Being Lazy

I apologize for neglecting my blog. Things have been a bit hectic since we got back from Brazil. I expect it all to settle down soon! No large trips on the horizon.

As I mentioned before, just had another Avastin shot into my eye last Wednesday. It was a bit traumatic for me, mainly because they wouldn't let Nate come with me AND they only spoke to me in German the whole time. It really was okay, as I could understand nearly everything they were saying, but it did make it stressful for me. At one point I was crying and asked for someone to hold my hand. The nurse took pity on me, all the time trying to reassure me that this procedure was normal! Anyhow, my eye is healing nicely and I have another appointment to see if the shot helped anything in about three weeks.

I thought that some of you might be interested in the technical things going on with the eye, so I am attaching here part of an e-mail I got from a doctor in the U.S.:
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I am sorry to hear that you had new bleeding in your eye. It is possible to have recurrent bleeding along the edge of scar tissue. Treatment in this setting is generally initiated to prevent extension of the scotoma (the central dark spot that you see corresponding to your scar). In some cases, vision may improve by a line or so, but scar tissue limits the final visual outcome.

You are correct that Avastin was initially used systemically to treat colon cancer patients. Later, it was found to be useful for certain eye conditions because it is an anti-vascular endothelial growth factor and anti-permeability agent. Essentially, Avastin stops the leakage from the choroidal neovascularization. But it is only a temporary fix and does not eliminate the problem vessels themselves. Therefore, repeat injections are usually the norm.

Avastin is usually used in elderly people because choroidal neovascularization occurs in wet macular degeneration, a common eye disease. But there are rarer eye conditions such as choroidal neovascularization in pseudoxanthoma elasticum, multifocal choroiditis, etc. where Avastin is helpful in temporarily stopping the leakage. Intraocular Avastin is used “off-label” because the FDA never approved it for the eye, but I would not call it experimental. In cases where a patient cannot afford Lucentis (an FDA-approved drug for the eye that is very similar to Avastin but costs over $2000 more per injection), Avastin is considered by some as the standard of care for choroidal neovascularization. In fact, there is a trial that will be starting soon that will directly compare Avastin and Lucentis to see if there is any difference beyond price. And there are some case reports of Avastin use in premature infants for a retinal disease called retinopathy of prematurity.

In terms of your situation, there have not been long term studies of someone using intraocular Avastin for decades. There are theoretical risks of increased risk of stroke and other thrombolic events, but again there are no long term studies. It seems reasonable to try Avastin again as recommended by your German doctor to see if it helps with your scotoma. Eventually, your scar will likely solidify and re-bleeding may not occur again or may only occur over long intervals of time. So you would not need a scheduled Avastin injection, but would need one if new leakage occurred that was making your vision and scotoma worse. But since I am not examining your eye myself, I will leave the specific recommendations up to your German doctor.

If you chose not to get the Avastin injection, the blood would likely turn into scar tissue enlarging your current scar and scotoma. There are very rare cases where a person gets a massive bleed that breaks forward into the vitreous (the gel filling the cavity of the eye). This is very rare so the odds are in your favor that it won’t happen to you.

Unfortunately, there is nothing you can do to prevent recurrent bleeds. Just keep monitoring with an Amsler grid and seek attention promptly if there is a change.
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Now you may feel like you wasted 15 minutes of your life, but I know some of you out there are closet doctors/nurses and probably found it interesting!

Not too long after my doctor appointment I got a hair cut.

Nate's first comment was, wow you look like a German now! I suppose I have entered that slippery slope between layered cut and mullet. With care, a blow dryer, and straightener I think I can avoid looking like MacGyver. I hope!