provide a nearly limitless number of cells.

APL-2 Injections

At the time of writing this, the APL-2 trial is in phase 2 of the FDA study. The drug is injected inside the eye monthly for 12 months and the patients is followed for 6 months after the treatment. This treatment has so far shown good results and is expected to enter phase 3 trials.

Stem Cells for Macular Degeneration

Stem cell transplantation is being studied around the world at this time. They are studying how stem cells can be used to grow new rods, cones, and RPE cells. One of the biggest obstacles is how to connect the new cells to the proper nerve pathway to the vision center in the brain. Researchers are trying different types of stem cells, different maturation of the stem cells, and how to deliver or place the stems cells on the retina.

You need to be careful of non-FDA clinical trials. There are clinics especially in Florida that are promoting their own clinical trials. There have been many people who have had significant problems with these stem cell applications. These clinics have bypassed the FDA regulated protocols by harvesting stem cells from the patients own fat tissue.

Less Common Forms of Macular Degeneration

Stargardt’s Disease

Stargardt’s disease is a form of macular degeneration. It is named after Dr. Karl Stargardt who was a German ophthalmologist that discovered the disease in 1909. He described 7 patients with recessive inherited macular degeneration. Stargardt’s disease develops in both eyes between the ages of six and twenty. Stargardt’s disease occurs from a defect in the ABCA4 gene. When both parents have the ABCA4 mutation, there is a twenty five percent chance of their children having Stargardt’s disease. The incidence of Stargardt’s disease is approximately 1 in 10,000 to 20,000. This also known as macular degeneration of children.

ABCA4 gene is responsible for the production of an abnormal protein which block the normal removal of byproducts from the retina’s photoreceptors. Lipofuscin or waste products build up in the retinal pigment epithelium (RPE). The RPE, rods, and cones break down as a result of the presence of these harmful waste deposits.
A rarer form is called autosomal dominant Stargardt-like macular dystrophy which is caused by gene ELOVL4.

Treatment for Stargardt’s Disease

There is no known treatment or cure for Stargardt’s disease. It is recommended that people with Stargardt’s disease wear sunglasses outside at all times. There is some evidence that vitamin A in people with Stargardt’s disease has a negative effect on the retina.
Gene therapy is being investigated at this time. A normal copy of ABCA4 can be developed and injected into the back of the eye.

Occasionally anti-VEGF drugs may be injected into the eye for treatment.

Macular Degeneration in a Young Person

Macular Degeneration in a Young Person

Vitelliform Macular Dystrophy or Best Disease

Vitelliform macular dystrophy or Best disease is a autosomal dominant macular disease. Autosomal dominant means that a single copy of the mutant gene from either parent can cause the disease. This disease is also characterized by the dominance as the penetrance of the gene being incomplete. That is not every one with the gene will develop the macular disease.

The disease is characterized by the development yellow or orange slightly elevated round collection of waste material that looks similar to an egg yolk. Mutations in RDS and VMD2 genes.

Large Elevated Yellowish Deposit

Large Elevated Yellowish Deposit

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The Cataract & Refractive
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James E. Croley III, M.D.

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