So what should you do, and is it better to have more injections and attend less or have fewer injections but go to the clinic for more appointments? The approach will very much depend on your individual case. There would appear to be no good reason to change treatment if you are having lucentis and only requiring infrequent injections. If you are requiring injections at most visit this might be due to the severity of disease which warrants more treatment or you may not be a responder to Lucentis so Eylea may help.

If you have been newly diagnosed you may be interested in starting on Eylea from the outset but your treatment options may be constrained by funding. Until there is national guidance through NICE it is unlikely that in most places Eylea will be available on the NHS until some time in 2013. If local health commissioners are convinced of the benefits in terms of cost and convenience for patients they may suggest usage pre-empting NICE guidance. In contrast with the Lucentis and Avastin debate,  Eylea has the advantage of being a licensed treatment for the eye. Although in Manchester and Cheshire some commissioners still prefer Avastin because of it’s lower cost it’s usage has been on the decline since the Lucentis price cut agreed later earlier this year.

If you want to have an up-to-date review of your wet AMD and want to be considered for Eylea at the earliest opportunity then please request a consultation using the contact details on this website.

When considering whether to have cataract surgery discuss with your optician what can be managed by optimising your glasses. If you are struggling with vision related tasks such as reading and driving and adjusting the glasses prescription is not likely to be helpful then you should discuss this at your hospital visit and make clear that the cataract is impairing your quality of life.

If the NHS won’t pay for your cataract operation will your private provider? One of the benefits of private healthcare was the expectation that you could have your consultation and surgery with the consultant of your choice with whom you had developed a relationship and trust. However although most private insurers do not place the same restrictions on cataract surgery some are trying to reduce how much they spend. This may involve a contract with a certain private hospital or individual providers who may have negotiated a lower fee.

The private insurer may therefore ask you to have your cataract surgery done by a hospital and surgeon you have had no previous contact with. This may leave you in the difficult position of losing the choice which you thought you had or face a surcharge from your consultant to cover the shortfall from the payment by your insurance company. Before accepting this type of limitation from your insurer do check the wording of your policy and discuss any concerns about your choice with your insurance company.

Despite the strong clinical evidence of benefit for patients affected by diabetic macular oedema and retinal vein occlusion, so far NICE have not recommended usage on the NHS on grounds of cost-effectiveness.

This could soon be about to change. The department of health has now agreed a price cut with Novartis who sell the drug in the UK. Instead of the previous arrangement for wet AMD patients whereby the company covered the drug cost after fourteen treatments, Lucentis is now provided at an agreed discount regardless of number of injections.

The actual discount is confidential and not public knowledge. Whatever the level it is a positive development which should mean savings for the NHS and allow NICE to reconsider the cost effectiveness for other diseases. In the UK it may also limit any further attempts to switch to Avastin on grounds of cost. The primary care trusts whose action led Novartis to initiate a judicial review of their policy to commission Avastin have also withdrawn their plans and will continue now with Lucentis usage. Some parts of Manchester and Cheshire may also need to review their policies.

It will also be interesting to see what effect this will have on the uptake of the new drug Eylea (Aflibercept, VEGF Trap Eye) in the UK. This has already had strong sales in the US but the European license is awaited. This should be announced very soon and Bayer should then be able to start promoting the treatment in the UK. The potential for a lower cost drug and fewer hospital visits is attractive but the overall number of injections required is not dissimilar to Lucentis. No doubt competition between Novartis and Bayer will mean price will need to be competitive. Hopefully patients and the NHS will benefit from this increased choice as well as reduction in costs.

This news spread through the media and gave the impression that the NHS was being sued by Novartis in an attempt to protect profits and prevent PCTs from saving money by using Avastin. Evan Davis on the Today programme questioned the value of funding Lucentis claiming that the switch to Avastin could save the NHS the equivalent of 3000 extra nurses.

Novartis have since confirmed that they are not seeking to sue the NHS but to clarify the legal position of primary care trusts who choose to offer Avastin and limit access to Lucentis. The company has not helped its image by taking this action but on the specific issues being questioned they have a potentially strong case.

Based on guidance from the General Medical Council a doctor may choose to prescribe an unlicensed treatment if it serves the patient’s needs better than a licensed alternative. PCTs who commissioned Avastin services have sometimes done so by suggesting potential benefits of Avastin over Lucentis. This has not been confirmed in the comparative studies and the effect of the two drugs appears to be equivalent. A local decision to save money would lead to postcode based prescribing and it is hard to justify a decision to change on this basis of cost when the nationally appointed government body NICE has judged a treatment to be cost-effective.

Any change to Avastin would therefore need to be centrally led and regulated but such a move would be difficult for the NHS without undermining the drug regulatory process and negating the value of NICE in making decisions on what treatments should be funded. The results of this judicial review will certainly be of interest though and will likely shape the direction of future Avastin usage in the UK.

The difficulty remains that regular monthly review is required for most patients placing a burden on the health service and repeated hospital visits and injections are also a burden for people. In many departments in Manchester and Cheshire maintaining monthly treatments and review is proving difficult potentially preventing the best possible results.

A long lasting treatment which does not repeating for many months is likely many years away. A step forward appears to be a new treatment called Eylea (aflibercept). This is a drug which was developed under the name VEGF Trap Eye. It is another eye injection treatment administered to the eye in the same way as Lucentis. It is potentially much more potent than Lucentis. Large clinical trials compared monthly Lucentis to Eylea given every month and every two months (after an initial series of three monthly injections). The group receiving Eylea every two months had equivalent visual results to Lucentis administered every month.

Eylea is already in use in the USA and has proven to be very popular. A European license is expected in summer 2012 and the national body NICE should advise on its availability for NHS patients later this year.

The counter argument is that fixed two monthly dosing still requires a similar number of injections compared to Lucentis. Eylea may be a step forward but if lucentis is working for patients there is is likely no benefit in changing. New patients may be considered for Eylea when it becomes available but much will depend on the eventual pricing (not yet revealed) and NICE guidance. The price of Lucentis may also change depending on how Eylea comes to market. If you are interested in being considered for Eylea treatment when it receives a UK license please enquire using the email information request form on this website.

In the meantime there is a lot of interest in the Avastin versus Lucentis studies which will report in the beginning of May at the US ARVO conference. The US CATT study will be presenting year two results and the first results from the UK IVAN trial should be available. Watch this space.

In Greater Manchester there are many cataract surgery providers now bidding for this business and you may be asked if you want to have your cataract operation in places you have never heard of. Whilst it is tempting to go for the surgeon or practice with the shortest waiting list is cataract surgery the same everywhere?

Fortunately government regulation sets certain minimum standards so you can expect a reasonable result wherever you have surgery. You may want to find out more about the department though, the plans for your surgery and aftercare. Some places may be able to offer more services in house, others may do part of it then send you back to your doctor or optician.

As a general rule if you are currently under a hospital eye service and have known eye problems requiring treatment such as glaucoma, diabetic retinopathy, macular degeneration and other retinal problems, it is better to remain under the care of the same department for your cataract surgery. Surgery can sometimes aggravate these other problems so you are best being managed under the care of those regularly manage your eye problems and have full access to your medical history.  This does not mean that others cannot manage your cataract but to guard against problems it is important for you to have full details of your eye problems and medical history to hand when being assessed.

VEGF levels are also increased in other retinal disease most notably retinal vein occlusions and diabetic macular oedema. Treatment with Lucentis has been studied in both major types of retinal vein occlusion. These are central retinal vein occlusion and branch retinal vein occlusion. Large studies reported in 2011, the BRAVO (branch vein occlusion) and CRUISE (central vein occlusion) studies. In both these studies patients were treated with monthly lucentis for a period of time and then as needed based on certain criteria.

The results have been very encouraging, just over 60% of patients in the BRAVO study had a meaningful improvement in vision of three lines on a standard vision chart.  In the CRUISE study nearly 50% of patients achieved three lines of improvement in their vision. There was approximately double the chance of this level of vision improvement compared to exisiting treatment approaches which included laser or simply observation.

At the time of writing the UK regulatory body NICE is still in the process of evaluating whether this should be funded on the national health service. The initial response so far as with diabetic macular oedema has been negative due to cost-effectiveness concerns. Ozurdex injection remains an alternative option and some patients choose to try for similar results as Lucentis using injections of Avastin. For this disease at present there is no study directly comparing these or a particular combination of these agents.  There is little doubt though that eye injection treatments (the specific choice of drug should be discussed with your doctor) are the current best option when considering treatment for this disease.

The price of Lucentis has been controversial since its introduction. Drug companies spend hundreds of millions of pounds developing new drugs so the price reflect the costs of research, development and is used to support the continuing process of innovation and development.

Lucentis treatment has the potential to prevent visual loss in diseases in which previously there was no effective treatment. Multiple doses are required for each patient so the cumulative cost over time makes it unaffordable for many patients especially in healthcare systems where there is no state funding.

Lucentis is a unique case because the pricing issue has been constantly highlighted by the widespread success in using Avastin for the same disease indications but at a significantly reduced cost by decanting small doses for injection into the eye from the vial of Avastin intended for injection into the veins. There are no studies so far indicating any benefit of Avastin over Lucentis apart from cost. The evidence is inconclusive but some point to the potential for higher side effects from Avastin and the quality standards for a product specifically designed for injection into the eye is higher than for injection into the veins. If the cost differential was not so high no doubt many Avastin users would prefer Lucentis but currently in many parts of the world there is pressure to switch to Avastin to save money.

The price of Lucentis around the world is based on the US price where the manufacturer Genentech is based. There can not be large differences in the price of the vial of Lucentis around the world because this would cause problems between markets and the potential for all to focus on the cheapest source. Novartis sells Lucentis in the UK and for the management of AMD a “reimbursement scheme” was agreed with the Department of Health so that after fourteen injections  any further doses were provided to the national health service free of charge. This has helped cap the total cost of Lucentis for each patient treated.

However, current worldwide economic pressures have led to increasing demands for a review of Lucentis pricing. When the National Institute for Health and Clinical Excellence (NICE) evaluated Lucentis for diabetic macular oedema (DMO) it was not approved on the grounds of lack of cost-effectiveness.  There are also recent reports of the Lucentis price being negotiated lower in Switzerland.

The NICE decision for DMO has been controversial because of the wealth of evidence pointing to the potential clinical benefit for diabetic patients. NICE is now considering an appeal and there are also indicators that Novartis is looking at the pricing possibly by a further enhancement of the reimbursement scheme. A well negotiated price would hopefully make Lucentis accessible to many more patients.

Recently new lens implants have been introduced which claim to offer the benefit of less dependence on glasses at all distances. They tend to be called “premium” or “multifocal” lenses. If the best possible results are achieved with such lenses there may be no need to wear glasses at all after surgery. However this is rare and although patients may be less dependent on glasses there may still be times when glasses are required to get the best vision for example for distance when driving or for doing fine near work or reading small print.

Two types of lenses are available. Multifocal lenses have focus for different distances in different zones within the single piece lens. Multiple images can potentially be perceived at one time but the brain effectively uses the information from the desired distance you are attempting to see. Another type called accommodating lenses claim to change position or shape to alter the effective power of the whole lens. One or the other may be appropriate for you and it is not uncommon to have different types of lenses in each eye to cover a greater range of distances.

This is a rapidly developing field. Such lenses can be certainly be considered when you are having cataract surgery. They do come at a higher cost and are not available on the National Health Service. They may not be suitable for patients with other eye disease for example macular degeneration or diabetic eye disease. The options should be carefully discussed with your surgeon.

A new type of laser called a “femtosecond laser” is being developed for use in cataract surgery.  This type of laser can precisely and consistently deliver short bursts of laser energy to a specific tissue. It is already in use for doing laser corneal surgery to correct for the need for glasses.

Femtosecond laser can cut through tissue in a very precise and controlled manner. It may in future by used to improve the quality of wounds. The entry into the capsule surrounding the cataract can be made in a more precise manner allowing more consistent siting of lens implants. The laser cannot remove the cataract but the laser energy can be use to do the initial work of breaking up the substance of the cataract allowing for more easy aspiration.

This exciting technology will be commercialised soon and as it develops it has the potential to further improve the consistency and reliability of cataract surgery.