For a live episode of the Brain and Eye Show on Doctor Radio, Kenneth Wald, MD, sat down with co-hosts Elisabeth J. Cohen, MD, and Steven L. Galetta, MD, to explore breakthroughs and challenges in retinal disease management. The discussion ranged from macular degeneration treatments and their risks to the complexities of retinal tears and cataract implant complications. Listener questions prompted engaging insights into managing these conditions, highlighting the delicate balance between cutting-edge therapies and practical patient care.
Below, we share an excerpt from the interview, edited for length and clarity. Sirius XM subscribers can listen to the full conversation here.
Dr. Galetta: I want to tackle early one of the topics I see on TV all the time. People are very concerned about it and what can we do about. And that’s the topic of macular degeneration. Are there two forms of this? What are we talking about on TV these days?
Dr. Wald: It’s a good topic to bring up because it is such a prevalent condition.
Many patients who have macular degeneration don’t even have symptoms. They’re unaware of it. It can only be diagnosed by an ophthalmologic examination, usually with a dilated pupil. We may find some early features of it which we call drusen, small yellow spots that don’t really affect the vision. Later there can be progressive degenerative changes, some of which lead to atrophy. That’s become an area of interest these days because we suddenly have some possibility of slowing the condition down, where previously there was none.
Fifteen or 20 years ago, the wet form was generally quickly devastating to vision. But over the last 15 or so years we have a pretty good treatment for that that could at least control it. The problem is treatment burden; patients have to come as frequently as every six weeks, indefinitely, to manage this condition.
We also have new treatments that are geared towards the dry form, which can hopefully slow disease progression. However, these medications can’t really reverse it or improve the vision, and that’s what’s controversial these days.
Dr. Cohen: Do you think the drugs that are being advertised on TV for wet AMD are that much better than the older drugs?
Dr. Wald: The studies are a little controversial. It’s not so much that they’re better. They work on very much the same principles. But the hope is they can work for longer. For many of the patients receiving these intraocular injections—which is no picnic to have someone insert a needle into your eye—the hope is that maybe some of these drugs can last four or more months, instead of six or eight weeks.
The real answer is that a lot of the studies don’t show that much difference, even with these newer drugs that are touted on commercial radio and television.
Dr. Cohen: Do you think any of the drugs for dry AMD are ready for primetime, or do you think we’re going to get better ones down the road?
Dr. Wald: That’s sort of the central issue in the field of the retina, because we do have this unmet need of dry age-related macular degeneration. And the word degeneration really is relevant here because the actual retina degenerates. We call that atrophy or geographic atrophy. When that happens, it usually starts without much change in the vision. But it’s relentlessly progressive.
“That’s sort of the central issue in the field of the retina, because we do have this unmet need of dry age-related macular degeneration.”
Kenneth Wald, MD
The drugs that are now on the market, Syfovre and Izervay, these drugs are given either every month or every other month, indefinitely. And patients will experience no visual improvement; they won’t get better. In fact, they’ll still get worse. But the thinking is, and the evidence shows, that they may get worse a little more slowly.
There are a lot of side effects and costs associated with these drugs. And there’s some question whether it really improves the visual function. Anatomically, [patients’ geographic atrophy] seems to slow down compared to untreated patients over long periods of time. Whether continuing to treat this over long periods of time will yield some longer, better visual functioning is still being determined. These drugs are pretty new, and we’re looking at two- and four-year data now.
Dr. Galetta: We have the same situation today with Alzheimer’s disease. The drugs do not change the fact that somebody’s going to continue to progress. They’re just going to do it slower. Why wouldn’t you take that chance that you’re going to slow your disease down? Is it the cost? Is it the side effects?
Dr. Wald: It is those things. Like all medical therapies, we’re balancing the risks and the benefits. These drugs have a very small therapeutic index. The benefit is small. We don’t even know how much better the visual functioning is going to be. It may have an anatomic benefit and very little visual functional benefit. That’s still being determined.
And there are side effects. Simply doing the injection produces a small but real risk of infection. The patients can have some increased risk, not negligible, of developing the wet form of macular degeneration. If that happens, you’re sometimes getting two injections a month; it’s a pretty intensive thing. There are other risks involved. You do have to carefully weigh which patients that it would make sense for. There are a lot of institutions, including our own, that have not really been on board with this form of therapy yet.
Dr. Cohen: Let’s try the phone lines. Caller from New Jersey, how can we help you today?
Listener 1: In February of last year, I experienced what looked like snakes in my field of vision. I went to the doctor and they lasered down a tear in the retina. Then a few months later they preemptively did the other eye. Everything seemed to be going well. I didn’t have a lot of floaters. But just recently on a follow-up visit, they found something on the front of my eye that I can best describe as it looks like a piece of partially cooked egg white. I’m waiting now to get a biopsy. Are these conditions related? And what could this thing be on the front of my eye?
Dr. Cohen: When you look in the mirror on the front of the eye, can you see what they’re talking about?
Listener 1: Yes.
Dr. Cohen: Is it sort of at the 3 or 9 o’clock position, and it kind of looks white?
Listener 1: Yes.
Dr. Cohen: That sounds like a pinguecula, which is related to sun exposure and is almost always benign and has nothing to do with your retinal tears. But your retinal tears are interesting. Dr. Wald, how often do you prophylactically, treat the second eye?
Dr. Wald: Well, that’s controversial. It depends on what the doctor saw. Obviously, you’ve developed what we call a vitreous separation and an associated tear in the retina. With treatment of the fellow eye, I’m guessing that they saw maybe an asymptomatic tear in the fellow eye. Otherwise, there aren’t too many abnormalities that we prophylactically treat in a situation like yours. But again, it’s difficult to say. I’m just glad your floaters got better and you’re seeing well. And, as Dr. Cohen said, it sounds like your external eye problem is unrelated to the floaters and the retinal tear.
Dr. Cohen: How often when someone has acute floaters, when you see them initially or in follow-up, do you find tears that need treatment?
Dr. Wald: If a patient comes in with floaters and we don’t see a tear, it’s pretty rare. However, if you found a tear—you know, I actually just published a paper on this about a year ago—it’s pretty common to find a second tear. It’s not even uncommon to have a detached retina. So, someone who has a sudden onset of floaters and a torn retina, they have to be watched closely for at least a year because they are at risk for other tears and even progression to a retinal detachment.
“Someone who has a sudden onset of floaters and a torn retina, they have to be watched closely for at least a year because they are at risk for other tears and even progression to a retinal detachment.”
Dr. Wald
Dr. Galetta: How quickly should somebody who develops floaters see a retina doctor?
Dr. Wald: You’d like it to be within a day or so. Because if you have this sudden onset of floaters, your risk of a torn retina is perhaps 5 or 10 percent. And if you are not treated promptly, if you have a torn retina, you may have as much as a 50/50 chance of going on to a very serious problem called a detached retina. Realistically, I’d say most people are seen within a couple of days, and it works out okay. It’s really the people who ignore it for a week or two that seem to develop retinal detachments.
Dr. Cohen: I am always the exception to all the rules. I had an acute floater at a show in New York, and then another one within several minutes. I left the show and went to Philly to see a doctor there. I was okay. I was seen the next day and the next week. But then two weeks later, I had two horseshoe tears. And I can’t believe he didn’t see them the first time because there wasn’t any reason, like blood, that would prevent a good exam.
Dr. Galetta: Dr. Wald, what do you think about that scenario? If you see somebody with a floater but you don’t see a tear, when do you say, ‘Hey, come back again’?
Dr. Wald: I’d say it depends on the risk factors. It’s a very common condition, and you just can’t examine people over and over for something that’s very unlikely to be a problem. But I’d look at their refractive error, meaning are they very nearsighted? Is there blood, as Dr. Cohen was saying, because that would diminish our ability to detect things. Do they have what we call precursor abnormalities, meaning lattice or other things that may give rise to retinal tear? And, what Dr. Cohen is saying, it is kind of unusual that you would examine someone initially and then find a tear a week or two later. And whenever that does happen, I always wonder, did I miss it? You just can’t know, because you looked and presumably you made your best effort.
“Isn’t that always the case in medicine? We’re always concerned that we missed something, that we didn’t quite make the diagnosis. We live with that concern every day.”
Dr. Wald
Isn’t that always the case in medicine? We’re always concerned that we missed something, that we didn’t quite make the diagnosis. We live with that concern every day.
Dr. Galetta: Is there any better way to look for a retinal tear than you just viewing? Is there a next-level thing that you can do these days?
Dr. Wald: We’d love to have that. In fact, one of our graduates, Jesse Jung, has reported on this very topic. They looked at our best optical tool, called an Optos, and really, it’s not as good. It’s probably pretty good, especially if you already know where the tear is and you can direct the photographer. But it’s not as good. You’ll still miss tears. So right now, in our field, we still have to really look hard.
Dr. Cohen: Our next caller is from Connecticut. How can we help you today?
Listener 2: I have a problem with one of my cataract implants. I had it done about 10 years ago, but in the last year or so, it moves a little bit, and it gets a drop of blood on the eye. And then for about two hours, you can’t really see out of that eye. It gets foggy. Then it goes away. They’ve been giving me cyclopentolate to dilate the eye so that it doesn’t happen that often, but it still happens. I can’t replace that implant because I’m on blood thinners and the doctor won’t even bother doing it.
Dr. Cohen: You’re calling the right person because one of Dr. Wald’s special interests and expertise is dealing with implants that aren’t in the right place and behaving properly.
Dr. Wald: It’s a tricky problem that you have. It depends on how much it’s bothering you. Sometimes we do replace the implants. The condition you seem to have—an implant that’s not stable and is causing occasional bleeding in the eye—is called UGH syndrome. The H stands for hemorrhage. The motion of the implant, as you’ve been describing it, rubs part of the eye tissue and causes bleeding. Sometimes Cyclogyl can help. Sometimes anti-inflammatories will help. Ultimately, if it’s a sporadic problem and you’re mostly seeing okay, I probably would do just what they’re doing. Just manage it conservatively with drops and accept that once in a while you’ll have this problem.
The alternative would be a surgery. Again, it all depends on the type of lens in your eye. Some are more apt to be maintained, repositioned, and fixated. Others have to be removed. But the presence of blood thinners doesn’t absolutely rule it out. We operate on people on blood thinners all the time. Most of the studies don’t show that there’s a significantly different risk involved. So it’s really a judgment of what to do.
It sounds like, from what I’m hearing, it’s an occasional problem that could be managed with drops for now. So, I think the main thing for you, because other issues like high eye pressure can come up—you just need to be followed closely. If you start having frequent bleeds and the lens is moving very significantly so you can’t see well, you may have to ultimately have a surgical procedure to correct it.
Dr. Cohen: But I think it’s an important point that blood thinners don’t make him a bad candidate for most eye procedures.
Dr. Wald: I definitely think about it. It would be a factor. If someone had a retinal detachment, I’m going to do the surgery. Nonetheless, if it’s a macular pucker, a less severe problem, or not progressive, I’ll weigh that a little bit. I feel like there’s still a slight increased risk of even severe complications. But most studies don’t really show that, and we are used to dealing with that all the time.
Dr. Cohen: And we generally would take the risk of bleeding in the eye over a stroke to the brain.
Dr. Wald: Correct.
Dr. Cohen: So, we’ll keep the patients on blood thinners. I always say brain trumps eye.
