Light at the end of the tunnel
Every year, hundreds of Manitobans develop wet macular degeneration - a debilitating eye condition that can eventually lead to blindness. But now, thanks to a new drug treatment, hope is in sight.
BY SUSIE STRACHAN
Winnipeg Health Region
Wave, November / December 2010
A bleak future was staring Rosalie Coghill literally right in the eye.
She was worried about not being able to drive, read, recognize the faces of her family and friends, work on her computer, or do tasks like housework. There was a common denominator in all of these worries, something she never thought she'd ever experience - losing her ability to see.
The culprit was a medical condition she'd never heard of before, but quickly became very familiar with. Like hundreds of other Manitobans over the age of 50, Coghill was experiencing age-related wet macular degeneration.
"It started in November of 2007. I went to see a matinee play at the Manitoba Theatre Centre with some friends. I was fine when I left home, but while I was watching the play, a big black spot appeared to one side of my sight," she says, recalling how upset she felt that day.
"At first, I thought it was a cataract, because my doctor recently told me I had slow-growing cataracts. My daughter, Kim, was worried that it was something different. She told me to call my doctor for another appointment, and this time, I was told it was macular degeneration."
Ten years ago, Coghill would have been in serious trouble, as age-related macular degeneration (AMD) was almost untreatable at the time. The condition can lead to blindness, although most people with the condition do retain some vision. But today, people like Coghill have hope, thanks in large measure to Lucentis, a new drug recently approved for use in treatment by the province, which is designed to keep AMD at bay.
AMD usually afflicts older adults in the area of the eye called the macula. People with macular degeneration can't read very well, have difficulty driving and have to resort to looking out of the corner of their eye in order to recognize faces.
A study released by the Canadian National Institute for the Blind (CNIB) and the Canadian Ophthalmological Society (COS) in 2009 shows the cost of vision loss - be it from age-related macular degeneration, glaucoma, complications due to diabetes and other causes - can be counted in both financial terms and in how it affects a person's life.
The study placed the total financial cost of vision loss in Canada at $15.8 billion per year, which includes $8.6 billion in direct health-related costs, along with $7.2 billion in indirect costs such as lost productivity and earnings, care and rehabilitation and assistive devices.
In human terms, the loss of vision can affect a person's self-esteem, dignity, family relationships, leisure activities and community involvement. They also may experience social isolation and stigma.
According to the study, seniors with vision loss face twice the risk of falls, four times the risk of hip fractures and a greater risk of incurring motor vehicle accidents and medication errors. They are admitted to nursing homes three years earlier on average than they would be otherwise. Statistically, vision loss doubles an elderly person's risk of premature death, likely due to factors such as falls and depression.
"This is a very fast-moving problem. I was worried I would lose my eyesight, and nothing could be done about it," says Coghill. "My head was spinning when the doctor told me the news. I'd never heard of wet AMD before. It's not the future I saw for myself."
Dr. Mathen Mathen is the Department Head of the Region's Eye Care Centre of Excellence at Misericordia Health Centre. He says there are two types of AMD: wet and dry. The dry form is most common, accounting for 85 to 90 per cent of AMD cases. It is caused by the loss of photoreceptors in the central part of the eye, and is slow to affect vision. People with early dry AMD have a chance of developing wet AMD over any given five-year period. Those with intermediate dry AMD have a chance of progressing to advanced dry AMD or wet AMD. Dry AMD may be treated with eyespecific multivitamins.
Wet AMD is the most rapidly progressing form of the condition, and can cause rapid vision loss. It occurs when abnormal blood vessels begin to grow under the macula, which is a part of the eye's retina. These new blood vessels leak fluid or blood, causing permanent damage to light-sensitive retinal cells, which die off and create blind spots in central vision. The macular area of the eye takes up just over two per cent of the retina, while the rest of the peripheral field is unaffected.
Wet AMD can be classified into three subtypes: predominantly classic, minimally classic and occult. Approximately 43 per cent of people with wet AMD in one eye progress to wet AMD in both eyes within five years.
In recent years, efforts have been made to treat AMD.
At the Region's Eye Care Centre of Excellence, options include:
- Photodynamic therapy, which uses a reaction between an injected drug and a laser to seal the blood vessels;
- Drugs such as Avastin and Lucentis, which can be injected directly into the affected eye;
- A thermal laser which can be used to seal the damaged blood vessels.
Rosie Jacuzzi, President & Chief Operating Officer of Misericordia Health Centre, says the eye centre is a leader in eye health. "We are the largest centre in Western Canada doing comprehensive eye care," she says. "As the eye care centre for the province, we do more than 8,200 eye surgeries a year," she says, noting the centre also includes the Lions Eye Bank for corneal transplants.
In the case of wet macular degeneration, patients come from all over the province for treatment. Many have been treated with a drug called Avastin, and those that meet research criteria are being moved over to Lucentis. There is an interesting connection between the two drugs.
Avastin, produced by Genetech, is an off-label drug approved for use in treating colorectal cancer and other cancers that was also found to be useful in treating wet AMD. It is injected directly into the vitreous area of the eye, and works by shrinking abnormal blood vessels.
Because Avastin was not officially approved for use in treating macular degeneration, Genetech created a new drug called Lucentis. This drug operates similarly to Avastin, but appears to be more effective in some cases. It works by inhibiting proteins called vascular endothelial growth factors, which stimulate the growth of new blood vessels in the body, and in particular, abnormal blood vessels in the retina, such as those associated with AMD.
When Avastin was first used to treat macular degeneration several years ago, the cost of the injections were as much as $200 each. When Lucentis was approved, the cost per injecton was $1,600. With the average patient requiring about 12 injections a year, the price difference posed a dilemma for patients and doctors alike.
Fortunately, in June of this year, Manitoba Health moved to cover the cost of Lucentis (Avastin was already covered) at the Eye Care Centre of Excellence, where Mathen has an office. The province also approved Lucentis for use - under the supervision of the Eye Care Centre of Excellence - in the offices of three other retinal specialists: Drs. Richard Leicht, Frank Stockl and Ravi Dookeran.
It is expected that up to 1,000 patients will partake in the program in the first year, at a cost of about $7 million.
Mathen says Lucentis has a 40 per cent rate of improving vision in those with agerelated wet macular degeneration. "The downside is the frequency, in that patients must receive the injections monthly for three months, at which point we check their vision for improvement."
Coghill's original treatment plan required her to receive injections of Avastin at a time before the Manitoba government covered the cost of Lucentis. She was working as part of a coalition that was lobbying the Manitoba government to include Lucentis as a covered drug, an issue she became very interested in after she was told some further bad news.
"I had seven Avastin (injections) in one year, but then it stopped working. My first doctor told me that either I had to go on Lucentis or go blind," she says. "As a senior on a fixed income, Avastin, though expensive, was still much more affordable than Lucentis, so I had a huge dilemma when I was told I'd have to pay for the Lucentis (injections). But I didn't want to lose my eyesight. And I worried about other seniors who couldn't afford Lucentis, so it became important for me that Manitoba get with the program."
Coghill says she is constantly checking her eyesight for further degeneration, and is hoping Lucentis is the miracle drug that will allow her to retain her vision for the rest of her life.
"Looking through the affected part of my eye is like looking through a milky shower curtain," she says. "I'm glad that it's only in the corner of my right eye and doesn't affect all of my vision."
Susie Strachan is a writer for Wave.
Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.
Read the November / December 2010 issue of Wave