Mr. Clark was a healthy looking 40 year old who had been sent to my office after failing the driver’s license vision test. His local eye doctor was unable to correct his vision to the driver’s level. He had then been sent to me for further evaluation. He had been diagnosed with diabetes ten years ago.
According to the internist, his glucose was a little high and he needed to watch his diet and keep taking diabetic medicine. Although he was supposed to have his retinas evaluated for diabetic damage, he hadn’t noticed any problem so didn’t keep his appointments.
I found that he had swelling of his macula, the center part of the retina that does the fine seeing. Years of having high glucose levels had damaged the blood vessels to the point that they no longer kept all the fluid in. The fluid leaked out damaging the photoreceptors. Ten years ago the only treatment was laser which in most cases kept the damage from worsening but with little vision improvement.
Today there are injections of an antigrowth hormone that stops the leaking without damaging the surrounding cells. The injections are given in the office with minimal discomfort. Lucentis is given every 4 weeks while Eylea is given every 4 weeks five times and then stretched to every 8 weeks. Most patients have to get injections for many years, possibly for the rest of their life but they can continue to read and drive. Staying on schedule is a major problemand is a common reason for failure.
Steroid injections have also been found to reduce swelling. Ozurdex lasts from 3 to 6 months. Iluvien is the latest medication to get FDA approval and works for three years. The steroid injections have a much higher incidence of complications such as glaucoma and cataracts and don’t appear to be as effective in controlling diabetic retinopathy but are a good alternative tor patients that cannot come as often and are very helpful for patients where the Lucentis or Eylea are not working as well.
A newer type of laser called micropulse laser is helpful in many cases too. Rather than damage the retina as traditional laser does, this laser stimulates the “pumps” that are in the retinal layers so that they pump out the fluid.
The challenge today is tailoring the treatment to the patient’s needs. To have the best vision possible, injections every 4 to 8 weeks are required. If recovering driving and reading vision aren’t as high a priority then laser, micropulse or steroid injections will keep their vision stable. When there is extreme damage then a combination will be necessary. Mr. Clark started Eylea injections and has since regained driving vision.