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Needle in the Eye

Posted Nov 21 2008 4:27pm
It's gory eye picture time.



This is from last Friday. I'm injecting a drug into the eye. The photo is taken from the top of the patient's head, so you can see the eyebrow at the bottom of the picture. The needle is going into the inferior eye. That big metal thing is a speculum to keep the eye open. You can see a bit of my gloved finger holding the needle on the patient's cheek. That's the orientation.

I do this a few times a week. Most of the time I'm injecting a "wonder-drug" called Avastin into the eyes of people with severe diabetic eye disease. One of the problems with diabetes is growth of new blood vessels or "neovascularization". The standard treatment is to blast them with a laser, but sometimes you but in all the laser you can, and the blood vessels still grow. Avastin is a biological drug that neutralizes the molecule that sends the signal for new blood vessels to grow. The molecule is called VEGF, which stands for vascular endothelial growth factor.

Avastin was developed by Genentech to be given intravenously for treatment of colon cancer. Most cancers rely upon growth of new blood vessels to nourish the cancer mass. Avastin kills colon cancer by interfering with the growth of the blood vessels that feed the cancer. An amazingly smart (and courageous) ophthalmologist, Philip Rosenfeld (MD, PhD) from Bascom Palmer Eye Institute figured that this VEGF inhibitor ought to work for growth of new blood vessels in the eye. About three years ago, he injected it into the eye of one of his patients, and the next day, the new blood vessels were gone. That injection has revolutionized the care of both diabetic eye disease and macular degeneration. I met Phil earlier this year in Hawaii, and he's one of the nicest, most generous smart guys I've ever met. We've been in touch by email since then, and he's helped me identify some top-notch retinal surgeons in Japan.

Avastin was approved by the FDA for use in colon cancer, but in the US, we're allowed to use a drug "off-label," meaning we can use it for treatment of conditions for which it was not specifically approved, as long as we let the patient know it's an off-label use. At Genentech, the same company, was developing a VEGF inhibitor to be specifically used in the eye -- sort of a cousin of Avastin. They were in the midst of the FDA study phase when Phil decided to try Avastin and it worked. They invested millions to get the new eye drug through the FDA approval process, only to have their own drug compete with it through "off-label" use. The cost of the new eye drug, $2,000 per dose (yeah, three zeros). The cost of Avastin per dose, less than $200.

You usually need to get the injection every six weeks or so. The cost difference is huge on a cumulative annual scale.

Anyway, I really enjoy this part of my work -- the procedures. During my internal medicine training at the University of Chicago, my co-residents found out that I was going on to do an ophthalmology residency. Many were envious. But one said, "Are you kidding. He's going to make a living sticking razor blades and needles in people's eyes." Yeah, and I love it.

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