Tag: #yutiq

Diffusing the bomb

.Reading time 12 minutes.

One Friday morning in early December, my uveitis specialist confirmed that the bleb in my right eye was leaking “briskly.” I knew it and hadn’t wanted to believe it. Earlier that week I had experienced what I can only describe as the same sensation as when my water broke at the end of pregnancy, but in my eye.. a burst one night that woke me. The deluge of tears didn’t come again but my eye felt less dry than usual, yet irritated.

I went home from that appointment and did what you’re not supposed to do. I “googled” bleb leak. One of the first articles that came up was called “A Ticking Time Bomb: How to Fix a Leaking Bleb” with subtitles such as “Danger, Danger” and a really gross picture of an infected eye. Wow, I thought, Merry Christmas to me! I closed my browser. I know better than to go down the “worst-case scenario” road. At least in broad daylight.

So, What in the world is a bleb? you might be asking.

Uveitis is inflammation of the eye. If the inflammation is in the middle or back of the eye, the most effective way to deal with it is a steroid injection or implant. While steroid injection slows or stops inflammation, it usually causes an increase in intraocular pressure. This side effect can damage the eye (the pressure can be too much for the optic nerve). There are multiple ways to reduce pressure (see Complications: high intraocular pressure / steroid-induced glaucoma). After drops and a shunt failed to reduce the pressure in my right eye, a trabeculectomy was performed six years ago.

A trabeculectomy is a procedure that lowers the pressure in the eye by removing a piece of the trabecular meshwork (tissue in your eye that allows aqueous humor (fluid) to drain, which gets blocked up causing pressure to rise). This removal allows for drainage but still in a controlled manner. The fluid drains through a piece of tissue stitched on the eye (like a trap door) to a bleb (small blister or reservoir) just under the eye surface (sclera).

The following Monday, my glaucoma specialist used the same term “briskly”. He placed a bandage contact lens in my eye to cover the bleb leak and help it repair. He gave me pressure-reducing drops to slow the leak and antibiotic drops to keep the eye from becoming infected.

The reason a bleb leak is a big deal? 

There are two main issues (“danger, danger”):

  • Infection: a leak means there’s an opening in the eye. If fluid can get out, bacteria and other organisms can get in and cause infection such as blebitis, endophthalmitis, etc. 
  • Hypotony: Normal eye pressure range is 12-22 mmHg. Anything below this is deemed “hypotony.” If you’re like me and have had pressure reducing surgeries, you may live in the hypotonous range. It only becomes an issue if it starts to cause problems, such as reshaping the eye due to pressure loss, known as shallow anterior chamber. (The front part of your eye, between the iris and the corner (see Anatomy of the Eye) is a liquid filled space called  the anterior chamber.)

Back to the drama. That first night, with the bandage contact lens, I didn’t sleep more than 2 hours before I woke with severe burning and pulsating pain in my right eye. I couldn’t get it to stop. My husband found me sobbing in the bathroom sometime around 2:30 AM. All the articles I had found in the middle of the night (now zooming down “worst-case scenario” road at lightning speed) said that a bandage contact lens was supposed to make the eye less irritated, or maybe cause a little discomfort. I stopped crying and called the doctor’s office.

By 5am my husband and I were back in Seattle, this time at the Harborview Emergency Room (thankfully my parents came over to stay with my kids). The residents decided to try another contact size. No one could get it in my eye. Finally, another size down, my eye seemed to tolerate the new lens. My husband and I even tried to nap in the car to test it. We headed home but I ended up taking it out again in the middle of the night. I was so exhausted I needed to sleep.

The next day, my doctor told me I could take the contact out if needed and put it back in. That night, around 3:00 AM I took it out (I’d had contacts once upon a time, I was sure I could handle it). Let me just tell you: do NOT try this at home. The contact bandage lens was so large, it took my husband and me three tries with multiple attempts each time to get the thing back in. I didn’t take it out after that. I decided I would do what it took to make it to the next appointment. 

Interspersed in these doctor’s visits, my older son turned 7, we celebrated Christmas and New Year’s Day. I began taking more fish oil, getting more omegas in my diet, drinking a ton of water, using lots of moisturizer, lubricating eye drops and gel, and a humidifier. My eye began to adjust to the lens and finally, I was able to sleep without waking up with pain every couple of hours.

About a month into the leak, my glaucoma specialist started seriously considering a second option. Autologous blood therapy, also known as autologous blood injection, is an in-office procedure during which he would take blood from my arm, and inject it into the bleb to stimulate healing. If that didn’t work, it would be the surgical repair of the bleb (the last resort). We decided to give my eye a few more weeks to heal since it’d had such a rough December.

During January my eye became so dry it was hard to focus on work some days. I took the dryness as a good sign. Less fluid meant that hopefully, the bleb was healing. When I went in to see my uveitis specialist on January 21st, the leak had healed! We took out the contact bandage lens but kept up with the drops until I could see the glaucoma specialist the following week to confirm. My right eye did not appreciate the constant drops and it was hard to trust that pressure-lowering drops were the right course of action when my pressure dropped to 2mmHg during one of the appointments in December. This is why you have to find a team of doctors in which you have the utmost faith.

I must say that now I am much more aware of the bleb! I’ve always been relatively careful around it; I know it’s there because it makes my eyelid uneven. Of course, one of the first questions I had asked back in December was: how do you think this happened? Will leaks be chronic now that it’s happened once? (i.e. how can I avoid this in the future)

The guess was that it was punctured, or just repeatedly scraped by, the eyelid holder that is often used when I receive my injections. Since I’ve been getting injections much more frequently the past two years, this makes sense. 

The Monday following my final glaucoma appointment, I got another Yutiq injection to attempt to curb the inflammation that might be causing the persistent vascularization. I was nervous for this one like I haven’t been in a while. I think it was just eye-appointment overkill. We didn’t use the eyelid holder for the numbing injection and then my doctor had the current department resident hold my eyelid for the Yutiq injection instead of the holder…and a lot of numbing and a lot of holding very still. It wasn’t as bad as I’d worked it up in my head.

My right eye has been through so much at times I just think it’s done. A few of those first nights with the bandage contact in, I wondered if the remaining vision in my right eye was worth the pain and the constant disruption of my family’s life. But the leak healed and it really didn’t take that long; it just felt that way.

I’m writing all this to say, if you are “googling” bleb leak in the middle of the night and looking at all the disgusting photos, or even if your eye looks like one of those disgusting photos, it might get better. It might not. But it might. Find something you would miss seeing: your kids, the sunrise, your best friend’s smile, and keep going. With a big bandage contact lens and a little perseverance (or more), you might just diffuse the bomb.

Related Abstracts:

Management of Overfiltering and Leaking Blebs With Autologous Blood Injection (Arch Ophthalmol.1995)

Autologous blood injection for late-onset filtering bleb leak (Am J Ophthalmol, 2001)

Treatment of Postfiltration Bleb Leaks with Autologous Blood (Opthalmol, 1995)

Stick a needle in my eye: intravitreal steroid implant injection tutorial

.Reading time 10 minutes.

This is when you start being offended by the phrase “I’d rather poke myself in the eye with a sharp stick/pencil/needle” or whatever iteration you hear. You don’t think it’s a common phrase until you start getting poked with a sharp needle in your eye to attempt to save your vision. Then you seem to hear it all the time. And you won’t joke about it or wish it on anyone. Cross my heart and hope to die… you know the rest.

An intravitreal steroid implant injection is a treatment for posterior uveitis during which an implant with corticosteroid is injected into the vitreous (clear gel part) of the eye. It’s a shot right at the target (localized) and allows the rest of the body to be spared side effects of high doses of steroids. Often implants are done in conjunction with lower doses of systemic medication.

The intravitreal implant technology is a relatively new advancement; the first implant was approved by the Federal Drug Administration (FDA) in 2009. The capsule design facilitates the sustained release of steroids, which allows for more time in between injections, theoretically. Realistically, every patient’s eye reacts differently to the treatment. One downside to these implants is that there is no manner of knowing when the implant has actually run its course and is no longer releasing medication.

Before intravitreal implants, corticosteroids were injected into the periocular space (around the eyeball). Now, with the implant injection into the vitreous, the lack of fluid flow in the vitreous humor leads to a higher concentration of the steroid, which is effective for inflammation control (https://www.ondrugdelivery.com/sustained-drug-delivery-posterior-segments-eye/).

However, increased ocular pressure and cataracts are almost unavoidable side effects of intravitreal steroid implants. Infection and retinal detachment are risks of the injections. Read more about side effects and complications of treatments here.

I’ve had eight intravitreal injections. Five in the left eye (Ozurdex and Iluvien) and three in the right (Iluvien, Ozurdex and, most recently, Yutiq). This is my experience and these are my tips.

Intravitreal implants are administered via in-office procedures that can be planned or immediate depending on the case and the patient’s insurance.

Injectable intravitreal steroid implants for uveitis include the following:

Ozurdex contains .7 mg of dexamethasone. The implant is 6mm long and .46mm in diameter. It biodegrades into lactic and glycolic acid. It is injected with a 22 gauge syringe and is projected to disperse steroids for around six months with a peak concentration at two months. Ozurdex was approved by the FDA in 2009 for “noninfectious uveitis affecting the back segment of the eye.”

Iluvien contains .19mg of fluocinolone acetonide. It is injected with a 25 gauge syringe and is projected to disperse steroids for 36 months (three years). This injection is indicated for diabetic macular edema. Iluvein was approved by the FDA in 2014.

Yutiq contains .18mg of fluocinolone acetonide with an initial dispersal rate of .25mg. It is 3.5mm long.  It is injected with a 25 gauge syringe and is projected to disperse steroids for 36 months (three years). Yutiq was approved by the FDA in 2018 for “treatment of chronic non-infectious uveitis affecting the posterior segment of the eye”.

Check out the individual product manufacturer websites for financial assistance if your insurance isn’t going to cover the procedure and device. You will need it. Bills for the injection and the visit run about $13,000 when billed through insurance in my experience. Your doctor’s office billing department should be able to assist or, hopefully, handle the whole process.

Don’t be afraid to ask for a prescription for valium or some type of relaxant to take ahead of time if you’re anxious (unless you’re pregnant or breastfeeding). I find that meditation and yoga practice in my daily life help manage my anxiety during injections.

Make sure to arrange for someone to drive you home after the injection.

The care team will begin by marking your forehead above your eye and confirming the eye and the injection. Cleaning of your eye, lid, and lashes comes next by way of drops. My doctor’s office uses numbing drops and a numbing gel, which is heavy and sticky but does the trick!  If you feel any stinging with the drops, tell the assistant or doctor and get more gel!

One of the worst parts (maybe the worst in my opinion) of the entire procedure is the eye speculum. This is the metal retractor that holds your eye open. Something that has helped the comfort of the injections for me immensely is that my doctor smushed down the speculum so it didn’t open so wide. If you have a smaller face, perhaps request a pediatric speculum or ask your doctor to reshape this device to the least possible width needed for the procedure.

Blink and the doctor places the speculum. Now is the time to start your deep breathing or relaxation technique. Focus on relaxing your face; tensing up and increased blinking will make the speculum more uncomfortable. 

Depending on the gauge of the implant injection needle, your doctor and your preference, your doctor will now inject medication into your eye to numb it. This hurts even with the numbing gel. Look where your doctor instructs. Breathe. Unclench your fists and go to your “happy place.”

Next comes the actual implant injection. This can feel like a lot of pressure on the eye depending on the injection. Ozurdex has a definite “click.” Yutiq seemed to require more pressure than Iluvien in my experience.

More than likely, your injection site will bleed (hemorrhage), especially if you opt for the numbing injection. One of the first injections I received bled so bad the blood spread throughout my entire eye. I stayed home from work. My husband and I had a snowboarding trip already planned that weekend with friends and I deleted the photos.

In addition, I was unprepared for all of the stares and flat out rude comments I received. It made me thankful for once to have posterior uveitis that normally is unseen (folks with Anterior or Panuveitis are probably used to this!). References people that I had never met made to physical or domestic abuse astounded me and still does when I get injections! So, decide ahead of time how you would like to react or not react to any comments that come up. I don’t even waste my breath on a response to comments or questions that are off-color or cruel.

I have found that putting an ice pack on the eye repeatedly for about 20 minutes at a time significantly decreased the bleeding and swelling for me. Make sure to rest the eye that day even if you don’t feel like it’s necessary. Take over-the-counter medication for pain or headaches.

The following survey was conducted with folks who get injections far more often than I, but I agree that injections can bring on anxiety and headaches. Survey: Intravitreal Injections Linked to Discomfort, Anxiety

Last, but not least, be diligent about any follow-up medications or drops your provider has prescribed.

Now, move about your life knowing that you are a badass who can handle getting a needle or two in the eye.

Medline Plus’s Version: Intravitreal injection

American Acadmeny of Opthalmology: Eye Injections