Clinicopathological findings of choroidal neovascularisation following verteporfin photodynamic therapy

AIMS: To report the clinicopathologic findings of surgically excised choroidal neovascularisation (CNV) three days after verteporfin photodynamic therapy (PDT). METHODS: In three patients (three eyes) with age related macular degeneration, the CNV was surgically removed three days after PDT. The CNV specimens were examined by light microscopy. RESULTS: The patients had subfoveal classic CNV. Fluorescein angiography revealed non-perfusion of the CNV after PDT and before surgery in all eyes. The light microscopy of the CNV membranes showed swollen and damaged endothelium. Thrombus formation or vascular occlusion in the CNV vessels was not detected. CONCLUSION: PDT did not cause a thrombosis of the vessels within the CNV three days after PDT. Severe endothelial damage of the CNV was observed and is likely a primary effect of PDT. Non-perfusion of the CNV at this stage is possibly secondary to occlusion at a deeper level, namely the underlying feeding choroid.     

Macular translocation for surgical management of subfoveal choroidal neovascularizations in patients with AMD: first results

Background: At present no satisfying treatment for subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD) is available. Visual results after successful surgical removal of subfoveal CNV are disappointing. This has been explained by a primary dysfunction of the retinal pigment epithelium (RPE) in the macular region and the surgical trauma to the RPE in patients with AMD. Therefore, Machemer and Steinhorst developed a technique for macular translocation after surgical removal of subfoveal CNV. We report our first experiences with this technique in patients with subfoveal CNV secondary to AMD. · Methods: Seven patients aged between 71 and 83 years with subfoveal CNV were included in the study. Visual acuity of the fellow eyes was below 20/400. All patients underwent pars plana vitrectomy. Retinal detachment was produced by subretinal infusion of balanced salt solution and a 360° retinotomy at the base of the vitreous was performed. After removal of the CNV, retinal rotation and reattachment, the retina bordering the retinotomy was coagulated with endolaser photocoagulation. Silicone oil was used as temporary tamponade. · Results: In all patients the subfoveal CNV was removed and the macula was translocated by a 15°–45° rotation onto functional RPE. The mean duration of follow-up was 11±3 months. Initial visual acuity ranged from 20/80 to hand movements. Final visual acuity was 20/100 to 20/400. Initially all patients complained of tilted vision. During follow-up the rotation of the image regressed and was well tolerated by all patients. Complications included the development of retinal detachment in three patients after silicone oil removal, development of a macula pucker, and a significant increase of lens opacity in the phakic eyes. · Conclusion: In our series rapid improvement of visual function was observed in one patient only, even if the macula appeared ophthalmoscopically and angiographically normal. Vitreoretinal complications occurred frequently during follow-up. Received: 2 February 1998 Revised version received: 6 April 1998 Accepted: 29 April 1998     

Intravitreal bevacizumab for the treatment of feeder vessel of subfoveal choroidal neovascularization

PURPOSE: To report in a single case the effectiveness of bevacizumab in the treatment of feeder vessels (FVs) of subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). METHODS: One patient received intravitreal bevacizumab (Avastin) (1.25 mg) which was repeated 4 weeks after the first intravitreal injection. Fluorescein angiography and optical coherence tomography (OCT) were performed. Visual acuity (VA) was also checked. RESULTS: Occlusion of the FVs was observed 4 weeks after starting treatment. During the follow-up period and in the final examination 13 months after the first injection, the FVs remained occluded. Complete resolution of macular edema and improvement of the VA were noticed after the second bevacizumab intravitreal injection. CONCLUSIONS: This report documents the successful occlusion of FVs of subfoveal neovascularization after two intravitreal bevacizumab injections in a patient who was followed up for 1 year after the occlusion. Further long-term investigation is warranted given the promising 12-month results.     

Change in retinal sensitivity due to excision of choroidal neovascularization and its influence on visual acuity outcome

PURPOSE: Excision of choroidal neovascular membranes (CNV) has been attempted as an alternative to photocoagulation for the management of subfoveal CNV. To evaluate functional results of CNV excision, we studied retinal sensitivity in the area corresponding to the CNV (CNV area). METHODS: Static microperimetry using a scanning laser ophthalmoscope was performed on 17 eyes before and after CNV excision. We studied whether CNV excision changed retinal sensitivity in the CNV area. To evaluate the relationship between retinal sensitivity and visual acuity, further testing was performed on nine patients who had subfoveal CNV from age-related macular degeneration (ARMD). RESULTS: Preoperatively, 5 of 17 eyes (29.4%) had retinal sensitivity in the CNV area. Postoperatively, 4 of 17 (23.5%) eyes had retinal sensitivity. Surgery did not significantly change retinal sensitivity in the CNV area (P>0.999). There was a significant correlation between the presence of retinal sensitivity and visual acuity. Postoperative visual acuity of eyes with retinal sensitivity in the CNV area was better than that of the eyes without sensitivity in the patients with subfoveal CNV from ARMD (P = 0.0017). CONCLUSIONS: In most cases, excision of CNV does not improve central retinal sensitivity, and patients have poor visual outcome. In some cases, however, postoperative sensitivity in the bed of CNV is preserved and visual outcome is relatively good. Better or worse preoperative retinal sensitivity does not predict better or worse visual acuity outcome, respectively.     

Subfoveal hemorrhage after verteporfin photodynamic therapy in treatment of choroidal neovascularization

BACKGROUND: To identify the frequency of new subfoveal hemorrhage and its impact on visual acuity 2 weeks following verteporfin photodynamic therapy (PDT) in the treatment of predominantly classic subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). METHODS: Retrospective, noncomparative, consecutive, interventional case series. At a tertiary retinal referral center, 104 eyes of 97 consecutive patients with predominantly classic subfoveal CNV were treated by PDT. Morphological outcomes include new subfoveal hemorrhage assessed on the photo review (pretreatment, 2 and 12 weeks after PDT). Visual acuity outcomes include moderate (3-5 ETDRS lines) and severe (6 and more ETDRS lines) loss of visual acuity at 2 weeks after PDT. RESULTS: In this study, 104 eyes of 97 patients were analyzed. CNV in all eyes was secondary to AMD. New subfoveal hemorrhage was found in 22% (23/104) of the eyes 2 weeks following PDT. 17.4% (4/23) of the eyes with new subfoveal hemorrhage had moderate or severe loss of visual acuity. In such eyes the 12-week examination revealed considerable resorption of the new subfoveal hemorrhage with some improvement of visual acuity. CONCLUSIONS: In 3.8% of the eyes that underwent PDT for predominantly classic subfoveal CNV secondary to AMD, new subfoveal hemorrhage may result in moderate or severe loss of visual acuity within 2 weeks. In all eyes with new subfoveal hemorrhage, considerable resorption of the hemorrhage and some improvement of the visual acuity were seen at 12 weeks. Candidates for PDT should be informed about the low risk of this complication.     

Utility of indocyanine green angiography guided laser photocoagulation of choroidal neovascularization in age-related macular degeneration

PURPOSE: The efficacy of photocoagulating choroidal neovascularization (CNV) of age-related macular degeneration with indocyanine green angiography(ICG) was evaluated. 1. The utility of ICG-guided laser photocoagulation for juxtafoveal and extrafoveal CNV, 2. The utility of photocoagulating feeder vessels of subfoveal CNV. METHODS: 1. We compared 139 eyes undergoing ICG-guided laser photocoagulation (IA group), with 85 eyes treated with fluorescein angiography (FAG)-guided laser photocoagulation(FA group), of juxtafoveal and extrafoveal CNV. 2. We treated 35 eyes of 35 patients in which feeder vessels detected by ICG served as targets of photocoagulation. RESULTS: 1. The success rate of laser photocoagulation was 81% in the IA group and 82% in the FA group. There was no statically significant difference between the IA and FA groups in terms of distance from the fovea, CNV size, or lesion type. The rates of maintained or improved visual acuity in groups of IA and FA at the final follow-up as compared with those before treatment, were 71% (61/86 eyes) and 65% (36/55 eyes), respectively. 2. The feeder vessels were obliterated in 66%. The percentage of eyes with maintained or improved visual acuity at six months and at final follow-up as compared to visual acuity before treatment was 64% and 58%, respectively. Thirteen(81%) of 16 eyes which had shown extrafoveal feeder vessel ingrowth sites and small CNV of 1-disc area or less showed feeder vessel closure. CONCLUSION: 1. ICG-guided laser photocoagulation of juxtafoveal and extrafoveal CNV should be performed actively in the same way as FAG-guided laser photocoagulation. 2. It is best to attempt to coagulate feeder vessels when they are extrafoveal and when the CNV is small.     

Optimizing treatment of choroidal neovascularization feeder vessels associated with age-related macular degeneration

PURPOSE: To optimize the method of treating choroidal neovascularization (CNV) associated with age-related macular degeneration (AMD). DESIGN: Experimental study and interventional case series. METHODS: The parameters associated with locating and then photocoagulating CNV feeder vessels were identified and optimized using published data and data derived from modeling the choroidal vasculature. Based on these optimized parameters, a prototype diagnostic/treatment system was designed that captures high-speed indocyanine green (ICG) angiogram images and facilitates analysis of the images by enhancing visualization of dye movement through CNV feeder vessels (FVs). The system also permits precise aiming and delivery of 810- nm wavelength photocoagulation laser energy to target FVs on a real-time ICG angiogram image of the choroidal vasculature. Target FVs are tracked by a joy-stick controlled laser aiming beam until an intravenously-injected high-concentration ICG dye bolus is observed to enter the target vessel, at which time the laser is fired. Proof of principle of the combined diagnosis/treatment system design for performing dye-enhanced photocoagulation (DEP) in the clinical setting and determination of the minimum DEP laser energy needed to close CNV FVs was made in 11 AMD patients requiring treatment of CNV, but for whom other treatment was not appropriate. RESULTS: Using ICG-DEP, CNV feeder vessels were closed with single pulse laser energy, delivering as little as 0.6 to 1.8 J of energy to the fundus, producing no visible change in the fundus. Successful FV closure was usually indicated immediately by presence of incarcerated ICG dye in the vessel adjacent to the burn site. The prototype system proved relatively easy to operate. After acquiring and interpreting diagnostic angiograms and repositioning a patient in front of the device, feeder vessel DEP and treatment evaluation required 15 to 20 minutes. CONCLUSIONS: Indocyanine green dye-enhanced photocoagulation of CNV feeder vessels, facilitated by use of a device that permits real-time visualization of the choroidal circulation while aiming the treatment laser beam, appears to minimize the amount of energy applied to the fundus and the volume of fundus tissue affected by treatment, compared with other treatment modalities. The combination diagnosis/treatment device should be useful in optimizing FV treatment and in refining and evaluating the efficacy of DEP in future clinical trials.     

Intravitreal triamcinolone acetonide for exudative age-related macular degeneration among Japanese patients

AIM: To study the results of intravitreal triamcinolone acetonide (TA) for exudative age-related macular degeneration (AMD) among Japanese patients. METHODS: 13 eyes of 12 Japanese patients (9 males and 3 females) with subfoveal choroidal neovascularization (CNV) of exudative AMD received intravitreal TA (8 mg). Visual acuity, size of CNV and serous retinal detachment, and complications related to treatment were evaluated for 6 months or longer. RESULTS: Postoperative maximum visual acuity significantly improved (p < 0.05). Postoperative eyes had a greater probability of a reduced size of CNV and/or retinal detachment compared to preoperative eyes. Seven eyes showed increased intraocular pressure (21 mm Hg or over), which was controlled well by medication. Cataract development and advancement were observed in 90% of phakic eyes. No other serious complications were found. CONCLUSIONS: Intravitreal TA might be an effective treatment for subfoveal CNV of exudative AMD among Japanese as well as Caucasian patients for a comparatively short period.     

Retinal pigment epithelial tear following photodynamic therapy for choroidal neovascularization secondary to AMD

PURPOSE: To describe retinal pigment epithelial tear following photodynamic therapy (PDT) for subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). DESIGN: Retrospective interventional case series. METHODS: A retrospective study in an institutional practice. We describe seven cases of retinal pigment epithelial (RPE) tear, which developed in seven eyes of seven patients following PDT. All eyes had subfoveal CNV secondary to AMD. RESULTS: Six eyes had occult subfoveal CNV, and one eye had recurrent classic subfoveal CNV. In five patients, the eye that developed the tear was the second eye, whereas the first eye had a disciform scar. In four eyes, the RPE tear developed after one PDT, in one eye the RPE tear developed after the second PDT, and in two eyes the RPE tear developed after the third PDT. In five of seven cases, there was a significant visual deterioration following the RPE tear. CONCLUSIONS: RPE tear is a complication that may occur following PDT in particular when the PDT is applied to an occult subfoveal CNV.     

Surgical extraction of subfoveal choroidal new vessels and submacular haemorrhage in age-related macular degeneration: results of a prospective study

· Background: The surgical extraction of subfoveal choroidal new vessels (CNV) is one of several possibilities to treat subfoveal CNV or haemorrhages in age-related macular degeneration (ARMD). · Methods: Prospective study, follow-up 3–6 months. Clinical and angiographic differentiation of three subgroups: (1) subfoveal well-defined CNV (24 eyes); (2) subfoveal ill-defined CNV with or without well-defined components (10 eyes); (3) submacular haemorrhages (20 eyes). · Results: The mean and median visual acuity and the proportion of eyes with ≥20/200 vision increased slightly in group 1 and decreased slightly in group 2; the differences were not significant. Group 3 demonstrated mean improvement but was heterogeneous, depending on the site and type of underlying CNV. The proportion of eyes with 3 or more lines of improvement after 3 months was 35.3% (7/17), 10% (1/10) and 38.9% (7/18) respectively. The proportion of eyes with a loss of 3 or more lines after 3 months was 5.9% (1/17), 20% (2/10) and 5.6% (1/18) respectively. The recurrence rate was 29.2% (7/24), 8.3% (1/11) and 25% (5/20). Intraoperative complications were iatrogenic central tears in 7.3% (4/55), peripheral tears in 14.5% (8/55) and peripheral retinal detachment in 3.6% (2/55). A postoperative retinal detachment was observed in 2 of 55 eyes (3.6%). All these complications could be managed without ill effect. · Conclusion: Subfoveal surgery might perserve remaining retinal function in eyes with well-defined CNV. However, subgroups of the MPS subfoveal laser trials with comparable initial visual acuity demonstrated postoperative functional stabilisation and similar recurrence rates in well-defined CNV. Though selected cases of submacular haemorrhage did profit from surgery, TPA-assisted gas injection will probably be a better alternative. Unfortunately, surgery for ill-defined CNV, found in the vast majority of eyes with exudative ARMD, seems to worsen the natural course. Surgery has to be combined with restoration of Bruch’s membrane before it can become a possible therapeutic option in ARMD. Received: 6 February 1998 Revised version received: 29 April 1998 Accepted: 12 May 1998     

Macular microcirculation blood flow in patients with age related macular degeneration treated with photodynamic therapy and transpupillary thermotherapy

PURPOSE: To assess the macular retinal and choroidal microcirculation blood flow in patients with exudative age related macular degeneration before and after photodynamic therapy (PDT) or transpupillary thermotherapy (TTT) with Doppler laser scanning (HRF--Heidelberg retinal flowmeter). MATERIAL AND METHODS: Thirty patients with exudative age-related macular degeneration were included in a prospective study. The diagnosis was established based on ophthalmic examination and fluorescein angiography results. In all cases the subfoveal choroidal neovascularization (CNV) was present. Control group consists of the fellow eyes with early stage of AMD (19 eyes) or with disciform scar (11 eyes). In 15 eyes with active CNV PDT was performed and in remaining 15--TTT. In all cases the macular blood flow was measured with Heidelberg retina flowmeter (HRF) before therapy and then 1 week, 4 weeks and 10-12 weeks after treatment. RESULTS: At the baseline examination in a group of eyes with active CNV the mean values of macular blood flow were significantly higher comparing to the fellow eyes and reached respectively: 678.6 +/- 125.0 AU and 298.4 +/- 79.2 AU (p=0.001). Four weeks after treatment all eyes showed the reduction of macular blood flow comparing to the baseline values (p=0.001). Ten to twelve weeks after laser therapy in all cases the increased macular blood flow was detected comparing to the previous examination (p=0.01). During the follow-up period the macular blood flow in the fellow eyes were significantly lower than in treated eyes. CONCLUSIONS: The measurement of macular blood flow using Doppler scanning laser (HRF--Heidelberg retinal flowmeter) may act as a non-invasive and useful diagnostic tool in assessment of CNV activity in patients with exudative age-related degeneration before and after PDT or TTT.     

Inferior limited macular translocation for subfoveal choroidal neovascularization secondary to age-related macular degeneration: 1-year visual outcome and recurrence report

PURPOSE: To report the 1-year visual outcomes and incidence of persistent and recurrent choroidal neovascularization (CNV) after limited macular translocation (LMT) for subfoveal CNV in patients with age-related macular degeneration (ARMD). DESIGN: Interventional case series. METHODS: Retrospective review of 102 consecutive eyes of 101 patients that had the inferior limited macular translocation procedure for subfoveal choroidal neovascularization secondary to ARMD. The outcome measures were visual acuity at 12 months after surgery, change in visual acuity from baseline, the proportion of eyes with moderate (3 or more lines) or severe (6 or more lines) visual acuity loss, and cumulative incidence of persistent or recurrent CNV and its impact on visual acuity. Cumulative incidence was estimated using Kaplan-Meier survival analysis methods. Association between persistence and recurrence of CNV and the Snellen visual acuity recorded at each follow-up visit was evaluated using the Wilcoxon rank-sum test. RESULTS: Eighty-six (84.3%) of 102 eyes completed the 1-year follow-up. By 12 months postoperatively, 35 (40.7%) of the 86 eyes achieved visual acuity of 20/100 or better while 34 (39.5%) of the 86 eyes experienced 2 or more Snellen lines of visual improvement. In the 52 eyes with effective translocation and complete laser photocoagulation of the CNV complex with sparing of the sensory fovea, the estimated incidence of recurrence was 34.6% at 12 months (95% confidence interval of 21%-48%). Sixty-five percent of the recurrences were subfoveal and caused a decrease in visual acuity. There was a trend toward worse median change in visual acuity in eyes with persistent or recurrent CNV. CONCLUSIONS: Limited macular translocation for the treatment of subfoveal CNV secondary to ARMD is associated with improvement in visual acuity in approximately 39.5% of eyes and enables complete laser photocoagulation of the neovascular complex with sparing of the sensory macula in approximately 60.4% of eyes that complete 1 year follow-up. Persistence and recurrence of CNV are common after LMT and are important causes of vision loss. Further studies are warranted to more precisely evaluate the risks and benefits of LMT in ARMD.     

Hypericin-enhanced argon laser photocoagulation for subfoveal choroidal neovascular membrane in age-related macular degeneration: a pilot study

PURPOSE: To evaluate the efficacy and safety of hypericin-enhanced argon laser photocoagulation (H-ALP) in the treatment of subfoveal choroidal neovascular membrane (CNM) secondary to age-related macular degeneration (ARMD). METHODS: After preliminary studies for definition of parameters, argon-green laser was administered 4 hours after single dose of oral 1800 mg hypericin (Saint-John's wort tablets, 0.3%, 300 mg) with a subthreshold light fluence, 24 J/cm2 in 34 eyes (20 with subfoveal classical and 14 with subfoveal occult CNM). Additionally, histopathologic examination was done in two eyes destined for enucleation and exenteration. Maintenance therapy (one tablet, twice a day) was performed for the following 6 months. Anatomic (complete closure of CNM) and functional success (improvement of final visual acuity in three or more Snellen lines) were analyzed with minimum 6-month follow-ups. RESULTS: Histopathologic examinations revealed photothrombosed choriocapillaries together with minimal retinal pigment epithelial disruption in H-ALP exposed areas. One to four (mean 1.88+/-0.91) treatment sessions were applied in 6 to 29 months (mean 12.2+/-5.1 months) follow-up period. Twenty-three (67.6%) eyes had 12 months follow-up. Two eyes in each group had functional success (20% in subfoveal classical and 14.3% in subfoveal occult CNM), which had a minimum 12-month follow-up. Anatomic success was achieved in 16 of 20 (80%) eyes with subfoveal classical and 10 of 14 (71.4%) eyes with subfoveal occult CNM. Severe gastric irritation was noted in 1 (2.9%) and pigment epithelial rupture in 2 (5.9%) patients. CONCLUSIONS: H-ALP is a novel and low-cost treatment for subfoveal CNM secondary to ARMD. It seems its efficacy depends on the photodynamic and antiproliferative properties of hypericin. Comparative studies are required to apply this new technique in ophthalmic practice.     

Dose-related structural effects of photodynamic therapy on choroidal and retinal structures of human eyes

PURPOSE: To determine the effects of photodynamic therapy (PDT) on choroidal and retinal structures of human eyes. METHODS: One eye from each of three patients with large malignant melanomas of the uvea destined for enucleation received PDT using verteporfin according to the approved treatment recommendations for patients with age-related macular degeneration. Two laser spots and two light doses (50 J/cm(2) and 100 J/cm(2)) were applied in unaffected chorioretinal areas. The effects of PDT were assessed by fluorescein and indocyanine-green angiography. The eyes were enucleated 1 week later, fixed in buffered paraformaldehyde/glutaraldehyde solution, bisected along the laser spots, and processed for light and electron microscopy. RESULTS: In agreement with the clinical angiographic findings of hypofluorescence, a rather selective occlusion of the choriocapillary layer was observed in the 50-J/cm(2) PDT areas, whereas the 100-J/cm(2) PDT areas additionally revealed closure of deeper choroidal vessels and focal alterations of the retinal pigment epithelium. The overlying neurosensory retina, including photoreceptors and retinal capillaries, was well preserved in all PDT areas. Electron microscopy showed that alterations of the choriocapillary endothelium comprised swelling, shrinkage and fragmentation of endothelial cells, detachment from their basement membrane up to complete degeneration of the endothelial lining, leading to platelet aggregation, degranulation, and thrombus formation. Complete occlusion of capillary lumina by fibrin, thrombocytes, and cellular debris was observed. Remaining intact endothelial cells appeared to be reorganized into novel smaller vascular channels within occluded lumina. CONCLUSIONS: PDT with verteporfin at a dosage used clinically induces selective occlusion of the physiological choriocapillaris without affecting deeper choroidal, retinal, and optic nerve vessels or the overlying retinal pigment epithelium and neurosensory retina. The main mechanism of action appears to be vascular thrombosis induced by cytotoxic damage of endothelial cells and platelet activation. An increase in light dose enhances the occlusive effect with thrombosis within deeper choroidal layers and damage to the retinal pigment epithelium. However, photoreceptors remained intact at all light doses used.     

Indirect scatter laser photocoagulation to subfoveal choroidal neovascularization in age-related macular degeneration

Background: Occult choroidal neovascularization (CNV), poorly defined on fluorescein angiography, is present in the majority of patients with exudative complications of age-related macular degeneration. For patients who present with this type of subfoveal CNV but who have useful visual acuity, no form of treatment is of proven benefit. Accordingly, a pilot randomized trial of indirect laser treatment was performed. The rationale of this treatment was to inhibit the CNV through laser-induced effects on the retinal pigment epithelium. Methods: Patients with occult subfoveal CNV without retinal pigment epithelial detachment and with visual acuity of 20/200 or better were randomized to treatment or control groups. A grid of laser burns was applied to the macula beyond the area of serous retinal detachment and of angiographically defined occult CNV Results: After an average follow-up of 38 months, there was no difference in mean final visual acuity (0.12 treated, 0.14 control) or clinical outcome between treated and untreated groups. Fluorescein angiography showed gradual enlargement in the occult CNV in 58% of eyes in both groups. A decrease in visual acuity to worse than 20/200 (54% of treated, 50% of control eyes) was associated with ingrowth of well-delineated CNV (6 treated, 7 control eyes) or progression to a fibroglial or atrophic scar (11 treated, 8 control eyes). Conclusions: No benefit was demonstrated for scatter photocoagulation of the macula in patients with age-related macular degeneration and occult subfoveal CNV with initially good visual acuity. There were, however, no complications related to treatment.     

Surgical treatment of extensive peripapillary choroidal neovascularization in elderly patients

PURPOSE: To report the visual outcomes and complications of surgical removal of extensive peripapillary choroidal neovascularization (PPCNV) in elderly patients. DESIGN: Retrospective review. PARTICIPANTS: Seventeen consecutive eyes of 17 patients older than age 55 undergoing PPCNV resection. METHODS: Retrospective review of eyes undergoing surgical removal of extensive PPCNV via pars plana vitrectomy. MAIN OUTCOME MEASURES: Preoperative and postoperative Snellen visual acuity. RESULTS: The mean age of patients was 76.9 years, and the mean duration of follow-up was 29.8 months. In 6 of 17 eyes, the PPCNV was extrafoveal; in two eyes, it was juxtafoveal; and in nine eyes, it was subfoveal. The cause of CNV was idiopathic (nine eyes), age-related macular degeneration (six eyes), presumed ocular histoplasmosis syndrome (one eye), and inflammation (one eye). All eyes were ineligible for laser treatment by MPS criteria. In eyes with extrafoveal CNV, the preoperative Snellen visual acuity ranged from 20/25 to 20/300, and the final visual acuity ranged from 20/40 to 20/800. The two eyes with juxtafoveal CNV had preoperative visual acuities of 20/125 and 20/300, and both had a postoperative acuity of 20/200. Eyes with subfoveal CNV had a range of preoperative visual acuity from 20/125 to 20/800, whereas the final visual acuity ranged from 20/30 to hand motions. Four of the nine eyes with subfoveal lesions had improved visual acuity. Overall, the final visual acuity was stable or improved in six eyes and worsened in 11 eyes. CNV recurrence was noted in four eyes and required reexcision, laser photocoagulation, or both. Surgical complications included retinal detachment (two eyes), retinal hole and epiretinal membrane (one eye), cystoid macular edema (two eyes), and subsequent cataract extraction (four eyes). CONCLUSIONS: Surgical removal of extensive PPCNV in the elderly does not often yield improvement or stabilization of visual acuity. However, 6 of 17 patients had stable or improved visual acuity.     

Fixation pattern and macular sensitivity in eyes with subfoveal choroidal neovascularization secondary to age-related macular degeneration. A microperimetry study

PURPOSE: To investigate the effects of subfoveal choroidal neovascularizzation (CNV) secondary to age-related macular degeneration (AMD) on macular functional parameters quantified with an automatic fundus perimeter. METHODS: 118 eyes of 98 consecutive patients with subfoveal CNV secondary to AMD were evaluated. Best corrected visual acuity (ETDRS charts), fundus photography, and fluorescein angiography were performed. Microperimetry (fundus-related perimetry) was used to quantify macular sensitivity and fixation pattern (location and stability). RESULTS: Of 118 eyes: 26 (21.9%) had central, 18 (15.1%) poor central and 74 (63.0%) eccentric fixation; 31 (26.0%) had stable, 42 (35.6%) relatively unstable and 45 (38.4%) unstable fixation. In 75 eyes (63.4%) a dense central scotoma was found. Angiographic classification of subfoveal CNV (occult versus classic) was not significantly related to fixation pattern (location: P = 0.274; stability: P = 0.385), and presence of dense scotoma (P = 0.41). CONCLUSION: Microperimetric quantification of macular sensitivity and fixation pattern in eyes with subfoveal CNV secondary to AMD offers new data about the impact of visual impairment in these eyes. Moreover, microperimetry improves the functional evaluation of subfoveal CNV in AMD.     

Surgical removal of subfoveal choroidal neovascularization in age-related macular degeneration

OBJECTIVE: To assess the results of surgical excision of subfoveal choroidal neovascularization (CNV) in patients with age-related macular degeneration (AMD). DESIGN: Retrospective, interventional, noncomparative case series. PARTICIPANTS AND INTERVENTION: Sixty-four consecutive patients undergoing surgical removal of AMD-related subfoveal CNV were studied. The surgical method included a small retinotomy, subretinal tissue plasminogen activator (t-PA), perfluoro-n-octane, and air-fluid exchange. MAIN OUTCOME MEASURES: Final visual acuity was the main outcome measure; surgical complications and recurrence rates were also assessed. RESULTS: Preoperative visual acuity ranged from 20/100 to 1/200, with a mean of 20/400. Average follow-up was 19 months. The best acuity achieved after surgery ranged from 20/20 to hand motions, with a mean of 20/200. Final visual acuity ranged from 20/50 to light perception, with a mean of 20/400. Final acuity was improved 3 or more lines in 19 eyes (30%) (median, 5 lines), stable in 27 eyes (42%), and 3 or more lines worse in 18 eyes (28%) (median, 4 lines). Factors associated with greater visual improvement included poorer initial acuity, larger CNV size, and smaller subretinal hemorrhage. Analysis of groups similar to Macular Photocoagulation Study subgroups A through D showed an average improvement of 1 line for group C (visual acuity, 20/200 or worse; CNV larger than 2 disc areas). Other preoperative, intraoperative, and postoperative factors, including recurrence and retinal detachment, did not have a significant effect on final visual outcome. CONCLUSIONS: After surgical excision of AMD-related subfoveal CNV, vision improved or stabilized in the majority of patients. Surgery may be of greatest value for patients with poorer vision, larger subfoveal CNV, and minimal hemorrhage. Further evaluation of this technique should be accomplished via completion of a controlled, randomized multicenter study.     

Surgical management of subfoveal choroidal neovascularization.

BACKGROUND: Subfoveal choroidal neovascularization (CNV) usually is associated with a poor visual prognosis. Laser photocoagulation of certain subfoveal membranes secondary to age-related macular degeneration (ARMD) appears preferable to observation based on recent Macular Photocoagulation Study (MPS) findings but is associated with decreased vision. The authors explored the use of vitreoretinal surgical techniques as an alternative method of eradicating subfoveal CNV. METHODS: After vitrectomy, a small retinotomy technique was used to extract or disconnect from the choroidal circulation subfoveal CNV in 58 eyes. There were 33 eyes with ARMD, 20 eyes with presumed ocular histoplasmosis, and 5 eyes with miscellaneous etiologies. Five eyes also received subfoveal RPE patches. RESULTS: With limited follow-up, significant improvement in vision (defined as 2 Snellen lines) was achieved in 7 of 22 eyes with ARMD CNV removal (1 eye 20/20), 0 of 4 eyes with ARMD CNV removal and RPE patches, and 1 of 7 eyes with ARMD CNV disconnection. Significant improvement was achieved in 6 of 16 eyes with presumed ocular histoplasmosis removal and 0 of 4 eyes with presumed ocular histoplasmosis CNV disconnection. In 5 eyes with miscellaneous CNV, 2 improved (20/20 and 20/40). CNV recurred in 29%. CONCLUSIONS: Some patients with subfoveal CNV appear to benefit from surgical removal. Only rarely do eyes with ARMD improve. Longer-term follow-up and refined case selection are required before this approach can be widely recommended.     

经瞳孔温热疗法(TTT)治疗年龄相关黄斑变性的隐匿型黄斑部视网膜下新生血管膜的疗效观察

目的:探讨TTT激光治疗年龄相关的黄斑变性（ARMD）的隐匿型视网膜下新生血管膜的初步疗效。方法:15例15眼患ARMD隐匿型CNV的患者行TTT治疗,根据CNV的大小选择不同的光斑大小和能量,均照射一分钟。结果:15例患者术后FFA均显示渗漏减少或消失,眼底检查显示出血、渗出、水肿减轻,但15例患者视力均无明显改善。结论:TTT对治疗本组隐匿型ARMD的CNV是有效的而无害的,但需要更多的病例来评价治疗效果。