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Retina Care

The practice of Hadi Zambarakji

Patient Information

Microincision phacoemulsification cataract surgery is usually performed under topical anaesthesia, but an anaesthetist may be needed is sedation is required. Cataract surgery procedures are performed at the Hospital of st. John and St. Elizabeth, The Wellington Platinum Centre, The Holly Private Hospital and the Spire London East Hospital. Please click on this link for post-operative instructions and general advice after phacoemulsification cataract surgery. You will find a brief discussion about lens implant options in this attachment.

 

You should receive as part of the cataract package a two-sided A4 sheet to help you administer your own eye drops and remember that they have gone in. Should you need another one, please click the link to the post-operative eye drops schedule for surgery done at the Spire London East (Monday), the Holly (Thursday), and the Hospital of St. John and St. Elizabeth or the Wellington Platinum Centre (Friday). A summary of the standard post operative eye drops schedule is listed in this document.

 

Vitreoretinal surgery is performed at the Hospital of st. John and St. Elizabeth or the Wellington Platinum Centre. Most cases are performed as a day case, in particular if surgery is performed in the morning, however an overnight stay is possible, in particular if a patient does not live locally. Surgery is usually performed under local anaesthesia with mild sedation if the latter considered necessary. Mr. Zambarakji works with a skilled and caring team of Nurses and Consultant Anaesthetist who will attend to your needs and ensure you have a satisfying experience. Some patients will be asked to posture after vitrectomy surgery. Please click on the link for post-operative instructions and general advice following vitrectomy surgery. We recommend hiring a posturing device for two weeks following surgery if your consultant has recommended post operative face down posturing. Please click on the link to facedownsupporthire.com. Alternatively, a selection of smaller face down pillows can be purchased from Amazon here and here.

 

For patients undergoing any form of ophthalmic surgery as a day case, please click on the link for general advice about driving, clothing, medications etc.

 

Intravitreal therapy is administered for the treatment of macular degeneration, diabetic retinopathy and retinal vascular venous occlusions. There are different ways of delivering drugs to the retina, a summary can be found in a short article I have written for the winter 2014 edition of the Holly House Hospital GP newsletter, this can be accessed on page 8 of the GP newsletter. More recently, a new treatment for symptomatic vitreomacular attachment (VMA) and small macular holes has been developed; this is based on the administration of a vitreolytic enzyme called Ocriplasmin (Jetrea) by an intravitreal injection. Various intravitreal medications can be delivered depending on the condition being treated. These include anti-VEGF agents including Ranibizumab (Lucentis), Bevacizumab (Avastin), as well as Aflibercept (Eylea). Other intravitreal agents include 2 steroid implants: the dexamethasone implant (Ozurdex) with a lasting efficacy of 4 months and the longer acting Fluocinolone implant (Iluvien) with a lasting efficacy of 36 months. Please click on this link for brief details about intravitreal anti-VEGF treatments for age related macular degeneration (Lucentis, Avastin and Eylea). Information about intravitreal therapy for diabetic macular oedema can be obtained by clicking on the diabetic macular oedema link. Patients who have received an intravitreal injection should be aware of the possible risks of intravitreal therapy. Dos and don’ts after intravitreal injections can be accessed here.

 

Avastin vs. Eylea or Lucentis for wet age-related macular degeneration. This article published in the British Medical Journal gives good support for the use of Avastin (Bevacizumab) which is a much less expensive option for the treatment of wet age-related macular degeneration by intraviteal injections. A group of clinical commissioning groups won a court battle against the pharmaceutical industry thus allowing the use of Avastin. By way of comparison, the hospital charge for the administration of Avastin is £385 compared to £1,150 for Eylea (Aflibercept) and £1,325 for Lucentis (Ranibizumab) (excluding the surgeon fee). Numerous trials have demonstrated that bevacizumab is noninferior to ranibizumab in the treatment of neovascular AMD and that both have similar safety profiles. The decision to use one drug over the other is multifactorial but the additional billions spent on licence medications does not make economic sense based on cost effectiveness models. Furthermore, a recent review and meta-analysis investigating the effect and protocol of anti-vascular endothelial growth factor treatment on wet AMD concluded the following: The superiority remains unclear between Ranibizumab (Lucentis) and intravitreal Bevacizumab (Avastin) in the treatment of neovascular AMD. Intravitreal Aflibercept (Eylea) dosed every 2 months required fewer injection times, but produced similar efficacy as monthly Ranibizumab.

 

Avastin (Bevacizumab) for diabetic macular oedema (DMO) and other conditions that are complicated by macular oedema: A recent meta-analysis published in the British Medical Journal in 2019 looked at the effecacy and safety of intravitreal Bevacizumab, Ranibizumab and Aflibercept for patients with choroidal neovascular age-related macular degeneration (cn-AMD), diabetic macular oedema (DMO), macular oedema due to retinal vein occlusion (RVO-MO) and myopic choroidal neovascularisation (m-CNV).

 

This study is a systematic review which means that it has put together the results of multiple randomised controlled trials to give a meaningful answer to the question. Vision gain was not significantly different in patients with cn-AMD, DMO, RVO-MO and m-CNV treated with Bevacizumab versus Ranibizumab. Similarly, vision gain was not significantly different between cn-AMD patients treated with Aflibercept versus Ranibizumab. Patients with DMO treated with Aflibercept experienced significantly higher vision gain at 12 months than patients receiving Ranibizumab or Bevacizumab; however, this difference was not significant at 24 months. Rates of systemic serious harms were similar across anti-VEGF agents.

 

The study concluded that intravitreal Bevacizumab was a reasonable alternative to Ranibizumab and Aflibercept in patients with cn-AMD, DMO, RVO-MO and m-CNV. The only exception was for patients with DMO and low visual acuity where treatment with Aflibercept was associated with significantly higher vision gain than Bevacizumab or Ranibizumab at 12 months; but the significant effects were not maintained at 24 months.

 

 

 

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