EFTA Document EFTA01763031

From: Boris Nikolic Sent: Sunday, May 19, 2013 11:48 PM To: Jeffrey Epstein ([email protected]) Subject: FW: Yesterday Please keep this confiden=ial. <=p> Mark is great but I do th=nk that he is trying his best to calm me down. It is the best if you read =rom my mail at the bottom first. Re his email:<=span> Snellen numbers — i= a test that show that I will most likely not have much improvement after =ataract surgery. He is explaining why it might His worry is something th=t I did not mention at all — his worry is that he will need to conti=ue killing my retina by laser (laser burns it my a heat), that he will need to continue to go in rounds and rounds. Essentially my =food vessels of retina are slowly collapsing. This ischemia is what =s producing Vascular growth factor hormone which as a result has a growth =f new fragile blood vessels growing where they should not be growing. As they are where they should not be 61--11; they are fragile and result in bleeding. As a consequence =f bleeding you get scaring an retinal detachments. c=p> Laser acts to burn these =schemic parts of retina so they stop producing vascular growth factor (and=by each treatment I am losing a part of my vision). Lucetis acts to block vas=ular growth factors but it needs repeat injections and has side effect. c=p> Neither of these stop und=rling problem that my small blood vessels are collapsing. <93> Sorry to bother you with =etails but just in case you wondered. <=p> Now really I need back to=work. <=p> B EFTA_R1_00068803 EFTA01763031 <=p> From: Mark B=umenkranz Sent: Sunday, May 19, 2013 11:56 AM To: Boris Nikolic Subject: Re: Yesterday Boris It is no worry at all. I enjoy all our interac=ions and trying to be of help. First of all I do think you notice si=nificant improvement in the right eye, even if the Snellen numbers ( ie 20=60...20/50 etc) don't change that much because the amount of brightness, lack of glare, improved colors etc should be dra=atic. And there is a possibility the Snellen acuity could improved b= 2-3 lines up to 20/40 or better too. We just have to wait and see.&=bsp; As to the lucentis, if it were me I would wait for s=veral reasons. First of all, the clinical appearance of the neovascu=arization is relatively benign, it is in fact hard to find without the ang=ogram and looks mostly if not totally regressed. We should give the laser time to work and see if it does the tr=ck. If not we can always add lucentis, but wouldn't it be better to =now whether we need it or not before injecting. Even if you were to =ave a very minor amount of bleeding we could inject then and then it would clear rapidly. The only issue in my mi=d is whether to prophylactically the areas that are non perfused now but w=thout neovascularization. That is probably the hardest question but if you=are being examined regularly with periodic angiograms then we should be able to pick anything starting up very quickl= so I think it is reasonable just to watch. If you want to speak di=ectly today I am just around the house working and would be happy to do so= best Mark Mark S. Blumenkranz MD Hl Smead Professor and Chairman Department of Ophthalmology Director, Byers Eye Institute at Stanford 2452 Watson Court Palo Alto, CA 94303-5353 Tel: Fax: 2 EFTA_R1_00068804 EFTA01763032 On Sat, May 18, 2013 at 10:17 PM, Boris Nikolic <=a href="mailto target="_blank" wrote: Hi Mark! Thank you so much for Yesterday's=visit. I am so sorry of I scared you (that I a= fainting or something) but I was very distressed after learning that I have two new neovascularization in my "healthy" eye. As that came after I heard from your ca=aract surgeon that a cataract surgery will probably not lead to a significant (some but not too much) improvement in my vision on my ri=ht eye, I was somewhat shaken. THANK YOU AGAIN for you care. My only question to you is whether I st=ll need a Lucentis injection. I am afraid that a) these neovascularization= have progressed somewhat fast (these were not there at all in February).&n=sp; If we count that my last Lucentis was given on January 28th=and perhaps has worked for 3 months or so would indicate that these two ne=vascularizations are only month old or so. b) As it takes some time for laser trea=ment to start working (6 weeks and more I think), I am afraid that there might be a chance for these neovascularization to grow and blee= — something that I can't afford in this eye. Do you think that it is worth having a =ucentis injection in this laser treated eye? Lucentis would start working immediately and might synergize with laser for neovasculariz=tion to dries off. On the other hand, there is a risk with=every Lucentis injection. Last time 2 weeks after Lucentis and a laser in this same eye, I developed new long floaters and OCT was in=icative of begging of PVD. What would you do in my shoes? I am so sorry to bother you but I am sc=red and confused. Thank you Boris 3 EFTA_R1_00068805 EFTA01763033 4 EFTA_R1_00068806 EFTA01763034