Sensorineural hearing loss in children

The objective of the study was to examine the aetiology of sensorineural hearing loss (SNHL) in a paediatric population presenting to the National Centre of Medical Genetics. A retrospective chart review from 1998 to 2006. One hundred and twenty nine children were investigated for SNHL. The average age of diagnosis of hearing loss was 36 months. The degree of hearing loss was mild in 8 children, moderate in 33 children, severe in 31 children and profound in 57 children. Eighty-five children (66%) were diagnosed with a hereditary hearing loss, 11 (8%) children had an acquired hearing loss and no cause found in 33 (26%) children. This is the first report of the causes of hearing loss in Irish children. The mean age of diagnosis in our cohort is high and emphasises the need for a neonatal screening programme. There remains a number of children for whom the cause of hearing loss remains unknown.

The quality of optometrists' referral letters for glaucoma

PURPOSE

The purpose of the study was to evaluate the quality of content of optometrist-initiated glaucoma referral letters arriving at the appointment booking centre at Moorfields Eye Hospital (MEH).

METHODS

The minimum standard of information required for an ophthalmologist to determine the appropriateness and urgency of glaucoma suspect referral was determined, and criteria for three standards of referral letter formulated: 'Ideal', 'Acceptable' and 'Fail'. These standards were applied to a prospective review of all optometrist-derived referrals for glaucoma or suspected glaucoma cases arriving in the MEH booking centre over a 4-month period. The contents of each letter were scrutinised and classified based on the criteria within each standard.

RESULTS

Forty-nine per cent of referral letters were found to be of 'acceptable' quality, 7%'ideal' quality and the remainder classed as "fail". The main reason for failure was an omission of non-clinical information, including patient and/or referring practice details, although 26% of letters failed to include an optic disc evaluation and 6% failed to provide intra-ocular pressure measurements. Two-thirds of 'acceptable' letters did not reach the 'ideal' standard due to a lack of discussion of risk factors, visual field analysis or recommendations for referral speed.

DISCUSSION

The information gleaned from this prospective study indicates a need to improve the quality of optometrists' glaucoma referral letters, particularly with respect to completion of all the items set out on the General Ophthalmic Services (GOS) 18 referral form.

'Minor' morbidity after parotid surgery via the modified Blair incision

OBJECTIVE

To assess the 'minor' morbidities subjectively experienced by the patient after parotid surgery; these include scar cosmesis and pain, 'contour' deformity following removal of parotid bulk, numbness of the pinna and gustatory sweating.

DESIGN

Retrospective study

SETTING

Tertiary Referral Centre.

PATIENTS

28 patients were included in the study.

RESULTS

Contour deformity, scarring and paraesthesia of the pinna secondary to great auricular nerve sacrifice are the most noticeable sequelae following parotidectomy.

DISCUSSION

Although facial nerve injury is the most serious morbidity following parotidectomy, it is relatively uncommon. Other 'minor' morbidities are more likely to cause post-operative problems. Despite there being a number of different approaches to the parotidectomy, with or without reconstruction, these have not been satisfactorily compared.

The clinical effectiveness and cost-effectiveness of screening for open angle glaucoma: a systematic review and economic evaluation

OBJECTIVES

To assess whether open angle glaucoma (OAG) screening meets the UK National Screening Committee criteria, to compare screening strategies with case finding, to estimate test parameters, to model estimates of cost and cost-effectiveness, and to identify areas for future research.

DATA SOURCES

Major electronic databases were searched up to December 2005.

REVIEW METHODS

Screening strategies were developed by wide consultation. Markov submodels were developed to represent screening strategies. Parameter estimates were determined by systematic reviews of epidemiology, economic evaluations of screening, and effectiveness (test accuracy, screening and treatment). Tailored highly sensitive electronic searches were undertaken.

RESULTS

Most potential screening tests reviewed had an estimated specificity of 85% or higher. No test was clearly most accurate, with only a few, heterogeneous studies for each test. No randomised controlled trials (RCTs) of screening were identified. Based on two treatment RCTs, early treatment reduces the risk of progression. Extrapolating from this, and assuming accelerated progression with advancing disease severity, without treatment the mean time to blindness in at least one eye was approximately 23 years, compared to 35 years with treatment. Prevalence would have to be about 3-4% in 40 year olds with a screening interval of 10 years to approach cost-effectiveness. It is predicted that screening might be cost-effective in a 50-year-old cohort at a prevalence of 4% with a 10-year screening interval. General population screening at any age, thus, appears not to be cost-effective. Selective screening of groups with higher prevalence (family history, black ethnicity) might be worthwhile, although this would only cover 6% of the population. Extension to include other at-risk cohorts (e.g. myopia and diabetes) would include 37% of the general population, but the prevalence is then too low for screening to be considered cost-effective. Screening using a test with initial automated classification followed by assessment by a specialised optometrist, for test positives, was more cost-effective than initial specialised optometric assessment. The cost-effectiveness of the screening programme was highly sensitive to the perspective on costs (NHS or societal). In the base-case model, the NHS costs of visual impairment were estimated as 669 pounds. If annual societal costs were 8800 pounds, then screening might be considered cost-effective for a 40-year-old cohort with 1% OAG prevalence assuming a willingness to pay of 30,000 pounds per quality-adjusted life-year. Of lesser importance were changes to estimates of attendance for sight tests, incidence of OAG, rate of progression and utility values for each stage of OAG severity. Cost-effectiveness was not particularly sensitive to the accuracy of screening tests within the ranges observed. However, a highly specific test is required to reduce large numbers of false-positive referrals. The findings that population screening is unlikely to be cost-effective are based on an economic model whose parameter estimates have considerable uncertainty. In particular, if rate of progression and/or costs of visual impairment are higher than estimated then screening could be cost-effective.

CONCLUSIONS

While population screening is not cost-effective, the targeted screening of high-risk groups may be. Procedures for identifying those at risk, for quality assuring the programme, as well as adequate service provision for those screened positive would all be needed. Glaucoma detection can be improved by increasing attendance for eye examination, and improving the performance of current testing by either refining practice or adding in a technology-based first assessment, the latter being the more cost-effective option. This has implications for any future organisational changes in community eye-care services. Further research should aim to develop and provide quality data to populate the economic model, by conducting a feasibility study of interventions to improve detection, by obtaining further data on costs of blindness, risk of progression and health outcomes, and by conducting an RCT of interventions to improve the uptake of glaucoma testing.

Laser trabeculoplasty for open angle glaucoma

BACKGROUND

Open angle glaucoma (OAG) is an important cause of blindness worldwide. Laser trabeculoplasty, a treatment modality, still does not have a clear position in the treatment sequence.

OBJECTIVES

The objective of this review was to study the effects of laser trabeculoplasty for OAG.

SEARCH STRATEGY

We identified trials from CENTRAL in The Cochrane Library, MEDLINE, EMBASE, LILACS and manual searching. We also contacted researchers in the field.

SELECTION CRITERIA

We included randomised controlled trials comparing laser trabeculoplasty with no intervention, with medical treatment, or with surgery. We also included trials comparing different technical modalities of laser trabeculoplasty.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted the data. We contacted trial investigators for missing information.

MAIN RESULTS

This review included 19 trials involving 2137 participants. Only five trials fulfilled the criteria of good methodological quality. One trial compared laser trabeculoplasty with topical beta-blocker to no intervention in early glaucoma. The risk of glaucoma progression was higher in the control group at six years of follow up (risk ratio (RR) 0.71 95% confidence interval (CI) 0.53 to 0.95). No difference in health-related quality of life was observed between the two groups. Three trials compared laser trabeculoplasty to medication (regimens used before the 1990s) in people with newly diagnosed OAG. The risk of uncontrolled intraocular pressure (IOP) was higher in the medication group compared to the trabeculoplasty group at six months and two years of follow up. Three trials compared laser trabeculoplasty with trabeculectomy. The risk of uncontrolled IOP was significantly higher in the trabeculoplasty group at six months but significant heterogeneity was observed at two years. Diode and selective laser are compared to argon laser trabeculoplasty in three trials and there is some evidence showing a comparable effect in controlling IOP at six months and one year of follow up.

AUTHORS' CONCLUSIONS

Evidence suggests that, in people with newly diagnosed OAG, the risk of uncontrolled IOP is higher in people treated with medication used before the 1990s when compared to laser trabeculoplasty at two years follow up. Trabeculoplasty is less effective than trabeculectomy in controlling IOP at six months and two years follow up. Different laser technology and protocol modalities were compared to the traditional laser trabeculoplasty and more evidence is necessary to determine if they are equivalent or not. There is no evidence to determine the effectiveness of laser trabeculoplasty compared to contemporary medication (prostaglandin analogues, topical anhydrase inhibitors and alpha2-agonists) and also with contemporary surgical techniques. Also there should be further investigation in to the effectiveness of laser trabeculoplasty in specific racial groups, specific diagnostic groups, such as pseudoexfoliation and pigmentary glaucoma and different stages of OAG. More research is also required determining cost-effectiveness of laser trabeculoplasty in the management of glaucoma.

Photodynamic therapy for neovascular age-related macular degeneration

BACKGROUND

In neovascular age-related macular degeneration (AMD) new vessels grow under the retina distorting vision and leading to scarring. This is exacerbated if the blood vessels leak. Photodynamic therapy (PDT) has been investigated as a way to treat the neovascular membranes without affecting the retina.

OBJECTIVES

The aim of this review was to examine the effects of PDT in the treatment of neovascular AMD.

SEARCH STRATEGY

We searched CENTRAL (Issue 1, 2007), MEDLINE (1966 to March 2007), EMBASE (1980 to March 2007). We contacted experts in the field and searched the reference lists of relevant studies.

SELECTION CRITERIA

We included randomised trials of PDT in people with choroidal neovascularisation due to AMD.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data. Risk ratios were combined using a fixed-effect model after testing for heterogeneity.

MAIN RESULTS

Three published trials were identified that randomised 1022 participants to verteporfin therapy compared to 5% dextrose in water. The TAP and VIP trials were performed by the same investigators using largely the same clinical centres and funded by manufacturers of verteporfin. Outcome data were available at 12 and 24 months after the first treatment. Participants received on average five treatments over two years. The risk ratio of losing three or more lines of visual acuity at 24 months comparing the intervention with the control group was 0.77 (95% confidence interval 0.69 to 0.87). The risk ratio of losing six or more lines of visual acuity at 24 months comparing the intervention with the control group was 0.62 (95% confidence interval 0.50 to 0.76). The results at 12 months were similar to those at 24 months. The most serious adverse outcome, acute (within seven days of treatment) severe visual acuity decrease, occurs in about one in 50 patients. Some outcomes from the more recent VIM trial could be included in the meta-analysis but have not greatly altered the findings.

AUTHORS' CONCLUSIONS

Photodynamic therapy in people with choroidal neovascularisation due to AMD is probably effective in preventing visual loss though there is doubt about the size of the effect. Outcomes and potential adverse effects of this treatment should be monitored closely. Further independent trials of verteporfin are required to establish that the effects seen in this study are consistent and to examine important issues not yet addressed, particularly relating to quality of life and cost. However, the advent of new interventions for AMD make this unlikely.

Causes of blind certifications in England and Wales: April 1999–March 2000

AIM

The last complete report on causes of blindness in England and Wales was for data collected during April 1990 to March 1991. This current study sought to update these figures, with data collected during April 1999 to March 2000, and examine variation in cause by age group.

METHODS

In England and Wales, registration for blindness is voluntary and is initiated by certification by a consultant ophthalmologist. The main cause of blindness was ascertained where possible for all certificates completed during April 1999 to March 2000 and tabulated by age group.

RESULTS

A total of 34 410 BD8 certificates were received, of which 13 788 (40%) were for people certified as blind. Different causes predominated within different age groups. Age related macular degeneration (AMD) was the lead cause in those aged 65 years and above, diabetic retinopathy was the lead cause in people of working ages (16-64 years), whereas cerebral visual impairment and disorders of the optic nerve accounted for over 40% of blind certificates completed for children.

CONCLUSION

Estimates of vision impairment based on certifications for blindness in England and Wales are likely to be imprecise. They do, however, give some measure of the burden at hospital level of sight impairing eye conditions. If factors determining the imprecision remain constant, temporal monitoring of causes may enable changes and development of new conditions leading to vision impairment to be detected.

Surgical interventions for age-related cataract

BACKGROUND

Cataract accounts for 50% of blindness globally and remains the leading cause of visual impairment in all regions of the world, despite improvements in surgical outcomes (WHO 2005). This number is expected to rise due to an aging population and increase in life expectancy. Although cataracts are not preventable, their surgical treatment is one of the most cost-effective interventions in healthcare.

OBJECTIVES

To compare the effects of different surgical interventions for age-related cataract.

SEARCH STRATEGY

We searched CENTRAL, MEDLINE, EMBASE up to July 2006, NRR Issue 3 2005, the reference lists of identified trials and we contacted investigators and experts in the field for details of published and unpublished trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTS).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and discrepancies were resolved by discussion. Where appropriate, risk ratios, odds ratios and weighted mean differences were summarised after assessing heterogeneity between the studies.

MAIN RESULTS

We identified 17 trials that randomised a total of 9627 people. Phacoemulsification gave a better visual outcome than extracapsular surgery but similar average cost per procedure in Europe but not in poorer countries. Extracapsular surgery with posterior chamber lens implant and ICCE with or without an anterior chamber intraocular lens (IOL) implant gave acceptable visual outcomes but extracapsular surgery had less complications. Manual small incision surgery provides better visual outcome than ECCE but slightly inferior unaided visual acuity compared to phacoemulsification.

AUTHORS' CONCLUSIONS

This review provides evidence from seven RCTs that phacoemulsification gives a better outcome than ECCE with sutures. We also found evidence that ECCE with a posterior chamber lens implant provides better visual outcome than ICCE with aphakic glasses. The long term effect of posterior capsular opacification (PCO) needs to be assessed in larger populations. The data also suggests that ICCE with an anterior chamber lens implant is an effective alternative to ICCE with aphakic glasses, with similar safety. Phacoemulsification provides the best visual outcomes but will only be accessible to the poorer countries if the cost of phacoemulsification and foldable IOLs decrease. Manual small incision cataract surgery provides early visual rehabilitation and comparable visual outcome to PHACO. It has better visual outcomes than ECCE and can be used in any clinic that is currently carrying out ECCE with IOL. Further research from developing regions are needed to compare the cost and longer term outcomes of these procedures e.g. PCO and corneal endothelial cell damage.

Screening for prevention of optic nerve damage due to chronic open angle glaucoma

BACKGROUND

Open angle glaucoma (OAG) is a primary, progressive optic neuropathy; the onset is without symptoms and progression occurs silently until the advanced stages of the disease, when it affects central vision. The blindness caused by OAG is irreversible. It has often been assumed to be a condition that fulfils the criteria for population screening, although this has not been supported by other in-depth non-systematic reviews. The focus of this review was to examine the evidence for the effectiveness of screening for OAG.

OBJECTIVES

To determine the impact of screening for OAG compared with opportunistic case findings or current referral practices on the prevalence of and the degree of optic nerve damage due to OAG in screened and unscreened populations.

SEARCH STRATEGY

We included any randomised controlled trial (RCT) evaluating population-based screening programmes for OAG with a minimum one year follow up. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (which contains the Cochrane Eyes and Vision Trials Register) (Issue 1, 2006), MEDLINE (1950 to February 2006) and EMBASE (1988 to February 2006). We also searched the National Research Register (Issue 1, 2006) and Zetoc for grey literature (29 June 2006). There were no language or date restrictions in the electronic searches.

SELECTION CRITERIA

We planned to include RCTs, including cluster RCTs.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the study abstracts identified by the electronic searches. We did not find any trials that met the inclusion criteria.

MAIN RESULTS

As no trials were identified, no formal analysis was performed.

AUTHORS' CONCLUSIONS

On the basis of current evidence, population-based screening for chronic OAG cannot be recommended, although much can be done to improve awareness and encourage at risk individuals to seek testing. In wealthy countries with equitable access to high quality eye care and health education, blindness from chronic OAG should become increasingly rare; much greater challenges face poor and emerging economies and countries where there are substantial health and wealth inequalities. Effectiveness of screening for OAG can be established only by high quality RCTs.

The epidemiology of medical treatment for glaucoma and ocular hypertension in the United Kingdom: 1994 to 2003

AIMS

To study trends in the prevalence of being treated for glaucoma and ocular hypertension from 1994 to 2003, and to examine factors determining treatment in 2002.

METHODS

Computerised data (the DIN-LINK database) from 131 general practices across the United Kingdom, in which half a million patients aged 40 years or more were registered annually, were used. On average 10 000 patients were treated for glaucoma and ocular hypertension annually.

RESULTS

Prevalence of being treated for glaucoma and ocular hypertension increased from 1.7% in 1994 to 2.3% in 2003. Those aged 85 years or more were 13 times (95% CI 12.2 to 13.8) more likely to be treated than those aged 40-64 years. Men were more likely to be treated than women (OR 1.24, 95% CI 1.19 to 1.28). Subjects "hard pressed" were less likely to be treated than "wealthy achievers" (OR 0.92, 95% CI 0.86 to 0.99). While use of topical beta blocker only medications has declined since 1995, use of topical prostaglandins and combination therapies has increased. In 2003, use of prostaglandins overtook beta blocker only medications.

CONCLUSION

Prevalence of being treated for glaucoma has increased over time, and rises with age. Differences in treatment by sex and social status could be explained by use of or access to health care or by underlying prevalence of disease. Trends in treated glaucoma emphasise the shift from use of topical beta blockers to newer therapies.

Leading causes of certification for blindness and partial sight in England & Wales

Background

Prevention of visual impairment is an international priority agreed at the World Health Assembly of 2002- yet many countries lack contemporary data about incidence and causes from which priorities for prevention, treatment and management can be identified.

Methods

Registration as blind or partially-sighted in England and Wales is voluntary and is initiated by certification by a consultant ophthalmologist. From all certificates completed during the year April 1999 to March 2000, the main cause of visual loss was ascertained where possible and here we present information on the leading causes observed and comment on changes in the three leading causes since the last analysis conducted for 1990–1991 data.

Results

13788 people were certified as blind, 19107 were certified as partially sighted. The majority of certifications were in the older age groups. The most commonly recorded main cause of certifications for both blindness (57.2 %) and partial sight (56 %) was degeneration of the macula and posterior pole which largely comprises age-related macular degeneration. Glaucoma and diabetic retinopathy were the next most commonly recorded main causes. Overall, the age specific incidence of all three leading causes has increased since 1990–1991 – with changes in diabetic retinopathy being the most marked – particularly in the over 65's where figures have more than doubled.

Conclusion

The numbers of individuals per 100,000 population being certified blind or partially sighted due to the three leading causes – AMD, diabetic retinopathy and glaucoma have increased since 1990. This may to some extent be explained by improved ascertainment. The process of registration for severe visual impairment in England and Wales is currently undergoing review. Efforts must be made to ensure that routine collection of data on causes of severe visual impairment is continued, particularly in this age of improved technology, to allow such trends to be monitored and changes in policy to be informed.

Non-steroidal anti-inflammatory agents for cystoid macular oedema following cataract surgery: a systematic review

AIM

To examine the effectiveness of non-steroidal anti-inflammatory drugs (NSAIDs) in the treatment of cystoid macular oedema (CMO) following cataract surgery.

METHODS

Systematic literature review of randomised controlled trials (RCTs) that evaluated the effects of NSAIDs in the treatment of CMO following cataract surgery was done according to the Cochrane Collaboration methodology.

RESULTS

Seven trials involving a total of 266 participants were included. Four trials studied the effects of NSAIDs in chronic CMO while the other three trials examined the effect of NSAIDs in acute CMO. Little evidence of effectiveness was found for oral indomethacin and topical fenoprofen for chronic CMO in two small trials. Treatment with topical 0.5% ketorolac for chronic CMO was found to be effective in two trials. Three trials examined the effect of topical NSAIDs on acute CMO. The comparisons among these studies were of a NSAID to placebo, prednisolone or another NSAID. Because of considerable heterogeneity between these study designs, their results were not combined in a meta-analysis.

CONCLUSION

A positive effect of topical NSAID (0.5% ketorolac tromethamine ophthalmic solution) on chronic CMO was noted. However, there is not enough evidence to show the effectiveness of NSAIDs in acute CMO following cataract surgery.

Intra-operative mitomycin C for glaucoma surgery

BACKGROUND

Trabeculectomy is performed as a treatment for glaucoma to lower the intraocular pressure (IOP). Mitomycin C (MMC) is an antimetabolite used during the initial stages of a trabeculectomy to prevent excessive postoperative scarring and thus reduce the risk of failure.

OBJECTIVES

To assess the effects of intraoperative MMC compared to placebo in trabeculectomy.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) on The Cochrane Library (Issue 1, 2005), MEDLINE (1966 to March 2005), EMBASE (1985 to 20 March 2005), SIGLE (1980 to December 2004), the National Research Register (Issue 1, 2005), LILACS (29 March 2005) and reference lists of articles. We also contacted researchers in the field.

SELECTION CRITERIA

We included randomised trials of intraoperative MMC compared to placebo in trabeculectomy surgery.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted trial investigators for missing information.

MAIN RESULTS

Eleven trials, involving a total of 698 participants, were included. The trials enrolled three types of participants (high risk of failure, trabeculectomy combined with cataract surgery, no previous surgical intervention). Mitomycin C appears to reduce the relative risk of failure of trabeculectomy both in eyes at high risk of failure (relative risk 0.32, 95% confidence interval 0.20 to 0.53) and those undergoing surgery for the first time (relative risk 0.29, 95% confidence interval 0.16 to 0.53). No significant effect on failure was noted in the group undergoing trabeculectomy combined with cataract extraction. Mean IOP was significantly reduced at 12 months in all three participant groups receiving MMC compared to placebo. No significant increase in permanent sight-threatening complications was detected. However, none of the trials were large enough or of sufficient duration to address the long-term risk of bleb infection and endophthalmitis which has been reported in observational studies. Some evidence exists that MMC increases the risk of cataract.

AUTHORS' CONCLUSIONS

Intraoperative MMC reduces the risk of surgical failure in eyes that have undergone no previous surgery and in eyes at high risk of failure. Compared to placebo it reduces mean IOP at 12 months in all groups of participants in this review. Apart from an increase in cataract formation following MMC, there was insufficient power to detect any increase in other serious side effects such as endophthalmitis.

Photodynamic therapy for neovascular age-related macular degeneration

BACKGROUND

In neovascular age-related macular degeneration (AMD) new vessels grow under the retina distorting vision and leading to scarring. This is exacerbated if the blood vessels leak. Photodynamic therapy (PDT) has been investigated as a way to treat the neovascular membranes without affecting the retina.

OBJECTIVES

The aim of this review was to examine the effects of PDT in the treatment of neovascular AMD.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which includes the Cochrane Eyes and Vision Group Trials Register) on The Cochrane Library (Issue 1, 2005), MEDLINE (1966 to January 2005), EMBASE (1980 to January 2005). We used the Science Citation Index to search for reports that cited relevant studies. We contacted experts in the field and searched the reference lists of relevant studies.

SELECTION CRITERIA

We included randomised trials of PDT in people with choroidal neovascularisation due to AMD.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data. Relative risks were combined using a fixed-effect model after testing for heterogeneity.

MAIN RESULTS

Two published trials were identified that randomised 948 participants to verteporfin therapy compared to 5% dextrose in water. Both trials were performed by the same investigators using largely the same clinical centres and funded by manufacturers of verteporfin. Outcome data were available at 12 and 24 months after the first treatment. Participants received on average five treatments over two years. The relative risk of losing three or more lines of visual acuity at 24 months comparing the intervention with the control group was 0.77 (95% confidence interval 0.69 to 0.87). The relative risk of losing six or more lines of visual acuity at 24 months comparing the intervention with the control group was 0.62 (95% confidence interval 0.50 to 0.76). The results at 12 months were similar to those at 24 months. The most serious adverse outcome, acute (within 7 days of treatment) severe visual acuity decrease, occurs in about one in 50 patients.

AUTHORS' CONCLUSIONS

Photodynamic therapy in people with choroidal neovascularisation due to AMD is probably effective in preventing visual loss though there is doubt about the size of the effect. Outcomes and potential adverse effects of this treatment should be monitored closely. Further independent trials of verteporfin are required to establish that the effects seen in this study are consistent and to examine important issues not yet addressed, particularly relating to quality of life and cost.