Treating AMD: the injection into the eye — how it goes, the intervals, the limits

The aim of treatment: holding the centre

The macula is the small centre of the retina with which you read, recognise faces and drive. Age-related macular degeneration attacks exactly there — and exactly for that reason the aim of any treatment is settled before the first injection is given: It is about holding on to the sight that is there today. Whatever tissue in the centre of the retina the condition has already destroyed, no treatment brings back. Whatever activity it still shows can, in the wet form, be controlled in many cases today.

This page describes the treatment. What AMD actually is, how it develops, how it is noticed and with what diagnostics it is assessed, is set out in full on the parent page: macular degeneration (AMD) — warning signs, the dry and wet forms, diagnostics. Anyone who has no diagnosis at all yet will find the framework for check-ups under eye screening, which looks for AMD before it causes symptoms. Here we begin after the diagnosis.

There is a treatment for only one of the two forms. That is the distinction on which everything on this page hangs, and it is set out in the very next section: wet AMD is treated with a medicine delivered into the eye. For dry AMD there is currently no curative treatment — there the measures consist of monitoring, of recognising a change into the wet form, and of dealing with the risk factors.

And one sentence many of those affected should hear first, because it meets the fear they arrive with: AMD almost never leads to complete blindness. What is affected is the centre of the image; the outer visual field is preserved. That does not make the condition harmless — reading, faces and driving all hang on that centre — but it does away with the idea that darkness is the inevitable end.

When treatment begins — and why the week counts

At the beginning there is always a thorough examination. We assess which form of AMD is present, how active the condition is and which treatment is medically sensible. On that basis we discuss with you, without hurry and in plain words, which approach comes into question for your situation. How such an assessment goes and what is measured is set out under eye examinations: what is checked at an ophthalmic check-up.

Three findings lead to the decision, and none of them is how you feel your vision alone:

• The form. Injection therapy comes into question for wet AMD. Where the examination shows dry AMD with no sign of activity, an injection would not be the more cautious course but the wrong one.
• The activity. It becomes visible on the cross-sectional scan of the retina (OCT): fluid in or under the retina, a detachment, an increase in thickness. These images decide when treatment starts, whether it continues and at what interval — they are what actually sets the rhythm of the therapy.
• Function. How badly is vision affected, and how much functioning tissue is left in the macula? Where the centre of the retina has scarred completely, an injection does not bring back the central vision that has been lost; at most it can still prevent what would additionally happen without it. Whether that justifies a series, we tell you openly — with the aim stated alongside, rather than beginning a series without naming what it still protects against.

With wet AMD in particular, prompt treatment matters, because vision can otherwise deteriorate markedly within a short time. That is not the rhetoric of urgency but the reason we keep short-notice appointments free for newly appeared distortion. If you notice new changes in your central vision, telephone rather than looking online for one of the next regular slots. Once the diagnosis is made and the indication is clear, the first injection should not follow weeks later.

Before the first treatment comes the consent discussion. We explain to you what the medicine does, how often it is likely to be given, which risks belong with it and which signs afterwards need reporting immediately — openly and transparently, before any treatment begins. Your consent belongs to this treatment as much as the injection itself does: you give it in writing, you can ask questions until you are satisfied, and you can also interrupt the treatment at any time later. We then tell you what that means for the findings — and the deciding is yours.

If you are being referred, or are referring: For colleagues who would like to send a patient with a macular finding, the pathways for referring physicians are set out. Bring any earlier findings and previous cross-sectional scans with you — for comparison they are worth more than any new single measurement, even when they come from another practice.

The treatment day: how an injection goes

For wet AMD the treatment is as a rule given by injection into the eye under local anaesthetic. The procedure takes only a few minutes and is done as an outpatient. The imaging (OCT) we schedule at a separate appointment whenever possible, and not on the day of the injection. For the treatment day itself, expect around half an hour.

What happens in that half hour, in the order in which you experience it:

• The check before the injection. On the treatment day we check your acuity and the findings at the slit lamp, and decide from that whether an injection is given today. The cross-sectional scan of the retina (OCT) is then as a rule already available, because we schedule it at an appointment of its own. An injection appointment without an assessment of the findings is not something we provide for.
• An inflamed eye is not injected that day. An infection on or around the eye, and acute inflammation inside the eye itself, are reasons to postpone the appointment — with every anti-VEGF medicine, because the injection could carry germs from the surface inwards. If on the morning of the appointment the eye is red, is sticky or wakes up gummed shut, if the eyelid margin is acutely inflamed or a stye sits beside it: say so when you arrive, rather than waiting quietly to see whether it is noticed. A postponed appointment is a postponed appointment. An appointment we push through with an inflamed eye is something else.
• Anaesthetic. The eye is anaesthetised with drops, usually several times over a few minutes. No general anaesthetic is needed, and you are awake throughout the treatment.
• Disinfection and draping. The eye, the eyelid margins and the surrounding skin are thoroughly disinfected, the eye is draped sterile, and the lids are held open with a small holder so that you do not have to keep from blinking. This is the part that feels most unfamiliar — and the most important one, because it keeps germs away from the injection site.
• The injection. The medicine is delivered with a very fine needle through the white sclera into the vitreous cavity, from the side and at a set distance from the edge of the cornea. That takes seconds. Most people feel a brief pressure. You are asked to look in a given direction — nothing more is required of you.
• Afterwards. The eye is rinsed, often given an ointment, and depending on the situation the intraocular pressure is checked before you leave. You are told what to watch for over the next few days, and when the next appointment is.

Which of our locations gives your injections, we tell you specifically before the treatment begins — together with the question of who gives them and how the monitoring in between is organised. Assessment and monitoring we do close to where you live, at our three locations in Zürich, Wetzikon and Meilen; an overview with directions and opening hours is under Locations.

The 24 hours afterwards

An irritated, watering, slightly pressing eye belongs to the normal course, and so does the feeling of a foreign body like a grain of sand — that is the after-effect of the disinfectant solution and the puncture, and as a rule it subsides overnight. A red patch on the white of the eye is a harmless bleed under the conjunctiva: it looks dramatic, does not hurt and as a rule disappears by itself within one to three weeks. New black spots or streaks that move with your gaze also occur; they usually come from small bubbles of air or medicine in the vitreous and become fewer over the next few days.

• Do not rub. That is the only rule that really counts — even when the eye itches or feels strange.
• Keep it clean. Do without swimming pools, saunas and hot tubs for the first few days; showering and washing your hair are no problem as long as no water runs into the eye under pressure. Leave eye make-up off until the next day.
• Use the drops you are prescribed, if you are given any, and carry on with your other eye drops as long as nothing else has been discussed.
• Working, reading, watching television you may do as soon as your vision is clear again. There is no rest period for the eyes as an organ — only for the treated eye in the first few hours.

Risks, side effects and the signs afterwards

The injections are given under local anaesthetic and are as a rule well tolerated. Most patients find the treatment uncomfortable rather than painful. Modern AMD treatments are regarded as very safe. Even so: No medical procedure is without risk. We tell you about that openly and transparently before any treatment begins — which is why it stands here and not in the small print.

Common, harmless, temporary

• Irritation, watering, the feeling of a foreign body for a few hours up to a day — the most common accompanying effect of all, and usually a consequence of the disinfectant solution rather than of the injection.
• A bleed under the conjunctiva, visible as a red patch on the white of the eye. Harmless, painless, as a rule gone in one to three weeks. If you take medicines that thin the blood it occurs more often and tends to take longer — that it is still visible in the third week does not mean something has gone wrong.
• New spots or streaks in the field of vision in the days after the injection, usually from small bubbles in the vitreous.
• Blurred vision for a few hours, among other things from the ointment and the anaesthetic.

Rare — and the reason for the warning signs

Rare complications can be, for example, inflammation or changes in pressure in the eye. The most important of them is inflammation inside the eye. It is rare, and it is treated immediately — but it is also the one complication of this treatment that can damage the eye permanently: It can leave permanent loss of vision behind despite immediate treatment. That is exactly why this page names the same three signs three times, and exactly why every day counts here. It typically shows itself in the first days after the injection, with an eye that becomes more painful, redder and worse instead of better. That is precisely the difference from the normal course: the normal course subsides.

• A rise in intraocular pressure immediately after the injection, usually brief and settling by itself; where glaucoma that diagnosis belongs in the planning, because there even brief peaks of pressure carry more weight. With many injections over years the pressure can also rise permanently and then require treatment of its own — which is why it is monitored over time and not only on the day of the injection.
• An injury to the lens or a tear in the retina — very rare, and the reason for the fixed injection site and the prescribed direction of gaze.
• A bleed inside the eye, which clouds vision severely for a time.
• Questions about the rest of the body. Some of the medicine reaches the circulation in small amounts. The prescribing information for anti-VEGF medicines therefore points to arterial thromboembolic events — stroke and heart attack. Events you have had therefore belong in the balance, and how recently such an event happened helps determine the timing: shortly afterwards it can be a reason to schedule the treatment differently, to choose differently, or to agree the approach with your cardiologist or neurologist. That is why we ask about it — and why this is a decision made from your findings, which this page cannot take off your hands. Tell us about such events with the date, if you know it.

What you should take from this is not a fear of the injection but a rule: What gets better in the days after an injection is normal. What gets worse needs looking at the same day. That one distinction replaces every list — and it is the reason we tell you at every appointment where to reach us outside consultation hours.

When the treatment is not enough — and what remains then

Not every eye responds sufficiently to the injections, and not every set of findings can be held quiet over the years. If the cross-sectional scan stays active despite regular treatment, or the interval can never be extended, that is no reason simply to carry on as before: the treatment is then reviewed — the medicine, the interval, the diagnosis itself. Sometimes a cause other than AMD is behind stubborn findings.

And there is the point at which a further injection no longer does any good. Once the centre of the retina has scarred, even a medicine that works well does not bring back the central vision that has been lost. Whether a continued series still protects what lies around it, or is only a burden without a return, is exactly the question — and we raise it rather than avoid it. An end to treatment is not a capitulation and not a verdict on your sight; it is the finding that the benefit no longer justifies the appointments. You decide with us, and you can take your time over it.

What remains afterwards is more than many expect. The outer visual field is preserved — orientation, movement and independence hang on it. For central vision there are magnifying aids, lighting and contrast solutions, read-aloud functions and advisory services for people with impaired sight. That is not a consolation category but a specialty of its own, and we issue you the documents you need for aids and for those who pay for them.

Fitness to drive belongs with it too, and we raise it ourselves rather than leaving it to you. It is uncomfortable and it is important; we assess it from the findings and tell you what applies — openly, but without leaving you alone with the result. Anyone unsure whether their own sight is still enough for driving asks us — not themselves.

The doctor treating you stays the same person — at the assessment, at the follow-up appointments and in the conversation in which it is decided what happens next. Treatment over years consists not only of injections but also of someone knowing your history.