Subfoveal Choroidal Neovascularization In Age-related Macular Degeneration Research Articles

Transpupillary thermotherapy (TTT) for age-related macular degeneration (AMD) – Is it time to say good-bye?

Abstract Purpose To evaluate the effectiveness of transpupillary thermotherapy (TTT) for the closure of classic and occult subfoveal choroidal neovascularization (CNV) and to discuss whether TTT is a useful treatment modality for age-related macular degeneration (AMD). Materials and methods The present paper is a retrospective review of the clinical results from a patient group which was treated with TTT in the University Eye Clinic in Mainz. From January 2000 to December 2002, a total of 20 eyes of 20 patients with subfoveal CNV (due to AMD in 16 eyes, due to pathologic myopia in 4 eyes) received TTT. The procedure was delivered using an infrared diode laser at 810 nm, equipped with a modified slit-lamp adapter with an adjustable beam width of 1.2, 2.0 and 3.0 mm. The spot size was selected so that the treatment beam entirely encompassed the lesion. For a 3 mm spot size, up to 800 mW was delivered to the treatment area using a wide-field contact lens. Power was adjusted in such a way that a barely detectable, light-gray appearance of the lesion was seen after 60 s. Patients were seen in follow-up at 6–8 weeks and re-treatment was considered at 12 weeks postoperatively, if persistence or worsening in the leakage of the lesion was observed. Results Twenty eyes with subfoveal CNV were treated with TTT and the healing process was followed for at least 6 months. After an average of 2.5 treatment sessions in 14/20 eyes, a rapid decline of CNV activity was observed with resolution of subretinal fluid accompanied by reduction of central scotoma and a significant relief of metamorphopsia. Four eyes with classic subfoveal CNV, due to pathologic myopia, showed closure of the CNV and no visual loss (more than 2 lines) in all cases. In the 16 eyes with occult subfoveal CNV in AMD, closure of the neovascular membrane was achieved in 10/16 eyes leading to a visual stabilization (within 2 lines) during the 6 months follow-up. Six of 16 eyes with AMD became legally blind despite repeated TTT treatment sessions (mean: 4.6 sessions; range: 3–6 sessions). A loss of central vision was due to persistence of macular leakage accompanied by choroidal bleeding, atrophy of the retinal pigment epithelium or progressive subfoveal fibrosis. Conclusion The results from this retrospective study demonstrate that occlusion of the neovascular membranes could be observed after TTT for subfoveal CNVs in AMD, as well for highly myopic eyes. Review of the literature shows that the success rate of TTT in AMD (60% after 6 months) is in accordance with the natural progression of occult CNVs in AMD.

INDOCYANINE GREEN–MEDIATED PHOTOTHROMBOSIS WITH AND WITHOUT INTRAVITREAL TRIAMCINOLONE ACETONIDE FOR SUBFOVEAL CHOROIDAL NEOVASCULARIZATION IN AGE-RELATED MACULAR DEGENERATION:

To determine the feasibility, safety, and clinical effect of treating patients with subfoveal choroidal neovascularization (CNV) in age-related macular degeneration (AMD) with indocyanine green (ICG)-mediated photothrombosis (IMP) with and without intravitreal triamcinolone acetonide (TA). Fifteen patients (19 eyes) participated in the study. Nine eyes of seven patients were treated with IMP immediately followed by an intravitreal injection of 4 mg of TA (Group A), and 10 eyes of 8 patients were treated with IMP only (Group B). Patients had a mean follow-up of 6.9 months (range: 3 to 12 months). Patients underwent single or two sessions of IMP. In Group A, visual acuity (VA) showed stability in 6 eyes (66.7%), improvement of VA in 2 eyes (22.2%), and worsening of VA in 1 eye (11.1%). Group B presented VA stability in 9 eyes (90%), and improvement in 1 eye (10%). In total, of the 15 patients (19 eyes) with IMP with or without intravitreal TA, 3 eyes (15.8%) showed improvement, 15 eyes (78.9%) stability, and 1 eye (5.3%) showed worsening of VA. A significant regression of the CNV and diminishing of subretinal fluid was demonstrated with fluorescein angiography and optical coherence tomography in both groups. No patient in Group A required retreatment. Four of 10 eyes (40%) in Group B required one retreatment during the study period. ICG-mediated photothrombosis with and without intravitreal TA may provide stability or improvement in visual acuity and fundus findings in subfoveal CNV in AMD. Further evaluation in a multicenter, randomized, placebo-controlled clinical trial with longer follow-up is needed to accurately assess the safety and efficacy of this new treatment modality.

Pegaptanib sodium for the treatment of neovascular age-related macular degeneration

This article reviews pegaptanib sodium, a compound developed by Eyetech Pharmaceuticals Inc. and Pfizer Inc., for the treatment of neovascular age-related macular degeneration (AMD). Traditional treatment approaches to neovascular AMD have included destructive therapies such as thermal laser photocoagulation and photodynamic therapy; the use of pegaptanib sodium heralds a new treatment approach that is a non-destructive therapy based on the inhibition of vascular endothelial growth factor activity in the eye. This diminishes the neovascular drive in the pathologically hyperpermeable state of the diseased eye. Pegaptanib sodium is one of the first therapeutics belonging to the class of compounds known as aptamers. The chemistry, mechanism of action, pharmacokinetics and rationale for the clinical use of the drug are reviewed. The article highlights and summarises the results of the multi-centre, randomised, sham-controlled clinical trials with pegaptanib sodium to treat subfoveal choroidal neovascularisation in AMD. In addition, the safety profile is reviewed.

Radiotherapy for subfoveal choroidal neovascularization in age-related macular degeneration: a randomized clinical trial

PURPOSE: To report results of 18-month follow up of external beam radiation therapy with photons for subfoveal classic or occult choroidal neovascularization (CNV) in age-related macular degeneration (ARMD). DESIGN: Randomized clinical trial. METHODS: A total of 161 patients with subfoveal CNV in ARMD were recruited in a prospective double-masked study. The posterior pole of the afflicted eye was given 1 Gy (4 × 0.25 Gy) in the control group and 8 Gy (4 × 2 Gy) or 16 Gy (4 × 4 Gy) in the treatment groups. At the time of treatment, and 6, 12, and 18 months post treatment, best-corrected visual acuity (BCVA), reading ability, and CNV size were measured. RESULTS: At the completion of the study 150 (93.2%), 139 (86.3%), and 137 (85.1%) patients were followed for 6, 12, and 18 months, respectively. The mean number of lines lost in the BCVA was −1.69, −2.2, and −3.23 in the 1 Gy group; −0.94, −1.25, and −1.73 in the 8 Gy group; −0.51, −0.67, and −1.93 in the 16 Gy group. The difference was significant after 12 months ( P = .016 for 8 Gy vs. 1 Gy; P = .006 for 16 Gy vs. 1 Gy), and 18 months ( P = .011 for 8 Gy vs. 1 Gy; P = .05 for 16 Gy vs. 1 Gy). The patients with classic CNV, or with an initial distance visual acuity ≥20/100, benefited more from treatment. A significant difference was not found between control group and treatment groups in the reading ability and in the CNV size. No radiation-associated side effects were reported thus far. CONCLUSION: The number of lines lost in the BCVA was less in the 8 Gy and 16 Gy treatment groups than in the control group during the complete follow up examination. Radiation therapy with 8 Gy and 16 Gy, without showing any difference in efficacy, resulted in a near stabilization of the BCVA in patients with subfoveal classic or occult CNV in ARMD. Further studies are necessary to determine the significance of repeated radiotherapy series with a dose of 8 Gy to improve the effect on the CNV size and thereby to prolong stabilization of distance visual acuity.

A 5-year follow-up study for distance visual acuity after low dose radiation on subfoveal choroidal neovascularization in age-related macular degeneration.

In a prospective study with a 5-year follow-up, we assessed the effect of a single series of low-dose radiation on the distance visual acuity in eyes with angiographically confirmed subfoveal choroidal neovascularization (CNV) in age-related macular degeneration (ARMD). The posterior pole of 12 eyes was treated with 5 Gy (4 x 1.25 Gy), and 34 eyes treated with 8 Gy (4 x 2 Gy). The best corrected distance visual acuity was measured at the time of treatment, and annually thereafter for 5 years. The study obtained complete follow-up for 11 patients in the 5-Gy group (nine classic, two occult CNVs), and 29 patients in the 8-Gy group (12 classic, 17 occult CNVs). At baseline, the mean distance visual acuity of the treated eyes was 0.16 (20/125) in the 5-Gy group, and 0.2 (20/100) in the 8-Gy group. Five years later, an average loss of 3.2 lines was present in the 5-Gy group, and 4 lines in the 8-Gy group. After 5 years, an average loss of 2 lines was found in a control group consisting of 18 second eyes with low stage dry ARMD, with a mean distance visual acuity of 0.5 (20/40) at baseline. Statistical analyses with Wilcoxon and Mann-Whitney U-tests showed that a single series of low dose radiation with either 5 Gy or 8 Gy was not able to stabilize the distance visual acuity of eyes with subfoveal CNV in ARMD during a 5-year follow-up.