Incidence of choroidal neovascularization in the fellow eye in the comparison of age-related macular degeneration treatments trials

OBJECTIVE

To assess the influence of drug; dosing regimen; and traditional, nontraditional, and genetic risk factors on the incidence of choroidal neovascularization (CNV) in the fellow eye of patients treated for CNV with ranibizumab or bevacizumab.

DESIGN

Cohort study of patients enrolled in a multicenter, randomized clinical trial.

PARTICIPANTS

Patients with no CNV in the fellow eye at the time of enrollment in the Comparison of Age-Related Macular Degeneration Treatments Trials (CATT).

METHODS

Eligibility criteria for the clinical trial required that study eyes have evidence on fluorescein angiography and optical coherence tomography of CNV secondary to age-related macular degeneration (AMD) and visual acuity between 20/25 and 20/320. Treatment for the study eye was assigned randomly to either ranibizumab or bevacizumab and to 3 different regimens for dosing over a 2-year period. The genotypes for 4 single nucleotide polymorphisms (SNPs) associated with risk of AMD were determined. Only patients without CNV in the fellow eye at baseline were considered at risk. The CATT ophthalmologists examined patients every 4 weeks through 2 years and recorded treatment for CNV in the fellow eye.

MAIN OUTCOME MEASURES

Development of CNV in the fellow eye.

RESULTS

Among 1185 CATT participants, 727 (61%) had no CNV in the fellow eye at enrollment. At 2 years, CNV had developed in 75 (20.6%) of 365 patients treated with ranibizumab and in 60 (16.6%) of 362 patients treated with bevacizumab (absolute difference, 4.0%; 95% confidence interval [CI], -1.7% to 9.6%; P = 0.17). The risk ratio for pro re nata dosing relative to monthly dosing was 1.1 (95% CI, 0.8-1.6). Greater elevation of the retinal pigment epithelium and fluid in the foveal center of the study eye were associated with increased incidence of CNV in the fellow eye. Incidence was not associated with genotype on rs1061170 (CFH), rs10490924 (ARMS2), rs11200638 (HTRA1), and rs2230199 (C3; P>0.35).

CONCLUSIONS

Through 2 years, there was no statistically significant difference between ranibizumab and bevacizumab in incidence of CNV in the fellow eye. Genotype on 4 SNPs previously found to be associated with AMD did not affect the risk of CNV in the fellow eye among CATT patients.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

[Vitreomacular adhesion in HD-OCT images in the age-related macular degeneration]

PURPOSE

The aim of this study was to evaluate an incidence of the vitreomacular adhesion in patients with age-related macular degeneration.

MATERIAL AND METHODS

We examined 472 eyes in 241 patients (136 W/ 105 M) in age of 54-92 years (mean 62.6 years +/- 8.5) with dry or wet age-related macular degeneration using Cirrus HD-OCT (Zeiss) macular cube 512x128 program or 5-line pro-gram.

RESULTS

Vitreomacular adhesion was observed in 139 eyes with dry age-related macular degeneration (29.4%, p=0.000*), in 101 eyes with drusen (21.4%, p=0.000*), in 38 eyes with retinal pigment epithelium alterations (8%, p=0.202), in 278 eyes with wet age-related macular degeneration (58.9%, p=0.001*), in 21 eyes with pigment epithelial detachment (4.4%, p=0.303), in 161 eyes with choroidal neovascularzation (34. 1%, p=0.031*/ and in 96 eyes with scar (20.4%, p=0.040*).

CONCLUSIONS

Probably, vitreomacular adhesion alone is not able to induce age-related macular degeneration, but it may be associated with choroidal neovascularization development, it can contribute to exudate formation and choroidal neovascularization, it may induces or sustains a chronic low-grade inflammation in the macula region.

New treatments for age-related macular degeneration

As the estimated life expectancy of the U.S. population increases, so will the incidence of age-related macular degeneration (AMD). Exudative (or "wet") AMD, which is characterized by choroidal neovascularization, carries a high risk of extreme central vision loss and can severely compromise an individual's independence and quality of life. The increasing burden of AMD has created an acute need for more effective treatments. During the last several years, treatment of exudative AMD with intravitreal injection of antivascular endothelial growth factor (anti-VEGF) has dramatically reduced the severe visual loss usually associated with this disorder. This article summarizes the clinical presentation of AMD and reviews the treatments that are currently available.

Complement factor H Y402H polymorphism and characteristics of exudative age-related macular degeneration lesions

PURPOSE

The Y402H polymorphism of the complement factor H (CFH) gene is associated with age-related macular degeneration (AMD) in many populations. The reported genotype-phenotype correlations in the CFH Y402H polymorphism have not been pronounced and no studies on the effect of the polymorphism on the subgroups within wet AMD have been performed. In this study, we wanted to evaluate whether the CFH Y402H polymorphism has an effect on clinical variables in recent exudative AMD lesions.

METHODS

The study included 172 patients with exudative AMD. The size of AMD lesions and the presence and area of other AMD lesion variables were recorded in fluorescein angiography (FA) and analysed in relation to the Y402H genotypes.

RESULTS

The median lesion size (classic + occult choroidal neovascularization [CNV] + serous pigment epithelium detachment [PED] + haemorrhage, if present) was 8.15 mm(2) in patients homozygous for the CFH risk allele (CC), 7.50 mm(2) in heterozygous patients (CT), and 7.05 mm(2) in those with the normal genotype (TT) (p = 0.599). Areas of classic and occult CNV, combined, without serous PED or haemorrhage were 6.37 mm(2), 5.00 mm(2) and 5.18 mm(2), respectively (p = 0.407). There was a trend for CC patients to have more frequently minimally classic and less frequently predominantly classic lesion composition than CT or TT subjects.

CONCLUSIONS

We detected no clear impact of the CFH Y402H polymorphism on recent exudative AMD lesion characteristics. Although the complement cascade is implicated in CNV formation and scarring processes in the retina, the Y402H polymorphism appears relatively neutral in these functions.

Dietary Antioxidants and the Long-term Incidence of Age-Related Macular Degeneration

PURPOSE

To assess the relationship between baseline dietary and supplement intakes of antioxidants and the long-term risk of incident age-related macular degeneration (AMD).

DESIGN

Australian population-based cohort study.

PARTICIPANTS

Of 3654 baseline (1992-1994) participants initially 49 years of older, 2454 were reexamined after 5 years, 10 years, or both.

METHODS

Stereoscopic retinal photographs were graded using the Wisconsin Grading System. Data on potential risk factors were collected. Energy-adjusted intakes of alpha-carotene; beta-carotene; beta-cryptoxanthin; lutein and zeaxanthin; lycopene; vitamins A, C, and E; and iron and zinc were the study factors. Discrete logistic models assessed AMD risk. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated after adjusting for age, gender, smoking, and other risk factors.

MAIN OUTCOME MEASURES

Incident early, late, and any AMD.

RESULTS

For dietary lutein and zeaxanthin, participants in the top tertile of intake had a reduced risk of incident neovascular AMD (RR, 0.35; 95% CI, 0.13-0.92), and those with above median intakes had a reduced risk of indistinct soft or reticular drusen (RR, 0.66; 95% CI, 0.48-0.92). For total zinc intake the RR comparing the top decile intake with the remaining population was 0.56 (95% CI, 0.32-0.97) for any AMD and 0.54 (95% CI, 0.30-0.97) for early AMD. The highest compared with the lowest tertile of total beta-carotene intake predicted incident neovascular AMD (RR, 2.68; 95% CI, 1.03-6.96; P = 0.029, for trend). Similarly, beta-carotene intake from diet alone predicted neovascular AMD (RR comparing tertile 3 with tertile 1, 2.40; 95% CI, 0.98-5.91; P = 0.027, for trend). This association was evident in both ever and never smokers. Higher intakes of total vitamin E predicted late AMD (RR compared with the lowest tertile, 2.83; 95% CI, 1.28-6.23; and RR, 2.55; 95% CI, 1.14-5.70 for the middle and highest tertiles, respectively; P = 0.22, for trend).

CONCLUSIONS

In this population-based cohort study, higher dietary lutein and zeaxanthin intake reduced the risk of long-term incident AMD. This study confirmed the Age-Related Eye Disease Study finding of protective influences from zinc against AMD. Higher beta-carotene intake was associated with an increased risk of AMD.

The relationship of dietary carotenoid and vitamin A, E, and C intake with age-related macular degeneration in a case-control study: AREDS Report No. 22

OBJECTIVE

To evaluate the relationship of dietary carotenoids, vitamin A, alpha-tocopherol, and vitamin C with prevalent age-related macular degeneration (AMD) in the Age-Related Eye Disease Study (AREDS).

METHODS

Demographic, lifestyle, and medical characteristics were ascertained on 4519 AREDS participants aged 60 to 80 years at enrollment. Stereoscopic color fundus photographs were used to categorize participants into 4 AMD severity groups and a control group (participants with < 15 small drusen). Nutrient intake was estimated from a self-administered semiquantitative food frequency questionnaire at enrollment. Intake values were energy adjusted and classified by quintiles. The relationship between diet and AMD status was assessed using logistic regression analyses.

RESULTS

Dietary lutein/zeaxanthin intake was inversely associated with neovascular AMD (odds ratio [OR], 0.65; 95% confidence interval [CI], 0.45-0.93), geographic atrophy (OR, 0.45; 95% CI, 0.24-0.86), and large or extensive intermediate drusen (OR, 0.73; 95% CI, 0.56-0.96), comparing the highest vs lowest quintiles of intake, after adjustment for total energy intake and nonnutrient-based covariates. Other nutrients were not independently related to AMD.

CONCLUSION

Higher dietary intake of lutein/zeaxanthin was independently associated with decreased likelihood of having neovascular AMD, geographic atrophy, and large or extensive intermediate drusen.

Photodynamic Therapy for Age-Related Macular Degeneration in Japanese Patients: Results After One Year

PURPOSE

To evaluate the effects of photodynamic therapy (PDT) with verteporfin 1 year after treatment in Japanese patients with age-related macular degeneration (AMD) and subfoveal choroidal neovascularization.

METHODS

Between May 2004 and March 2005, PDT was performed on 102 eyes of 98 patients (60 men and 38 women) with AMD and subfoveal choroidal neovascularization. Patients were followed for at least 12 months after PDT.

RESULTS

The mean visual acuities in logarithm of the minimum angle of resolution (logMAR) units were 0.978 at baseline, 0.919 at 3 months, 0.895 at 6 months, 0.892 at 9 months, and 0.874 at 12 months. After PDT, the logMAR visual acuity improved by >0.3 logMAR units or more in 28 eyes (27%) and deteriorated by >0.3 logMAR units or more in 13 eyes (13%). Stable or improved vision was achieved in 93% of patients with polypoidal choroidal vasculopathy (PCV).

CONCLUSIONS

The visual outcome in our patients was similar to that of an earlier major Japanese study, and similar to or better than outcomes in Western studies. Differences between Caucasians and Japanese might influence the characteristics of PCV. It is possible that PDT is more effective for AMD patients with PCV than for other AMD patients. Further observations and longer follow-up are necessary.

Neovascularization Associated with Large Retinal Pigment Epithelial Detachment in Elderly Korean Patients: Subdivision According to Indocyanine Green Angiographic Features

PURPOSE

In Korean patients, to subdivide the neovascular forms of age-related macular degeneration (AMD) associated with large retinal pigment epithelial detachment (PED), according to the indocyanine green angiographic features.

METHODS

Indocyanine green angiograms (ICGA) of 67 elderly patients (72 eyes) who presented with a PED of at least 1 disc diameter were evaluated retrospectively.

RESULTS

Polypoidal choroidal vasculopathy (PCV) and typical choroidal neovascularization (CNV)-associated PEDs were identified in 18 eyes (25%) and 19 eyes (26%), respectively. In ten eyes (13.9%), the exact type of neovascularization, whether PCV or CNV, could not be determined. Pure serous PEDs were identified in seven eyes (10%). The remaining 18 eyes (25%) were classified as having retinal angiomatous proliferation (RAP)-associated PED based upon the angiographic findings of vascular connections between the retinal vasculature and the neovascular complex.

CONCLUSIONS

Three subset groups of PCV, CNV, and RAP were present with similar frequency in neovascularized AMD with a large PED in these Korean patients. In particular, RAP, previously thought to be rare in Asian patients, was found to be present with considerable frequency.

[Frequency of recurrence after Verteporfin photodynamic therapy in AMD]

INTRODUCTION

Photodynamic treatment (PDT) with verteporfin is used to treat choroidal subfoveal neovascularization in age-related macular degeneration (AMD). However, the impact of recurrence after PDT on functional results has not been assessed, although it was previously shown to be higher than 50% after thermal laser treatment for juxtafoveal lesions, and visual prognosis was dramatically worsened by recurrence of choroidal neovascularization.

METHOD

Sixty-nine consecutive patients treated with PDT for CNV in AMD were followed every 3 months for up to 3 years.

RESULTS

The observed recurrence rate was 17.4%. Recurrence was not associated with a decrease in visual acuity The average number of treatments was 3.0, increasing to 4.9 in case of recurrence.

CONCLUSION

The recurrence rate is significantly lower after PDT than after thermal laser. It does not have a negative impact on functional outcome.

Polypoidal choroidal vasculopathy in Korean patients with large submacular hemorrhage

PURPOSE

To determine and compare the clinical characteristics, visual prognosis and treatment of hemorrhagic polypoidal choroidal vasculopathy (HPCV) with those of hemorrhagic choroidal neovascularization (HCNV) due to age-related macular degeneration (ARMD).

MATERIALS AND METHODS

Retrospective analysis of 44 consecutive eyes with a submacular hemorrhage comprising more than 50% of the neovascular lesion. Patients were diagnosed as having HPCV or HCNV on the basis of indocyanine green angiography.

RESULTS

Of the 44 eyes with submacular hemorrhage, 26 were classified as HPCV and 18 as HCNV. The baseline patient characteristics were similar for both groups. At the final follow-up the HPCV group had 17 eyes showing visual improvement, four showing maintained vision, and five showing visual deterioration. In contrast, the HCNV group had four eyes showing visual improvement, one showing maintained vision, and 13 showing visual deterioration. Visual acuity of < 0.1 at follow-up was found in 7 (27%) of HPCV eyes and 10 (56%) of HCNV eyes. PDT was performed in 15 HPCV eyes, of which 13 (87%) showed improvement or no change in visual acuity, while only 2 (22%) of the 9 HCNV eyes responded similarly after PDT. Eyes treated with PDT did not have better outcomes compared to eyes that underwent other types of treatment (Fisher's exact test, p > 0.05).

CONCLUSION

PCV accounts for the largest proportion of submacular hemorrhage in Koreans. PCV showed a better visual prognosis than CNV.

Cigarette Smoking, CFH, APOE, ELOVL4, and Risk of Neovascular Age-Related Macular Degeneration

OBJECTIVE

To examine if the genes encoding complement factor H (CFH), apolipoprotein E (APOE), and elongation of very-long-chain fatty acids-like 4 (ELOVL4) confer risk of neovascular age-related macular degeneration (AMD) in an independent or interactive manner when controlling for smoking exposure.

METHODS

We studied 103 unrelated patients with neovascular AMD who each had at least 1 sibling with normal maculae. Smoking histories were obtained. Genotyping was performed by analyzing amplified genomic fragments from CFH, APOE, and ELOVL4 by direct sequencing or by restriction endonuclease digests. Conditional logistic regression analysis was used to build a multifactor model.

RESULTS

For CFH, only the CC genotype carried a statistically significant elevation of disease risk (odds ratio, 49.37; 95% confidence interval, 6.20-393.22; P<.001). No significant association was observed between neovascular AMD and APOE or ELOVL4. No significant interactions were found between smoking and having the CFH or APOE genotype nor were significant interactions found between the CFH, ELOVL4, and APOE genotypes.

CONCLUSIONS

Smoking and having the CFH CC genotype independently increase risk of neovascular AMD. APOE and ELOVL4 genotypes do not seem to modify risk.

CLINICAL RELEVANCE

Smoking 10 pack-years or more and having the CFH CC genotype increase one's risk of neovascular AMD 144-fold compared with smoking less than 10 pack-years and having the CT or TT genotype.

Laser treatment in patients with bilateral large drusen: the complications of age-related macular degeneration prevention trial

OBJECTIVE

To evaluate the efficacy and safety of low-intensity laser treatment in the prevention of visual acuity (VA) loss among participants with bilateral large drusen.

DESIGN

Multicenter randomized clinical trial. One eye of each participant was assigned to treatment, and the contralateral eye was assigned to observation.

PARTICIPANTS

A total of 1052 participants who had > or =10 large (>125 microm) drusen and VA> or =20/40 in each eye enrolled through 22 clinical centers.

INTERVENTION

The initial laser treatment protocol specified 60 barely visible burns applied in a grid pattern within an annulus between 1500 and 2500 mum from the foveal center. At 12 months, eyes assigned to treatment that had sufficient drusen remaining were retreated with 30 burns by targeting drusen within an annulus between 1000 and 2000 mum from the foveal center.

MAIN OUTCOME MEASURE

Proportion of eyes at 5 years with loss of > or =3 lines of VA from baseline. Secondary outcome measures included the development of choroidal neovascularization or geographic atrophy (GA), change in contrast threshold, change in critical print size, and incidence of ocular adverse events.

RESULTS

At 5 years, 188 (20.5%) treated eyes and 188 (20.5%) observed eyes had VA scores > or = 3 lines worse than at the initial visit (P = 1.00). Cumulative 5-year incidence rates for treated and observed eyes were 13.3% and 13.3% (P = 0.95) for choroidal neovascularization and 7.4% and 7.8% (P = 0.64) for GA, respectively. The contrast threshold doubled in 23.9% of treated eyes and in 20.5% of observed eyes (P = 0.40). The critical print size doubled in 29.6% of treated eyes and in 28.4% of observed eyes (P = 0.70). Seven treated eyes and 14 observed eyes had an adverse event of a > or =6-line loss in VA in the absence of late age-related macular degeneration or cataract.

CONCLUSION

As applied in the Complications of Age-Related Macular Degeneration Prevention Trial, low-intensity laser treatment did not demonstrate a clinically significant benefit for vision in eyes of people with bilateral large drusen.

Estimating the Yearly Number of Eyes with Treatable Neovascular Age-Related Macular Degeneration Using a Direct Standardization Method and a Markov Model

PURPOSE

To estimate the number of treatable eyes with neovascular subfoveal age-related macular degeneration (ARMD) in France.

METHODS

A literature search for studies documenting neovascular ARMD incidence rates and direct standardization according to age and gender were performed. Projection to the year 2025 was based on OECD (Organization for Economic and Co-operation Development) data. A cohort of patients aged 75 years was simulated by a seven-state Markov model. The mean treatment duration was fixed arbitrarily at 2 years. The probability of ARMD in the second eye was fixed at 30% at 5 years. Monthly mortality incidence was modeled from INSEE (Institut National de la Statistique et des Etudes Economiques) mortality tables. The time horizon of the model was 25 years. Sensitivity analyses were performed.

RESULTS

Based on the Rotterdam Study, 30,192 citizens per year will develop ARMD in one eye. Among them, 17,585 will be neovascular and 13,805 neovascular subfoveal ARMD. Taking into account the second eye, mortality, and a 2-year treatment duration, the number of neovascular subfoveal treatable eyes yearly would be 37,019 by 2025. Treatment duration was the most sensitive parameter. The number of eyes would be 18,899, 53,204, 67,535, and 80,162, for treatment lasting 1, 3, 4, and 5 years, respectively. A 2% yearly increase is expected up to 2025, due to population aging and the 1950s baby boom.

CONCLUSIONS

According to the study model, the yearly number of subfoveal neovascular ARMD treatable eyes in France will be 37,019 by 2025. Average treatment duration was the most sensitive parameter.

Australian Angiogram Review Panel--monitoring the use of photodynamic therapy with verteporfin

BACKGROUND

Photodynamic therapy with verteporfin for choroidal neovascularization (CNV) secondary to macular disease received an Australian government grant in 2002 to fund treatment for 3 years. Funding was restricted to subfoveal predominantly classic CNV where visual acuity was at least 6/60. Access to this funding was via review of angiograms by an expert panel, the Angiogram Review Panel (ARP), managed by the Royal Australian and New Zealand College of Ophthalmologists.

METHODS

De-identified data from the ARP were obtained for the period June 2002 to April 2005 inclusive and the panel's outcomes were analysed. Health Insurance Commission and Department of Veteran Affairs data for photodynamic therapy for the same interval were also retrieved.

RESULTS

A total of 7198 submissions to the ARP were received for 5867 individuals in this period. Overall 86.6% eyes submitted were accepted for initial funding (treatments 2-4). There was no change over time in the percentage rejected during this period. The first reviewer accepted 77.2%. And the second reviewer accepted a further 7.7%. An additional 1.6% were accepted on appeal. It was estimated that 29.2% of this initial cohort received five or more treatments.

CONCLUSIONS

The ARP data indicate an incidence of subfoveal predominantly classic CNV secondary to macular disease in Australia of about 2000 eyes per annum. Only one quarter of patients received five or more treatments. The panel provided a unique opportunity to estimate the 'whole of nation' incidence of predominantly classic subfoveal CNV secondary to macular disease and thus provides a firm foundation upon which to plan public health spending as new treatments become available.

Pseudoxanthoma elasticum

Pseudoxanthoma elasticum (PXE) is an inherited disorder that is associated with accumulation of mineralized and fragmented elastic fibers in the skin, vessel walls, and Bruch's membrane. Clinically, patients exhibit characteristic lesions of the skin (soft, ivory-colored papules in a reticular pattern that predominantly affect the neck), the posterior segment of the eye (peau d'orange, angioid streaks, choroidal neovascularizations), and the cardiovascular system (peripheral arterial occlusive disease, coronary occlusion, gastrointestinal bleeding). There is no causal therapy. Recent studies suggest that PXE is inherited almost exclusively as an autosomal recessive trait. Its prevalence has been estimated to be 1:25,000-100,000. The ABCC6 gene on chromosome 16p13.1 is associated with the disease. Mutations within the ABCC6 gene cause reduced or absent transmembraneous transport that leads to accumulation of substrate and calcification of elastic fibers. Although based on clinical features the diagnosis appears readily possible, variability in phenotypic expressions and the low prevalence may be responsible that the disease is underdiagnosed. This review covers current knowledge of PXE and presents therapeutic approaches.

HIGH PREVALENCE OF MYOPIA IN JAPANESE PATIENTS WITH IDIOPATHIC FOCAL SUBRETINAL NEOVASCULARIZATION

PURPOSE

To determine whether myopia is more prevalent in Japanese patients with idiopathic focal subretinal neovascularization (IFSN) than in normal control subjects.

METHODS

Forty-seven eyes of 46 patients with an initial diagnosis of IFSN and 291 eyes of 291 controls were studied. Refractive errors were measured with an autorefractometer, and the spherical equivalent of the refractive error was used for the statistical analyses. All patients had undergone fluorescein angiography (FA) to confirm the presence of the choroidal neovascularization. In addition, indocyanine green angiography (ICGA) had been performed to determine whether chorioretinal atrophy and breaks of Bruch's membrane, which are consistent with myopic retinopathy, were present.

RESULTS

The mean age of the patients in the control group was not significantly different from that of patients in the IFSN group. The mean spherical equivalent of the refractive errors was -2.62 +/- 2.70 diopters (D) in the control group and -5.24 +/- 3.41 D in the IFSN group (P = 0.00005). The incidence of high myopia was significantly higher in the IFSN group (41.3%) than in the control group (12.0%, P < 0.0001). FA and ICGA showed no chorioretinal atrophy and lacquer cracks, thus confirming that patients with myopic retinopathy were excluded from the IFSN group. During the mean follow-up period (44.7 months), myopic retinopathy did not develop in any of the eyes in the IFSN group.

CONCLUSION

Japanese patients with IFSN were highly myopic, suggesting that myopia may play a role in the development of choroidal neovascularization in IFSN patients.

Risk factors for the incidence of Advanced Age-Related Macular Degeneration in the Age-Related Eye Disease Study (AREDS) AREDS report no. 19

PURPOSE

To describe the association of demographic, behavioral, medical, and nonretinal ocular factors with the incidence of neovascular age-related macular degeneration (AMD) and central geographic atrophy (CGA) in the Age-Related Eye Disease Study (AREDS), a randomized trial of antioxidants and zinc supplementation prophylaxis for development of advanced AMD.

DESIGN

Clinic-based prospective cohort study.

PARTICIPANTS

Of individuals with early or intermediate AMD at baseline with a median follow-up of 6.3 years, 788 were at risk of developing advanced AMD in one eye (the fellow eye had advanced AMD), and 2506 were at risk in both eyes.

METHODS

The incidence of neovascular AMD and CGA was assessed from stereoscopic color fundus photographs taken at baseline and at annual visits beginning at year 2.

MAIN OUTCOME MEASURES

Neovascular AMD was defined as photocoagulation for choroidal neovascularization, or photographic documentation at the reading center of any of the following: nondrusenoid retinal pigment epithelial detachment, serous or hemorrhagic retinal detachment, hemorrhage under the retina or the retinal pigment epithelium, and subretinal fibrosis. Central geographic atrophy was defined as geographic atrophy involving the center of the macula.

RESULTS

In multivariable models, in persons at risk of advanced AMD in both eyes, while controlling for age, gender, and AREDS treatment group, the following variables were statistically significantly associated with the incidence of neovascular AMD: race (odds ratio [OR], white vs. black, 6.77; 95% confidence interval [CI], 1.24-36.9) and larger amount smoked (OR, >10 vs. < or =10 pack-years [a pack-year is an average of 1 pack of cigarette smoked per day for a year], 1.55; 95% CI, 1.15-2.09). The following were statistically significantly associated with the incidence of CGA: less education (OR, high school graduate or less vs. college graduate, 1.75; 95% CI, 1.10-2.78), greater body mass index (BMI) (OR, obese vs. nonobese, 1.93; 95% CI, 1.25-2.65), larger amount smoked (OR, >10 pack-years vs. < or =10 pack-years, 1.82; 95% CI, 1.25-2.65), and antacid use (OR, 0.29; 95% CI, 0.09-0.91). In persons at risk of developing advanced AMD in one eye, the incidence of neovascular AMD was associated with diabetes (OR, 1.88; 95% CI, 1.07-3.31), and the incidence of CGA was associated with use of antiinflammatory medications (OR, 0.22; 95% CI, 0.08-0.59).

CONCLUSIONS

Results suggest that, among persons with early or intermediate AMD, smoking and BMI are modifiable factors associated with progression to advanced AMD, and suggest other associations (e.g., use of antacids and antiinflammatory medications) that warrant further study. This article contains additional online-only material available at http://www.ophsource.org/periodicals/ophtha. .

[Choroidal neovascularization in children--prevalence, diagnostics and treatment]

Choroidal neovascularization (CNV) belongs to the rare retinal disorders in children. Authors present 3 cases of CNV, which were diagnosed in patients between 12-15 years of age (2 females and 1 male). Complete ophthalmological examination including fluorescein angiography, indocyanine angiography and optical coherence tomography were performed in all cases. Laboratory tests to exclude the systemic diseases were also done. CNV in young people maybe a result of high myopia, angioid streaks, ocular histoplasmosis, trauma or it could be idiopathic. In our series, we found idiopathic CNV in 2 eyes and 1 CNV after traumatic choroidal break. Stabilization of visual acuity was achieved after argon laser treatment in 2 cases.

Incidence of patients presenting with exudative maculopathy and neovascular retinal disease in an urban population

PURPOSE

To determine the incidence of exudative macular and neovascular retinal disease presenting within a defined urban population.

STUDY DESIGN

prospective, observational, consecutive case series.

PATIENTS AND METHODS

Patients referred to ten ophthalmic centers within a defined 10-week period with a newly diagnosed exudative macular and/or neovascular retinal disease were examined fundoscopically, angiographically and quantified according to age and underlying disease.

RESULTS

A total of 527 eyes of 426 patients were referred. The most frequent disease was neovascular age-related macular degeneration (AMD, 199/527, 37.8%, 184 patients), followed by diabetic maculopathy and/or proliferative diabetic retinopathy (199/527, 37.8%, 128 patients) and venous occlusive disease (67/527, 12.7%, 67 patients). The majority of neovascular AMD consisted of occult without classic choroidal neovascularization (CNV, 115/ 199, 57.8%); predominantly classic CNV was seen more often than minimally classic CNV (43/199, 21.6% vs. 27/ 199, 13.6%). The overwhelming majority of the diabetic cases had diabetic macular edema (179/199, 89.9%); only 10.1% had vasoproliferative disease. All other causes of CNV, macular edema/exudation, and retinal neovascularization were observed in < 5% of all patients.

CONCLUSION

The main causes of exudative maculopathy are CNV due to neovascular AMD and diabetic macular edema. Proliferative diabetic retinopathy is the main cause of retinal neovascularization. The number of patients with neovascular AMD presents a future challenge for ophthalmologists.

Polypoidal choroidal vasculopathy and exudative age-related macular degeneration in Greek population

PURPOSE

To study the prevalence, the clinical features, and the visual prognosis without treatment of polypoidal choroidal vasculopathy (PCV) in a large series of Greek patients presenting with exudative maculopathy.

METHODS

The medical records, photographs,as well as fluorescein and indocyanine green(ICG) angiograms of a series of 268 consecutive elderly white Greek patients, who were originally diagnosed as having exudative age-related macular degeneration (AMD) were reviewed retrospectively.

RESULTS

In all, 22 of the 268 (8.2%) patients initially suspected of having AMD were ultimately diagnosed with PCV. In 15 of the 22(68.2%) patients with PCV, the polypoidal lesions were located in the peripapillary area. Large soft drusen were present in only two fellow eyes of the 10 (20%) patients with unilateral PCV compared with 120 fellow eyes of the 148 (81.1%) patients with unilateral AMD. At the last examination, 11 of the 22(50%) patients with PCV and 120 of the 246(48.8%) patients with AMD presented a visual acuity of less than 6/60 in at least one eye due to scar formation in the macula.

CONCLUSIONS

PCV is not an infrequent disease in Greece. A measurable number of Greek patients with findings suggestive of exudative AMD will instead have PCV. ICG angiography is important in differentiating between these two clinical entities. In Greeks, polypoidal lesions are predominantly peripapillary and are not usually associated with macular drusen in the fellow eye. PCV and exudative AMD do not differ significantly in terms of their natural course and visual prognosis in Greek patients.

Extremely Discordant Sib-Pair Study Design to Determine Risk Factorsfor Neovascular Age-Related Macular Degeneration

OBJECTIVE

To search for factors that contribute to the development of neovascular age-related macular degeneration (AMD).

METHODS

In a matched-pair case-control study, we studied sib pairs in which the index sibling had neovascular AMD in at least 1 eye and the unaffected sibling had normal maculae (or at most only a few small drusen) and was past the age at which the index case was diagnosed. Factors studied included sex, iris color, education, alcohol consumption, body mass index, vitamin use, smoking history, hypercholesterolemia, aspirin use, hypertension, other cardiovascular disease, any autoimmune disease, and non-insulin-dependent diabetes mellitus. Conditional logistic regression was performed to identify predictors of neovascular AMD.

RESULTS

On the basis of 73 sib pairs, multivariate regression analysis revealed a statistically significant 2% increase in risk of neovascular AMD with each pack-year of smoking (odds ratio, 1.02; 95% confidence interval, 1.01-1.04; P =.007). Suggestive but nonsignificant associations were also observed for mean lifetime alcohol consumption, adult lifetime body mass index, and hypertension in multivariate regression analyses.

CONCLUSION

Using extremely discordant sib pairs to study risk factors for AMD, a novel approach in epidemiological design, we found evidence that smoking is a risk factor for neovascular AMD.

[Frequency of neovascular lesion types in wet age-related macular degeneration]

Age-related macular degeneration (AMD) is the most common cause of legal blindness among the urbanized world. Neovascular type of the disease which is responsible for majority of severe vision loss in course of AMD has received few years ago a new treatment modality--photodynamic therapy (PDT) with verteporfin (Visudyne). Efficacy of PDT depends on angiographic feature of chorioneovascularization (CNV). There are three main types of CNV: predominantly classic, minimally classic and occult with no classic CNV. No population studies on prevalence of these types are available. We analyzed fluorescein angiography (FA) performed in Eye Clinic of Silesian School of Medicine in Katowice, Poland. FA were performed between January 2002 and March 2004. 2942 cases of CNV due to AMD was identified and their type was stated. Statistical assessment of CNV types frequency was executed. CNV location and size was defined as well. Visual acuity data from patients medical history was used for deeper analysis.