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Guymer RH, Chen FK, Hodgson LAB, Caruso E, Harper CA, Wickremashinghe SS, Cohn AC, Sivarajah P, Tindill N, Luu CD, Wu Z. Subthreshold Nanosecond Laser in Age-Related Macular Degeneration: Observational Extension Study of the LEAD Clinical Trial. Ophthalmol Retina 2021; 5:1196-1203. [PMID: 33662615 DOI: 10.1016/j.oret.2021.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 06/12/2023]
Abstract
PURPOSE To evaluate the long-term effect of subthreshold nanosecond laser (SNL) treatment on progression to late age-related macular degeneration (AMD). DESIGN Observational extension study of a randomized, sham-controlled trial. PARTICIPANTS Two hundred twelve participants with bilateral large drusen. METHODS The Laser Intervention in the Early Stages of AMD (LEAD) study was a 36-month trial where participants were randomized to receive SNL or sham treatment in 1 eye at 6-monthly intervals up to 30 months. After the completion of the LEAD study, the 2 largest recruiting sites offered remaining participants an opportunity to enroll in a 24-month observational extension study. This study thus examined all participants from these 2 sites who were enrolled in the LEAD study at baseline, including the additional observational data. MAIN OUTCOME MEASURES Time to develop late AMD, defined on multimodal imaging, between those randomized the SNL or sham treatment. RESULTS Overall, no significant difference was found in the rate of progression over a 60-month period in those randomized to the SNL compared with the sham group (adjusted hazard ratio [HR], 0.63; 95% confidence interval [CI], 0.36-1.09; P = 0.098), similar to the findings at 36 months in the LEAD Study. However, evidence of treatment effect modification continued to emerge based on the coexistence of reticular pseudodrusen (RPD; P = 0.007, adjusted interaction). Namely, progression was slowed significantly with SNL treatment for those without coexistent RPD (adjusted HR, 0.34; 95% CI, 0.16-0.71; P = 0.004), but it was not significantly different for those with RPD (adjusted HR, 1.81; 95% CI, 0.67-4.88; P = 0.239). CONCLUSIONS A 24-month observational extension study to the LEAD Study confirmed that SNL treatment did not significantly reduce the overall rate of progression to late AMD in a cohort with intermediate AMD. However, the persistence of a potential beneficial treatment effect in those without coexistent RPD over a longer follow-up duration of an additional 24 months without additional treatment is encouraging. These findings provide further justification for future trials to examine the potential value of SNL treatment for slowing progression in intermediate AMD.
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Affiliation(s)
- Robyn H Guymer
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia; Ophthalmology, Department of Surgery, The University of Melbourne, Melbourne, Australia.
| | - Fred K Chen
- Centre for Ophthalmology and Visual Science (incorporating Lions Eye Institute), The University of Western Australia, and the Department of Ophthalmology, Royal Perth Hospital, Perth, Australia
| | - Lauren A B Hodgson
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
| | - Emily Caruso
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
| | - Colin A Harper
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia; Ophthalmology, Department of Surgery, The University of Melbourne, Melbourne, Australia
| | - Sanjeewa S Wickremashinghe
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia; Ophthalmology, Department of Surgery, The University of Melbourne, Melbourne, Australia
| | - Amy C Cohn
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
| | - Pyrawy Sivarajah
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
| | - Nicole Tindill
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
| | - Chi D Luu
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia; Ophthalmology, Department of Surgery, The University of Melbourne, Melbourne, Australia
| | - Zhichao Wu
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia; Ophthalmology, Department of Surgery, The University of Melbourne, Melbourne, Australia
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Limon U, Sezgin Akcay BI. Bevacizumab simultaneous combined with dexamethasone implant for treatment of neovascular serous retinal pigment epithelial detachment secondary to neovascular age-related macular degeneration. Eur J Ophthalmol 2021; 32:NP32-NP36. [PMID: 33781113 DOI: 10.1177/11206721211006572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To evaluate the add-on effect of simultaneous intravitreal dexamethasone implant to bevacizumab for treatment of neovascular serous retinal pigment epithelial detachment (PED) secondary to neovascular age-related macular degeneration (nAMD). METHODS A 72-year-old male patient was previously treated with intravitreal bevacizumab and aflibercept for neovascular serous PED secondary to nAMD. Because of the recurrences in neovascular PED patient was treated with simultaneous intravitreal injection of bevacizumab and dexamethasone implant. RESULTS At the initial visit, the patient's the best corrected visual acuity (BCVA) in the left eye was 20/800. His left eye had neovascular serous PED with a height of 1100 µm and a largest linear diameter of 3953 µm accompanied by subretinal fluid. He received four intravitreal bevacizumab and five intravitreal aflibercept injections. Although there was a decrease in PED sizes from time to time during the 16-month treatment period, PED height was 926 µm and PED greatest linear diameter was 5820 µm at the end of 16th month. Later, the patient could not have an injection for 3 months (he could not come to his controls during the pandemic period), and when he arrived 3 months later, the PED height was 910 µm and the greatest linear diameter was 5830 µm. With a single simultaneous intravitreal injection of bevacizumab and dexamethasone implant, the PED regressed to 168 µm in height after 3 months. The BCVA increased to 20/200. Any clinical toxic effects did not occur and intraocular pressure did not rise for 3 months after injection. CONCLUSION Simultaneous intravitreal bevacizumab and dexamethasone implant injection effectively and safely treated treatment-resistant neovascular serous PED. This therapy may be a novel alternative therapy for treatment resistant neovascular serous PED secondary to nAMD. However, further studies are required to understand its effectiveness and safety.
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Affiliation(s)
- Utku Limon
- University of Health Sciences, Umraniye Training and Research Hospital Eye Clinic, Istanbul, Turkey
| | - Betül Ilkay Sezgin Akcay
- University of Health Sciences, Umraniye Training and Research Hospital Eye Clinic, Istanbul, Turkey
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Statement and supplementary statement from the BVA, the DOG, and the RG on laser treatment of drusen in age-related macular degeneration (AMD) : August 2017, update October 2018. Ophthalmologe 2020; 117:1-10. [PMID: 30997527 DOI: 10.1007/s00347-019-0889-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Tode J, Richert E, Koinzer S, Klettner A, von der Burchard C, Brinkmann R, Lucius R, Roider J. Selective Retina Therapy Reduces Bruch's Membrane Thickness and Retinal Pigment Epithelium Pathology in Age-Related Macular Degeneration Mouse Models. Transl Vis Sci Technol 2019; 8:11. [PMID: 31737435 PMCID: PMC6855371 DOI: 10.1167/tvst.8.6.11] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 09/03/2019] [Indexed: 01/15/2023] Open
Abstract
Purpose To investigate the effect of selective retina therapy (SRT) on age-related macular degeneration (AMD)-like alterations of retinal pigment epithelium (RPE) and Bruch's membrane (BrM) in AMD mouse models as therapeutic approach for the treatment of dry AMD. Methods In B6.129P2-Apoetm1Unc/J (ApoE−/−) and B6.129X1-Nfe2I2tm1Ywk/J (NRF2−/−), one randomized eye of each mouse in groups of 15 mice was treated by SRT (532 nm, 300 ms, ∼1.4-μs pulse, 100 Hz, 50-μm spot), the fellow eye and healthy C57BL/6J mice served as controls. Clinical examinations were obtained at treatment day and 1 month later, followed by enucleation to analyze BrM thickness and ultrastructural RPE morphology. Results Nearly all ApoE−/− and NRF2−/− mice showed AMD-like retinal alterations. BrM thickness was increased in both mouse models, RPE had vacuoles within the cell body and shortened apical microvilli. SRT neither affected neuroretinal anatomy nor function. BrM thickness as well as AMD-like ultrastructural alterations of the RPE were significantly reduced in laser-treated eyes compared with fellow control and untreated control eyes. Conclusions SRT reduces BrM thickness and AMD-like RPE alterations in AMD mouse models without damage to structural or functional properties of neuroretina. It may be a prophylactic or therapeutic option for dry AMD. Translational Relevance SRT shows therapeutic effectivity in murine AMD models and might therefore become an option for the treatment of dry AMD.
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Affiliation(s)
- Jan Tode
- Christian-Albrechts-University of Kiel, University Medical Center, Department of Ophthalmology, Arnold-Heller-Str. 3, Kiel, Germany
| | - Elisabeth Richert
- Christian-Albrechts-University of Kiel, University Medical Center, Department of Ophthalmology, Arnold-Heller-Str. 3, Kiel, Germany
| | - Stefan Koinzer
- Christian-Albrechts-University of Kiel, University Medical Center, Department of Ophthalmology, Arnold-Heller-Str. 3, Kiel, Germany
| | - Alexa Klettner
- Christian-Albrechts-University of Kiel, University Medical Center, Department of Ophthalmology, Arnold-Heller-Str. 3, Kiel, Germany
| | - Claus von der Burchard
- Christian-Albrechts-University of Kiel, University Medical Center, Department of Ophthalmology, Arnold-Heller-Str. 3, Kiel, Germany
| | - Ralf Brinkmann
- Institute for Biomedical Optics, University of Lübeck and Medical Laser Center Lübeck GmbH, Peter-Monnik-Weg 4, Lübeck, Germany
| | - Ralph Lucius
- Christian-Albrechts-University of Kiel, Institute of Anatomy, Olshausenstr. 40, Kiel, Germany
| | - Johann Roider
- Christian-Albrechts-University of Kiel, University Medical Center, Department of Ophthalmology, Arnold-Heller-Str. 3, Kiel, Germany
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Femtosecond Laser Pulse Ablation of Sub-Cellular Drusen-Like Deposits. Sci Rep 2019; 9:15633. [PMID: 31666658 PMCID: PMC6821800 DOI: 10.1038/s41598-019-52137-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 10/07/2019] [Indexed: 12/03/2022] Open
Abstract
Age-related macular degeneration (AMD) is a condition affecting the retina and is the leading cause of vision loss. Dry AMD is caused by the accumulation of lipid deposits called drusen, which form under the retina. This work demonstrates, for the first time, the removal of drusen-like deposits underneath ARPE-19 cell layers using femtosecond laser pulses. A novel cell culture model was created in response to the limited access to primary cell lines and the absence of animal models that recapitulate all aspects of AMD. In the cell culture model, deposits were identified with fluorescent stains specific to known deposit constituents. Trains of sub-10 femtosecond laser pulses from a Ti:Sapphire laser were used to successfully ablate the deposits without causing damage to surrounding cells. This drusen removal method can be used as a potential treatment for dry-stage AMD.
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Guymer RH, Wu Z, Hodgson LA, Caruso E, Brassington KH, Tindill N, Aung KZ, McGuinness MB, Fletcher EL, Chen FK, Chakravarthy U, Arnold JJ, Heriot WJ, Durkin SR, Lek JJ, Harper CA, Wickremasinghe SS, Sandhu SS, Baglin EK, Sharangan P, Braat S, Luu CD. Subthreshold Nanosecond Laser Intervention in Age-Related Macular Degeneration. Ophthalmology 2019; 126:829-838. [DOI: 10.1016/j.ophtha.2018.09.015] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 09/11/2018] [Accepted: 09/11/2018] [Indexed: 01/12/2023] Open
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Waugh N, Loveman E, Colquitt J, Royle P, Yeong JL, Hoad G, Lois N. Treatments for dry age-related macular degeneration and Stargardt disease: a systematic review. Health Technol Assess 2019; 22:1-168. [PMID: 29846169 DOI: 10.3310/hta22270] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Age-related macular degeneration (AMD) is the leading cause of visual loss in older people. Advanced AMD takes two forms, neovascular (wet) and atrophic (dry). Stargardt disease (STGD) is the commonest form of inherited macular dystrophy. OBJECTIVE To carry out a systematic review of treatments for dry AMD and STGD, and to identify emerging treatments where future NIHR research might be commissioned. DESIGN Systematic review. METHODS We searched MEDLINE, EMBASE, Web of Science and The Cochrane Library from 2005 to 13 July 2017 for reviews, journal articles and meeting abstracts. We looked for studies of interventions that aim to preserve or restore vision in people with dry AMD or STGD. The most important outcomes are those that matter to patients: visual acuity (VA), contrast sensitivity, reading speed, ability to drive, adverse effects of treatment, quality of life, progression of disease and patient preference. However, visual loss is a late event and intermediate predictors of future decline were accepted if there was good evidence that they are strong predictors of subsequent visual outcomes. These include changes detectable by investigation, but not necessarily noticed by people with AMD or STGD. ClinicalTrials.gov, the World Health Organization search portal and the UK Clinical Trials gateway were searched for ongoing and recently completed clinical trials. RESULTS The titles and abstracts of 7948 articles were screened for inclusion. The full text of 398 articles were obtained for further screening and checking of references and 112 articles were included in the final report. Overall, there were disappointingly few good-quality studies (including of sufficient size and duration) reporting useful outcomes, particularly in STGD. However we did identify a number of promising research topics, including drug treatments, stem cells, new forms of laser treatment, and implantable intraocular lens telescopes. In many cases, research is already under way, funded by industry or governments. LIMITATIONS In AMD, the main limitation came from the poor quality of much of the evidence. Many studies used VA as their main outcome despite not having sufficient duration to observe changes. The evidence on treatments for STGD is sparse. Most studies tested interventions with no comparison group, were far too short term, and the quality of some studies was poor. FUTURE WORK We think that the topics on which the Health Technology Assessment (HTA) and Efficacy Mechanism and Evaluation (EME) programmes might consider commissioning primary research are in STGD, a HTA trial of fenretinide (ReVision Therapeutics, San Diego, CA, USA), a visual cycle inhibitor, and EME research into the value of lutein and zeaxanthin supplements, using short-term measures of retinal function. In AMD, we suggest trials of fenretinide and of a potent statin. There is epidemiological evidence from the USA that the drug, levodopa, used for treating Parkinson's disease, may reduce the incidence of AMD. We suggest that similar research should be carried out using the large general practice databases in the UK. Ideally, future research should be at earlier stages in both diseases, before vision is impaired, using sensitive measures of macular function. This may require early detection of AMD by screening. STUDY REGISTRATION This study is registered as PROSPERO CRD42016038708. FUNDING The National Institute for Health Research HTA programme.
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Affiliation(s)
- Norman Waugh
- Division of Health Sciences, University of Warwick, Coventry, UK
| | | | | | - Pamela Royle
- Division of Health Sciences, University of Warwick, Coventry, UK
| | | | | | - Noemi Lois
- Ophthalmology, Royal Victoria Hospital, Belfast, UK.,Wellcome-Wolfson Centre for Experimental Medicine, Queens University, Belfast, UK
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Eng VA, Wood EH, Boddu S, Karth PA, Leng T. Preventing Progression in Nonexudative Age-Related Macular Degeneration With Subthreshold Laser Therapy: A Systematic Review. Ophthalmic Surg Lasers Imaging Retina 2019; 50:e61-e70. [PMID: 30893458 DOI: 10.3928/23258160-20190301-13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 05/09/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Age-related macular degeneration (AMD) is the leading cause of irreversible blindness among the elderly in developed countries. Subthreshold retinal laser therapy is a new technique that targets drusen - a marker of nonexudative AMD - without causing incidental retinal damage associated with conventional laser photocoagulation. This review summarizes published literature on subthreshold retinal laser therapy as prophylactic treatment of nonexudative AMD. PATIENTS AND METHODS A literature search of the PubMed, Medline, and Embase databases was conducted from January 1997 to April 2018. Studies were analyzed based upon study design, laser parameters, drusen reduction, changes in visual acuity (VA), and the development of choroidal neovascularization (CNV) and/or geographic atrophy (GA). RESULTS Twelve studies involving 2,481 eyes treated with subthreshold retinal laser therapy were included in this review. Treatment led to increased drusen reduction, and studies with significant VA improvement were associated with significant drusen reduction. There was no significant change in the risk of developing CNV or GA. CONCLUSIONS Subthreshold retinal laser therapy is effective for reducing drusen and potentially improving vision in patients with nonexudative AMD. This therapy does not show benefits in reducing development of CNV or GA. Thus, its long-term efficacy to prevent progression to advanced AMD cannot yet be recommended. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e61-e70.].
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Abstract
Introduction Laser photocoagulation has been a valuable tool in the ophthalmologist's armamentarium for decades. Conventional laser photocoagulation relies on visible retinal burns as a treatment endpoint, which is thought to result in photocoagulative necrosis of retinal tissue. Recent studies have suggested that using subthreshold (ST) laser, which does not cause detectable damage to the retina may also have therapeutic effects in a variety of retinal diseases. Areas covered: We review the proposed biological mechanisms mediating the therapeutic effects of subthreshold laser on the retina, followed by the evidence for ST laser efficacy in retinal diseases such as diabetic macular edema, central serous chorioretinopathy, age-related macular degeneration, and retinal vein occlusion. Expert Commentary Multiple clinical studies demonstrate that subthreshold laser does not cause structural damage to the retina based on multimodal imaging. Evidence suggests that there is a therapeutic effect on decreasing diabetic macular edema and subretinal fluid in chronic central serous retinopathy; however, the effect may be relatively modest and is not as efficacious as first line treatments for these diseases. Given the repeatability and lack of damage to the retina by this treatment, subthreshold laser deserves further study to determine its place in the retina specialist's armamentarium.
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Affiliation(s)
- Spencer M Moore
- School of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Daniel L Chao
- Department of Ophthalmology, Shiley Eye Institute, University of California, San Diego, La Jolla, CA, USA
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Findlay Q, Jobling AI, Vessey KA, Greferath U, Phipps JA, Guymer RH, Fletcher EL. Prophylactic laser in age-related macular degeneration: the past, the present and the future. Eye (Lond) 2018; 32:972-980. [PMID: 29520049 PMCID: PMC5944648 DOI: 10.1038/s41433-018-0035-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 01/14/2018] [Indexed: 11/09/2022] Open
Abstract
The presence of drusen in the posterior eye is a hallmark feature of the early stages of age-related macular degeneration and their size is an indicator of risk of progression to vision-threatening forms of the disease. Since the initial observations that laser treatment can resolve drusen, there has been great interest in whether laser treatment can be used to reduce the progression of age-related macular degeneration. In this article, we review the development of lasers for the treatment of those with age-related macular degeneration. We provide an overview of the clinical trial results that demonstrated drusen resolution but that had mixed effects on progression of disease. In addition, we provide a summary of the recent developments in pulsed lasers that are designed to reduce the energy applied to the posterior eye to provide the therapeutic effects of conventional continuous wave lasers while reducing the secondary tissue effects.
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Affiliation(s)
- Quan Findlay
- Department of Anatomy and Neuroscience, The University of Melbourne, Parkville, 3010, VIC, Australia
| | - Andrew I Jobling
- Department of Anatomy and Neuroscience, The University of Melbourne, Parkville, 3010, VIC, Australia
| | - Kirstan A Vessey
- Department of Anatomy and Neuroscience, The University of Melbourne, Parkville, 3010, VIC, Australia
| | - Ursula Greferath
- Department of Anatomy and Neuroscience, The University of Melbourne, Parkville, 3010, VIC, Australia
| | - Joanna A Phipps
- Department of Anatomy and Neuroscience, The University of Melbourne, Parkville, 3010, VIC, Australia
| | - Robyn H Guymer
- Centre for Eye Research Australia, University of Melbourne, Royal Victorian Eye and Ear Hospital, Parkville, VIC, Australia.
| | - Erica L Fletcher
- Department of Anatomy and Neuroscience, The University of Melbourne, Parkville, 3010, VIC, Australia
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Tode J, Richert E, Koinzer S, Klettner A, von der Burchard C, Brinkmann R, Lucius R, Roider J. Thermal Stimulation of the Retina Reduces Bruch's Membrane Thickness in Age Related Macular Degeneration Mouse Models. Transl Vis Sci Technol 2018; 7:2. [PMID: 29736323 PMCID: PMC5931258 DOI: 10.1167/tvst.7.3.2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 03/16/2018] [Indexed: 01/04/2023] Open
Abstract
Purpose To investigate the effect of thermal stimulation of the retina (TS-R) on Bruch's membrane (BrM) thickness in age-related macular degeneration (AMD) mouse models as a novel concept for the prophylaxis and treatment of dry AMD. Methods Two knockout AMD mouse models, B6.129P2-Apoetm1Unc/J (ApoE−/−) and B6.129X1-Nfe2I2tm1Ywk/J (NRF2−/−), were chosen. One randomized eye of each mouse in four different groups (two of different age, two of different genotype) of five mice was treated by TS-R (532 nm, 10-ms duration, 50-μm spot size), the fellow eye served as control. Laser power was titrated to barely visible laser burns, then reduced by 70% to guarantee for thermal elevation without damage to the neuroretina, then applied uniformly to the murine retina. Fundus, optical coherence tomography (OCT), and fluorescein angiography (FLA) images were obtained at the day of treatment and 1 month after treatment. Eyes were enucleated thereafter to analyze BrM thickness by transmission electron microscopy (TEM) in a standardized blinded manner. Results Fundus images revealed that all ApoE−/− and NRF2−/− mice had AMD associated retinal alterations. BrM thickness was increased in untreated controls of both mouse models. Subvisible TS-R laser spots were not detectable by fundus imaging, OCT, or FLA 2 hours or 1 month after laser treatment. TEM revealed a significant reduction of BrM thickness in laser-treated eyes of all four groups compared to their fellow control eyes. Conclusions TS-R reduces BrM thickness in AMD mouse models ApoE−/− and NRF2−/− without damage to the neuroretina. It may become a prophylactic or even therapeutic treatment option for dry AMD. Translational Relevance TS-R may become a prophylactic or even therapeutic treatment option for dry AMD.
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Affiliation(s)
- Jan Tode
- Christian-Albrechts-University of Kiel, University Medical Center, Department of Ophthalmology, Kiel, Germany
| | - Elisabeth Richert
- Christian-Albrechts-University of Kiel, University Medical Center, Department of Ophthalmology, Kiel, Germany
| | - Stefan Koinzer
- Christian-Albrechts-University of Kiel, University Medical Center, Department of Ophthalmology, Kiel, Germany
| | - Alexa Klettner
- Christian-Albrechts-University of Kiel, University Medical Center, Department of Ophthalmology, Kiel, Germany
| | - Claus von der Burchard
- Christian-Albrechts-University of Kiel, University Medical Center, Department of Ophthalmology, Kiel, Germany
| | - Ralf Brinkmann
- Institute for Biomedical Optics, University of Lübeck, and Medical Laser Center Lübeck GmbH, Lübeck, Germany
| | - Ralph Lucius
- Christian-Albrechts-University of Kiel, Institute of Anatomy, Kiel, Germany
| | - Johann Roider
- Christian-Albrechts-University of Kiel, University Medical Center, Department of Ophthalmology, Kiel, Germany
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Kern K, Mertineit CL, Brinkmann R, Miura Y. Expression of heat shock protein 70 and cell death kinetics after different thermal impacts on cultured retinal pigment epithelial cells. Exp Eye Res 2018; 170:117-126. [PMID: 29454858 DOI: 10.1016/j.exer.2018.02.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/25/2018] [Accepted: 02/14/2018] [Indexed: 12/19/2022]
Abstract
Recent technologies are broadening the possibility to treat the retinal pigment epithelium (RPE) with different thermal impacts, from sublethal to lethal ranges. Thus temperature-dependent subcellular molecular responses need to be elucidated in more detail. In this study, RPE cell viability and expression of heat shock protein 70 (Hsp70) were investigated after thermal irradiation with different temperature increase using an in-vitro model. Primary porcine RPE cell cultures were irradiated with different laser power of a thulium laser (λ = 1940 nm, beam-diameter 30 mm) for 10 s, such that the maximal temperatures at the center of the culture dish (Tmax) reach 40, 44, 47, 51 or 59 °C after 10-s irradiation. The temperature distribution across the culture dish shows a Gaussian decay from central position to the periphery of the dish. At 3, 24 and 48 h after irradiation cell viability was assessed with fluorescence microscopy using cell viability-indicating fluorescence dyes, followed by the determination of the threshold temperature for apoptotic change and death of RPE cells. Intracellular localization and amount of Hsp70 were investigated with immunofluorescence and western blotting, respectively. The threshold temperature (at the 10th second of irradiation: T10s) for cellular apoptosis and complete cell death showed a decrease over time after irradiation, suggesting a long-term process of thermally induced cell death. For complete cell death the threshold T10s was 52.1 ± 0.6 °C, 50.1 ± 1.4 °C, and 50.1 ± 0.8 °C, for 3, 24 and 48 h, respectively, whereas for the apoptotic changes 48.6 ± 1.8 °C, 47.2 ± 1.3 °C, and 46.7 ± 0.9 °C, respectively. Quantitative analysis of Hsp70 with western blotting showed a significant increase in intracellular Hsp70 at lethal irradiation with Tmax ≥ 51 °C, up to 19.6 ± 2.3 fold after 48 h at 59 °C, whereas sub-lethal irradiations with Tmax ≤ 44 °C led to a slight tendency of time-dependent increases (up to 1.8 ± 1.1 fold) over 48 h. Immunostainings for Hsp70 showed a circle- or ring-pattern of the Hsp70 staining during 3-48 h after irradiation, and the range of the 1st and 3rd quartiles of T10s for heat-induced Hsp70 expression over this time period was between 44.8 °C and 48.2 °C. A very strong staining of Hsp70 was observed at the border to the damaged zone, where many cells show the strong staining in the whole cytoplasmic space, while some cells in the nucleus, or some cells show the signs of cell migration and proliferation. Moreover, among the cells showing high intensity of Hsp70 staining, there are small round cells like apoptotic cells. Results suggest that RPE cell death after thermal irradiation may take time, and mostly undergoes through apoptosis, unless cells are immediately killed. Thermal irradiation-induced Hsp70 expression is not only temperature-dependent, but also depends largely on the existence of neighboring cell death, suggesting the crucial role of Hsp70 in apoptosis and wound healing processes of RPE cells. The increase of Hsp70 over 24-48 h indicates its long-term roles in cell responses both after sublethal and lethal thermal laser irradiations.
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Affiliation(s)
- Katharina Kern
- Institute of Biomedical Optics, University of Lübeck, Lübeck, Germany; Medical Laser Center Lübeck, Lübeck, Germany
| | | | - Ralf Brinkmann
- Institute of Biomedical Optics, University of Lübeck, Lübeck, Germany; Medical Laser Center Lübeck, Lübeck, Germany
| | - Yoko Miura
- Institute of Biomedical Optics, University of Lübeck, Lübeck, Germany; Medical Laser Center Lübeck, Lübeck, Germany; Department of Ophthalmology, University of Lübeck, Lübeck, Germany.
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Treatment of Serous Pigment Epithelium Detachment with Subthreshold Micropulse Diode Laser Photocoagulation: A Case Report. Eur J Ophthalmol 2018; 19:887-9. [DOI: 10.1177/112067210901900501] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Laser photocoagulation as treatment of non-exudative age-related macular degeneration: state-of-the-art and future perspectives. Graefes Arch Clin Exp Ophthalmol 2017; 256:1-9. [DOI: 10.1007/s00417-017-3848-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 10/31/2017] [Accepted: 11/04/2017] [Indexed: 01/18/2023] Open
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[Statement from the BVA, the DOG and the RG on laser treatment of drusen in age-related macular degeneration (AMD) : August 2017]. Ophthalmologe 2017; 114:1008-1014. [PMID: 28980062 DOI: 10.1007/s00347-017-0574-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Chidlow G, Plunkett M, Casson RJ, Wood JP. Investigations into localized re-treatment of the retina with a 3-nanosecond laser. Lasers Surg Med 2016; 48:602-15. [DOI: 10.1002/lsm.22506] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2016] [Indexed: 12/15/2022]
Affiliation(s)
- Glyn Chidlow
- Ophthalmic Research Laboratories; Hanson Institute Centre for Neurological Diseases; Frome Rd Adelaide SA 5000 Australia
- Discipline of Ophthalmology and Visual Sciences; University of Adelaide; Frome Rd Adelaide SA 5005 Australia
| | - Malcolm Plunkett
- Ophthalmic Research Laboratories; Hanson Institute Centre for Neurological Diseases; Frome Rd Adelaide SA 5000 Australia
| | - Robert J. Casson
- Ophthalmic Research Laboratories; Hanson Institute Centre for Neurological Diseases; Frome Rd Adelaide SA 5000 Australia
- Discipline of Ophthalmology and Visual Sciences; University of Adelaide; Frome Rd Adelaide SA 5005 Australia
| | - John P.M. Wood
- Ophthalmic Research Laboratories; Hanson Institute Centre for Neurological Diseases; Frome Rd Adelaide SA 5000 Australia
- Discipline of Ophthalmology and Visual Sciences; University of Adelaide; Frome Rd Adelaide SA 5005 Australia
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Vavvas DG, Daniels AB, Kapsala ZG, Goldfarb JW, Ganotakis E, Loewenstein JI, Young LH, Gragoudas ES, Eliott D, Kim IK, Tsilimbaris MK, Miller JW. Regression of Some High-risk Features of Age-related Macular Degeneration (AMD) in Patients Receiving Intensive Statin Treatment. EBioMedicine 2016; 5:198-203. [PMID: 27077128 PMCID: PMC4816836 DOI: 10.1016/j.ebiom.2016.01.033] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 01/26/2016] [Accepted: 01/27/2016] [Indexed: 12/26/2022] Open
Abstract
Importance Age-related macular degeneration (AMD) remains the leading cause of blindness in developed countries, and affects more than 150 million worldwide. Despite effective anti-angiogenic therapies for the less prevalent neovascular form of AMD, treatments are lacking for the more prevalent dry form. Similarities in risk factors and pathogenesis between AMD and atherosclerosis have led investigators to study the effects of statins on AMD incidence and progression with mixed results. A limitation of these studies has been the heterogeneity of AMD disease and the lack of standardization in statin dosage. Objective We were interested in studying the effects of high-dose statins, similar to those showing regression of atherosclerotic plaques, in AMD. Design Pilot multicenter open-label prospective clinical study of 26 patients with diagnosis of AMD and the presence of many large, soft drusenoid deposits. Patients received 80 mg of atorvastatin daily and were monitored at baseline and every 3 months with complete ophthalmologic exam, best corrected visual acuity (VA), fundus photographs, optical coherence tomography (OCT), and blood work (AST, ALT, CPK, total cholesterol, TSH, creatinine, as well as a pregnancy test for premenopausal women). Results Twenty-three subjects completed a minimum follow-up of 12 months. High-dose atorvastatin resulted in regression of drusen deposits associated with vision gain (+ 3.3 letters, p = 0.06) in 10 patients. No subjects progressed to advanced neovascular AMD. Conclusions High-dose statins may result in resolution of drusenoid pigment epithelial detachments (PEDs) and improvement in VA, without atrophy or neovascularization in a high-risk subgroup of AMD patients. Confirmation from larger studies is warranted. High dose lipophilic statin administration was associated with regression of large soft drusen and vision gain in 10/23 AMD patients. Duration of treatment before a positive response was observed was usually 1–1.5 years. Patients on high-dose statin appeared to be protected from progression to “wet” neovascular-AMD.
There is a lack of effective therapies for dry age-related macular degeneration (AMD), one of the leading causes of blindness affecting millions. Although AMD shares similarities with atherosclerosis, prior studies on statins and AMD have failed to show improvement. A limitation of these studies has been the heterogeneity of AMD disease and the lack of standardization in statin dosage. Here, we present for the first time evidence that treatment with high-dose atorvastatin (80 mg) is associated with regression of lipid deposits and improvement in visual acuity, without atrophy or neovascularization, in high-risk AMD patients.
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Affiliation(s)
- Demetrios G. Vavvas
- Corresponding authors at: 243 Charles St., Boston, MA 02114, USA.243 Charles St.BostonMA02114USA
| | - Anthony B. Daniels
- Corresponding authors at: 243 Charles St., Boston, MA 02114, USA.243 Charles St.BostonMA02114USA
| | | | | | | | | | | | | | | | | | - Miltiadis K. Tsilimbaris
- Corresponding authors at: 243 Charles St., Boston, MA 02114, USA.243 Charles St.BostonMA02114USA
| | - Joan W. Miller
- Corresponding authors at: 243 Charles St., Boston, MA 02114, USA.243 Charles St.BostonMA02114USA
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Virgili G, Michelessi M, Parodi MB, Bacherini D, Evans JR. Laser treatment of drusen to prevent progression to advanced age-related macular degeneration. Cochrane Database Syst Rev 2015; 2015:CD006537. [PMID: 26493180 PMCID: PMC4733883 DOI: 10.1002/14651858.cd006537.pub3] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Drusen are amorphous yellowish deposits beneath the sensory retina. People with drusen, particularly large drusen, are at higher risk of developing age-related macular degeneration (AMD). The most common complication in AMD is choroidal neovascularisation (CNV), the growth of new blood vessels in the centre of the macula. The risk of CNV is higher among people who are already affected by CNV in one eye.It has been observed clinically that laser photocoagulation of drusen leads to their disappearance and may prevent the occurrence of advanced disease (CNV or geographic atrophy) associated with visual loss. OBJECTIVES To examine the effectiveness and adverse effects of laser photocoagulation of drusen in AMD. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015, Issue 7), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to August 2015), EMBASE (January 1980 to August 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to August 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 3 August 2015. SELECTION CRITERIA Randomised controlled trials (RCTs) of laser treatment of drusen in AMD in which laser treatment had been compared with no intervention or sham treatment. Two types of trials were included. Some trials studied one eye of each participant (unilateral studies); other studies recruited participants with bilateral drusen and randomised one eye to photocoagulation or control and the fellow eye to the other group. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies and extracted data. We pooled data from unilateral and bilateral studies using a random-effects model. For the bilateral studies, we estimated the within-person correlation coefficient from one study and assumed it was valid for the others. MAIN RESULTS The update of this review found two additional studies, totaling 11 studies that randomised 2159 participants (3580 eyes) and followed them up to two years, of which six studies (1454 participants) included people with one eye randomised to treatment and one to control. Studies were conducted in Australia, Europe and North America.Overall, the risk of bias in the included studies was low, particularly for the larger studies and for the primary outcome development of CNV. Photocoagulation did not reduce the development of CNV at two years' follow-up (odds ratio (OR) 1.07, 95% confidence interval (CI) 0.79 to 1.46, 11 studies, 2159 participants (3580 eyes), high quality evidence). This estimate means that, given an overall occurrence of CNV of 8.3% in the control group, we estimated an absolute risk reduction by no more than 1.4% in the laser group, according to the lower CI limit. Only two studies investigated the effect on the development of geographic atrophy and could not show a difference, but estimates were imprecise (OR 1.30, 95% CI 0.38 to 4.51, two studies, 148 participants (148 eyes), low quality evidence).Among secondary outcomes, photocoagulation led to drusen reduction (OR 9.16, 95% CI 6.28 to 13.4, three studies, 570 participants (944 eyes), high quality evidence) but was not shown to limit loss of 3 or more lines of visual acuity (OR 0.99, 95% CI 0.81 to 1.22, nine studies, 2002 participants (2386 eyes), moderate quality evidence).In a subgroup analysis, no difference could be shown for conventional visible (eight studies) versus subthreshold invisible (four studies) photocoagulation for the primary outcomes (P value = 0.29). The effect in the subthreshold group did not suggest a relevant benefit (OR 1.27, 95% CI 0.82 to 1.98). No study used micropulse subthreshold photocoagulation.No other adverse effects (apart from development of CNV, geographic atrophy or visual loss) were reported. AUTHORS' CONCLUSIONS The trials included in this review confirm the clinical observation that laser photocoagulation of drusen leads to their disappearance. However, treatment does not result in a reduction in the risk of developing CNV, and was not shown to limit the occurrence of geographic atrophy or visual acuity loss.Ongoing studies are being conducted to assess whether the use of extremely short laser pulses (i.e. nanosecond laser treatment) cannot only lead to drusen regression but also prevent neovascular AMD.
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Affiliation(s)
- Gianni Virgili
- University of FlorenceDepartment of Translational Surgery and Medicine, Eye ClinicLargo Brambilla, 3FlorenceItaly50134
| | - Manuele Michelessi
- Fondazione G.B. Bietti per lo studio e la ricerca in Oftalmolologia‐IRCCSOphthalmologyVia Livenza n 3RomeItaly00198
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 N. Wolfe StreetMailroom W5010BaltimoreMarylandUSA21205
| | - Maurizio B Parodi
- University Vita‐Salute, Ospedale San RaffaealeDepartment of OphthalmologyMilanItaly
| | - Daniela Bacherini
- University of FlorenceDepartment of Translational Surgery and Medicine, Eye ClinicLargo Brambilla, 3FlorenceItaly50134
| | - Jennifer R Evans
- London School of Hygiene & Tropical MedicineCochrane Eyes and Vision Group, ICEHKeppel StreetLondonUKWC1E 7HT
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Jobling AI, Guymer RH, Vessey KA, Greferath U, Mills SA, Brassington KH, Luu CD, Aung KZ, Trogrlic L, Plunkett M, Fletcher EL. Nanosecond laser therapy reverses pathologic and molecular changes in age‐related macular degeneration without retinal damage. FASEB J 2014; 29:696-710. [DOI: 10.1096/fj.14-262444] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- A. I. Jobling
- Department of Anatomy and NeuroscienceThe University of MelbourneVictoriaAustralia
| | - R. H. Guymer
- Centre for Eye Research AustraliaUniversity of MelbourneRoyal Victorian Eye and Ear HospitalVictoriaAustralia
| | - K. A. Vessey
- Department of Anatomy and NeuroscienceThe University of MelbourneVictoriaAustralia
| | - U. Greferath
- Department of Anatomy and NeuroscienceThe University of MelbourneVictoriaAustralia
| | - S. A. Mills
- Department of Anatomy and NeuroscienceThe University of MelbourneVictoriaAustralia
| | - K. H. Brassington
- Centre for Eye Research AustraliaUniversity of MelbourneRoyal Victorian Eye and Ear HospitalVictoriaAustralia
| | - C. D. Luu
- Centre for Eye Research AustraliaUniversity of MelbourneRoyal Victorian Eye and Ear HospitalVictoriaAustralia
| | - K. Z. Aung
- Centre for Eye Research AustraliaUniversity of MelbourneRoyal Victorian Eye and Ear HospitalVictoriaAustralia
| | - L. Trogrlic
- Department of Anatomy and NeuroscienceThe University of MelbourneVictoriaAustralia
| | | | - E. L. Fletcher
- Department of Anatomy and NeuroscienceThe University of MelbourneVictoriaAustralia
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Garcia Filho CADA, Yehoshua Z, Gregori G, Nunes RP, Penha FM, Moshfeghi AA, Zhang K, Feuer W, Rosenfeld PJ. Change in drusen volume as a novel clinical trial endpoint for the study of complement inhibition in age-related macular degeneration. Ophthalmic Surg Lasers Imaging Retina 2014; 45:18-31. [PMID: 24354307 DOI: 10.3928/23258160-20131217-01] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Accepted: 12/04/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND OBJECTIVE To evaluate the change in drusen volume following treatment with eculizumab, a systemic inhibitor of complement component 5. PATIENTS AND METHODS Single-center, prospective, randomized, double-masked clinical trial. Patients were randomized 2:1 to receive intravenous eculizumab or placebo over 26 weeks. MAIN OUTCOME MEASURE decrease in drusen volume of at least 50% at 26-week follow-up. RESULTS Mean drusen cube root volumes were 0.49 mm and 0.47 mm (P = .64) at baseline and 0.51 mm and 0.42 mm (P = .17) at 26 weeks in the eculizumab and placebo groups, respectively. In the placebo group, one eye had a decrease in drusen volume of at least 50% and two eyes developed neovascularization through 26 weeks. CONCLUSION Systemic complement inhibition with eculizumab did not significantly reduce drusen volume. Drusen growth was dependent on the number of complement at-risk alleles. Future trials should consider the use of a composite clinical trial endpoint in which efficacy is defined by the treatment’s ability to prevent drusen growth, neovascularization, and the formation of geographic atrophy over 1 year.
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Current treatment limitations in age-related macular degeneration and future approaches based on cell therapy and tissue engineering. J Ophthalmol 2014; 2014:510285. [PMID: 24672707 PMCID: PMC3941782 DOI: 10.1155/2014/510285] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 12/10/2013] [Indexed: 01/01/2023] Open
Abstract
Age-related macular degeneration (AMD) is the leading cause of blindness in the Western world. With an ageing population, it is anticipated that the number of AMD cases will increase dramatically, making a solution to this debilitating disease an urgent requirement for the socioeconomic future of the European Union and worldwide. The present paper reviews the limitations of the current therapies as well as the socioeconomic impact of the AMD. There is currently no cure available for AMD, and even palliative treatments are rare. Treatment options show several side effects, are of high cost, and only treat the consequence, not the cause of the pathology. For that reason, many options involving cell therapy mainly based on retinal and iris pigment epithelium cells as well as stem cells are being tested. Moreover, tissue engineering strategies to design and manufacture scaffolds to mimic Bruch's membrane are very diverse and under investigation. Both alternative therapies are aimed to prevent and/or cure AMD and are reviewed herein.
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Hartmann KI, Gomez ML, Bartsch DUG, Schuster AK, Freeman WR. Effect of change in drusen evolution on photoreceptor inner segment/outer segment junction. Retina 2012; 32:1492-9. [PMID: 22481478 DOI: 10.1097/iae.0b013e318242b949] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the integrity of photoreceptor inner segment/outer segment (IS/OS) junction after change of drusen size in age-related macular degeneration using spectral-domain optical coherence tomography. METHODS Drusen volume raster scans were performed with the Spectralis spectral-domain optical coherence tomography (Heidelberg Engineering) through 2,624 drusen in 14 eyes with clinically dry age-related macular degeneration, which had been longitudinally followed-up between 23 and 28 months without intervention (mean, 26.3 months). All eyes had Early Treatment Diabetic Retinopathy Study visual acuity. A total of 416 of 2,624 drusen were analyzed. RESULTS Of 416 drusen, 83 (20%) were found to have regressed spontaneously (Group A), 212 (51%) showed no change in size (Group B), and 121 (29%) progressed (Group C). Mean drusen size of all drusen was 63.7 ± 25.7 μm. Cross-sectional analysis of drusen morphology showed a correlation between drusen size and disrupted IS/OS junction/photoreceptor integrity (r = -0.48, P < 0.001). Of the drusen that regressed over time, there was intact IS/OS junction integrity. Even drusen that caused a major disruption showed IS/OS restoration in 74% of the drusen (P < 0.001). CONCLUSION Progression of drusen shows structural disruption of the IS/OS junction. After drusen regression, the IS/OS junction is either able to restore as drusen regress or was artifactitiously compressed and not initially visible because of the initial drusen compression of the IS/OS junctional line. Therefore, drusen evolution may play an important role in affecting the photoreceptor IS/OS junction integrity.
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Affiliation(s)
- Kathrin I Hartmann
- Department of Ophthalmology, University of California, San Diego, La Jolla, California 92037, USA.
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Risk Factors for Conversion to Neovascular Age-related Macular Degeneration Based on Longitudinal Morphologic and Visual Acuity Data. Ophthalmology 2012; 119:1432-7. [DOI: 10.1016/j.ophtha.2012.02.048] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Revised: 02/28/2012] [Accepted: 02/28/2012] [Indexed: 11/22/2022] Open
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Friberg TR, Bilonick RA, Brennen P. Is drusen area really so important? An assessment of risk of conversion to neovascular AMD based on computerized measurements of drusen. Invest Ophthalmol Vis Sci 2012; 53:1742-51. [PMID: 22395875 DOI: 10.1167/iovs.11-9338] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To assess the relative risk of an eye's conversion to wet age-related macular degeneration (AMD) based primarily on drusen measurements obtained from analysis of digitized images. METHODS Four hundred forty-four subjects (820 eyes) enrolled in the Age-Related Eye Disease Study (AREDS I) and 78 subjects (129 eyes) from the Prophylactic Treatment of AMD trial (PTAMD) were studied retrospectively. Drusen size, distribution, drusen area, and hyperpigmentation in two central macular regions on baseline fundus images were determined using an image analysis algorithm. The relative risk for choroidal neovascularization (CNV) based on drusen area, presence of one or five large drusen, hyperpigmentation, and fellow eye status was calculated. RESULTS Odds ratios (ORs) for measured drusen area within the 1000- and 3000-μm regions were 1.644* (1.251-2.162) and 1.278 (0.927-1.762) for AREDS eyes and 0.832 (0.345-2.005) and 1.094 (0.524-2.283) for PTAMD eyes (*P < 0.05). In the 1000-μm region, respective ORs for the presence of a large druse, hyperpigmentation, and fellow eye affected were 2.60, 1.71, and 6.44* for AREDS eyes and 8.24, 1.37, and 17.56* for PTAMD eyes; for the 3000-μm region, ORs were 3.45*, 3.40*, and 4.59* for AREDS and nonsignificant, 6.58, and 11.62* for PTAMD eyes, respectively. CONCLUSIONS Total drusen area, presence of large drusen, and the presence of hyperpigmentation were not consistent risk factors for an eye's development of CNV. Risk depended on study cohort as well as location. Having an affected fellow eye was the strongest and most consistent risk factor across all models. A larger drusen area does not necessarily increase an eye's risk of conversion to CNV.
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Affiliation(s)
- Thomas R Friberg
- Department of Ophthalmology and Bioengineering, UPMC Eye Center, University of Pittsburgh, 203 Lothrop Street, Pittsburgh, PA 15213, USA.
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Pepple K, Mruthyunjaya P. Retinal pigment epithelial detachments in age-related macular degeneration: classification and therapeutic options. Semin Ophthalmol 2011; 26:198-208. [PMID: 21609233 DOI: 10.3109/08820538.2011.570850] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Retinal pigment epithelial detachment (PED) is an important predictor of vision loss in patients with age-related macular degeneration (AMD). Here we review the historical PEDs subtypes, include recent insights into PED pathogenesis provided by modern imaging modalities, and summarize the current options for treatment.
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Rencová E, Bláha M, Studnička J, Blažek M, Bláha V, Dusová J, Malý J, Kyprianou G, Vašátko T, Langrová H. Haemorheopheresis could block the progression of the dry form of age-related macular degeneration with soft drusen to the neovascular form. Acta Ophthalmol 2011; 89:463-71. [PMID: 20102350 DOI: 10.1111/j.1755-3768.2009.01710.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To evaluate the influence of haemorheopheresis on anatomical and functional findings in patients with soft-drusen maculopathy. METHODS We investigated 29 eyes (16 patients) and randomized 25 eyes (16 controls) with soft-drusen maculopathy [soft, confluent and reticular drusen, drusenoid retinal pigment epithelium detachment (RPED)]. Each patient received a series of eight haemorheophereses (cascade filtration of 1.5 plasma volume) within 10 weeks. The patients were followed up using Early Treatment Diabetic Retinopathy Study (ETDRS) charts, optical coherence tomography, fluorescein angiography, electroretinography and measurements of pulsed ocular blood flow. RESULTS After the procedures, there was a substantial reduction in rheologically active substances [lipoproteins, α2-macroglobulin, immunoglobulin M (IgM), fibrinogen], plasma and blood viscosity. At the 1.5-year follow-up, we noticed soft drusen absorption; reattachment of drusenoid RPED and stabilization or improvement of visual acuity occurred in 72% of patients in comparison to only 39% of patients in the control group. Full-field electroretinograms showed significantly higher scotopic activity of treated patients in comparison with the control group, and mainly insignificant differences in photopic activity between both groups. Despite the significant increase of activity in the paramacular retina in treated patients, the differences in amplitudes of multifocal electroretinography (mfERG) average responses were insignificant between groups. CONCLUSION Haemorheopheresis seems to be capable of changing the activity of promoters of the natural course of soft-drusen maculopathy, its development and progression. Visual acuity and electrical activity of the retina can be stabilized or even improved. The therapy has been shown to be effective and safe.
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Affiliation(s)
- Eva Rencová
- Department of Ophthalmology, Charles University, Hradec Králové, Czech Republic
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Long-term SD-OCT/SLO imaging of neuroretina and retinal pigment epithelium after subthreshold infrared laser treatment of drusen. Retina 2011; 31:235-42. [PMID: 21157398 DOI: 10.1097/iae.0b013e3181ec80ad] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE The purpose of this study was to determine the long-term effect of subthreshold diode laser treatment for drusen in patients with nonexudative age-related macular degeneration with spectral domain optical coherence tomography combined with simultaneous scanning laser ophthalmoscope. METHODS Eight eyes of four consecutive age-related macular degeneration patients with bilateral drusen previously treated with subthreshold diode laser were imaged with spectral domain optical coherence tomography/scanning laser ophthalmoscope. Abnormalities in the outer retinal layers' reflectivity as seen with spectral domain optical coherence tomography/scanning laser ophthalmoscope were retrospectively analyzed and compared with color fundus pictures, and autofluorescence images were acquired immediately before and after the laser treatment. RESULTS A focal discrete disruption in the reflectivity of the outer retinal layers was noted in 29% of the laser lesions. The junction in between the inner and outer segment of the photoreceptor was more frequently affected, with associated focal damage of the outer nuclear layer. Defects of the retinal pigment epithelium were occasionally detected. These changes did not correspond to threshold burns on color fundus photography but corresponded to focal areas of increased autofluorescence in the majority of the cases. CONCLUSION Subthreshold diode laser treatment causes long-term disruption of the retinal photoreceptor layer as analyzed by spectral domain optical coherence tomography/scanning laser ophthalmoscope. The concept that subthreshold laser treatment can achieve a selected retinal pigment epithelium effect without damage to rods and cones may be flawed.
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Frennesson CI, Bek T, Jaakkola A, Nilsson SEG. Prophylactic laser treatment of soft drusen maculopathy: a prospective, randomized Nordic study. Acta Ophthalmol 2009; 87:720-4. [PMID: 18937820 DOI: 10.1111/j.1755-3768.2008.01396.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE This study aimed to investigate whether mild laser treatment of soft drusen maculopathy might reduce the incidence of choroidal neovascularization (CNV) and/or significantly reduce loss of visual acuity compared with outcomes in a control group. METHODS A total of 135 patients (mean age 70.4 years) were randomized into a treatment group of 67 subjects and a control group of 68 subjects. The treatment group was subdivided into a group of 54 subjects with bilateral soft drusen and a group of 13 subjects with unilateral soft drusen in the study eye and advanced AMD in the fellow eye. The control group was subdivided into a bilateral group of 54 subjects and a unilateral group of 14 subjects. Sub-threshold or barely visible laser spots were scattered on and between drusen in the posterior pole. Inclusion of patients was stopped prematurely as other studies did not show any benefit from the treatment. Mean follow-up time was 3.7 years. RESULTS More CNVs developed in the treated group (4/54 eyes in the bilateral group, 3/13 eyes in the unilateral group; 7/67 eyes in total) than in the control group (3/54 eyes in the bilateral group, 2/14 eyes in the unilateral group; 5/68 eyes in total) but these differences were not statistically significant for either the bilateral or unilateral groups (p = 0.20-0.32). No CNV developed in the bilateral treated group before 4 years of follow-up. Visual acuity was significantly reduced from baseline to the last follow-up in all groups (p < 0.0001-0.02) except the unilateral control group (p = 0.08), but there were no significant differences between the treated and control groups for either the bilateral or unilateral groups (p = 0.17-0.97). CONCLUSIONS Mild prophylactic laser treatment of soft drusen maculopathy was neither beneficial nor harmful and cannot be recommended.
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Parodi MB, Virgili G, Evans JR. Laser treatment of drusen to prevent progression to advanced age-related macular degeneration. Cochrane Database Syst Rev 2009:CD006537. [PMID: 19588397 DOI: 10.1002/14651858.cd006537.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Drusen are amorphous yellowish deposits beneath the sensory retina. People with drusen, particularly large drusen, are at higher risk of developing age-related macular degeneration (AMD). The most common complication in AMD is choroidal neovascularisation (CNV), the growth of new blood vessels in the centre of the macula. The risk of CNV is higher among patients who are already affected by CNV in one eye.It has been observed clinically that laser photocoagulation of drusen leads to their disappearance and may prevent the occurrence of advanced disease (CNV or geographic atrophy) associated with visual loss. OBJECTIVES To examine the effectiveness and adverse effects of laser photocoagulation of drusen in AMD. SEARCH STRATEGY We searched CENTRAL, MEDLINE and EMBASE on 14 November 2008. SELECTION CRITERIA Randomised controlled trials (RCTs) of laser treatment of drusen in AMD in which laser treatment had been compared with no intervention or sham treatment. Two types of trials were included. Some trials studied one eye of each patient (unilateral studies); other studies recruited patients with bilateral drusen and randomised one eye to photocoagulation or control and the fellow eye to the other group. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies and extracted data. We pooled data from unilateral and bilateral studies using a random-effects model. For the bilateral studies, we estimated the within-patient correlation coefficient from one study and assumed it was valid for the others. MAIN RESULTS We found nine studies which randomised 2216 people: four unilateral trials, three bilateral trials and two trials that included both a unilateral and a bilateral study arm.Overall, the studies were of moderate quality. Only half of the trials reported adequate allocation sequence generation, allocation concealment and masking of visual acuity outcome assessors.Although two (of the nine) studies reported significant drusen disappearance at two years, photocoagulation did not appear to affect the development of CNV at two years follow up (nine studies, 1767 people followed up, odds ratio (OR) 1.04, 95% CI 0.71 to 1.51) or the loss of three or more lines of visual acuity (six studies, 1628 people followed up, OR 1.17, 95% CI 0.75 to 1.82). AUTHORS' CONCLUSIONS The trials included in this review confirm the clinical observation that laser photocoagulation of drusen leads to their disappearance. However, there is no evidence that this subsequently results in a reduction in the risk of developing CNV, geographic atrophy or visual acuity loss.
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Affiliation(s)
- Maurizio B Parodi
- Department of Ophthalmology, University of Udine, Piazzale Santa Maria della Misericordia, Udine, Italy, 33100
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Rosenfeld PJ, Martidis A, Tennant MT. Age-Related Macular Degeneration. Ophthalmology 2009. [DOI: 10.1016/b978-0-323-04332-8.00100-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Friberg TR, Brennen PM, Freeman WR, Musch DC, Study Group TPTAMD. Prophylactic Treatment of Age-Related Macular Degeneration Report Number 2: 810-Nanometer Laser to Eyes With Drusen: Bilaterally Eligible Patients. Ophthalmic Surg Lasers Imaging Retina 2009; 40:530-8. [DOI: 10.3928/15428877-20091030-01] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2008] [Indexed: 11/20/2022]
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Abstract
Age-related macular degeneration is the leading cause of blindness in elderly populations of European descent. The most consistent risk factors associated with this ocular condition are increasing age and cigarette smoking. Genetic investigations have shown that complement factor H, a regulator of the alternative complement pathway, and LOC387715/HtrA1 are the most consistent genetic risk factors for age-related macular degeneration. Although the pathogenesis of this disease is unknown, oxidative stress might have an important role. Treatment with antioxidant vitamins and zinc can reduce the risk of developing advanced age-related macular degeneration by about a quarter in those at least at moderate risk. Intravitreal injections of ranibizumab, a monoclonal antibody that inhibits all forms of vascular endothelial growth factor, have been shown to stabilise loss of vision and, in some cases, improve vision in individuals with neovascular age-related macular degeneration. These findings, combined with assessments of possible environmental and genetic interactions and new approaches to modulate inflammatory pathways, will hopefully further expand our ability to understand and treat age-related macular degeneration.
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Affiliation(s)
- Hanna R Coleman
- Division of Epidemiology and Clinical Research, National Eye Institute, National Institutes of Health, Bethesda, MD, USA
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Abstract
BACKGROUND/PURPOSE Recent attention has focused upon several reports of retinal pigment epithelium (RPE) tears following vascular endothelial growth factor (VEGF)-modulating therapy. The authors review the clinical features, etiologies, imaging characteristics, and pathogenesis of RPE tears and their relationship with intravitreal anti-VEGF treatments. METHODS The authors conducted a comprehensive literature search of RPE tears or rips of any etiology using the PubMed database. They have also included a retrospective analysis of an additional five cases of RPE tears following anti-VEGF therapy, four after bevacizumab and one after ranibizumab. RESULTS Thirty-three cases of RPE tear after treatment with pegaptanib, bevacizumab, or ranibizumab have been previously reported in the literature. The authors have collected and analyzed the clinical features for 25 of these cases for which this information was available. The authors have also included analysis of an additional five cases. Common features of each of these 30 cases included advanced age of the patient, the presence of fibrovascular pigment epithelial detachment (PED) or PED associated with choroidal neovascularization (CNV), and diagnosis of the tear within 4 to 8 weeks of the first or second injection. CONCLUSIONS RPE tears may develop during the course of anti-VEGF therapy for age-related macular degeneration-related PED. Patients with high-risk lesions, especially large irregular PED associated with CNV, should be counseled and monitored for this complication, which may limit visual prognosis.
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Affiliation(s)
- Louis K Chang
- Jules Stein Eye Institute, Department of Ophthalmology, University of California-Los Angeles, 100 Stein Plaza, Los Angeles, CA 90095, USA
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Abstract
The retinal pigment epithelium (RPE) maintains retinal function as the metabolic gatekeeper between photoreceptors (PRs) and the choriocapillaries. The RPE and Bruch's membrane (BM) suffer cumulative damage over lifetime, which is thought to induce age-related macular degeneration (AMD) in susceptible individuals. Unlike palliative pharmacologic treatments, replacement of the RPE has a curative potential for AMD. This article reviews mechanisms leading to RPE dysfunction in aging and AMD, laboratory studies on RPE transplantation, and surgical techniques used in AMD patients. Future strategies using ex vivo steps prior to transplantation, BM prosthetics, and stem cell applications are discussed. The functional peculiarity of the macular region, epigenetic phenomena leading to an age-related shift in protein expression, along with the accumulation of lipofuscin may affect the metabolism in the central RPE. Thickening of BM with age decreases its hydraulic conductivity. Drusen are deposits of extracellular material and formed in part by activation of the alternative complement pathway in individuals carrying a mutant allele of complement factor H. AMD likely represents an umbrella term for a disease entity with multifactorial etiology and manifestations. Presently, a slow progressing (dry) non-neovascular atrophic form and a rapidly blinding neovascular (wet) form are discerned. No therapy is currently available for the former, while RPE transplantation and promising (albeit non-causal) anti-angiogenic therapies are available for the latter. The potential of RPE transplantation was demonstrated in animal models. Rejection of allogeneic homologous transplants in patients focused further studies on autologous sources. In vitro studies elucidated cell adhesion and wound healing mechanisms on aged human BM. Currently, autologous RPE, harvested from the midperiphery, is being transplanted as a cell suspension or a patch of RPE and choroid in AMD patients. These techniques have been evaluated from several groups. Autologous RPE transplants may have the disadvantage of carrying the same genetic information that may have led to AMD manifestation. An intermittent culturing step would allow for in vitro therapy of the RPE, its rejuvenation and prosthesis of BM to improve the success RPE transplants. Recent advances in stem cell biology when combined with lessons learned from studies of RPE transplantation are intriguing future therapeutic modalities for AMD patients.
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Affiliation(s)
- Susanne Binder
- Department of Ophthalmology, Rudolf Foundation Clinic, Hospital of the City of Vienna, Vienna, Austria.
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Affiliation(s)
- Catherine Cukras
- Scheie Eye Institute, Department of Opthalmology, University of Pennsylvania, 51 North 39th Street, Philadelphia, PA 19104, USA
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Laser treatment in patients with bilateral large drusen: the complications of age-related macular degeneration prevention trial. Ophthalmology 2006; 113:1974-86. [PMID: 17074563 DOI: 10.1016/j.ophtha.2006.08.015] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2006] [Revised: 08/09/2006] [Accepted: 08/11/2006] [Indexed: 11/26/2022] Open
Abstract
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.
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Gehrs KM, Anderson DH, Johnson LV, Hageman GS. Age-related macular degeneration--emerging pathogenetic and therapeutic concepts. Ann Med 2006; 38:450-71. [PMID: 17101537 PMCID: PMC4853957 DOI: 10.1080/07853890600946724] [Citation(s) in RCA: 442] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Today, the average life expectancy in developed nations is over 80 years and climbing. And yet, the quality of life during those additional years is often significantly diminished by the effects of age-related, degenerative diseases, including age-related macular degeneration (AMD), the leading cause of blindness in the elderly worldwide. AMD is characterized by a progressive loss of central vision attributable to degenerative and neovascular changes in the macula, a highly specialized region of the ocular retina responsible for fine visual acuity. Estimates gathered from the most recent World Health Organization (WHO) global eye disease survey conservatively indicate that 14 million persons are blind or severely visually impaired because of AMD. The disease has a tremendous impact on the physical and mental health of the geriatric population and their families and is becoming a major public health burden. Currently, there is neither a cure nor a means to prevent AMD. Palliative treatment options for the less prevalent, late-stage 'wet' form of the disease include anti-neovascular agents, photodynamic therapy and thermal laser. There are no current therapies for the more common 'dry' AMD, except for the use of antioxidants that delay progression in 20%-25% of eyes. New discoveries, however, are beginning to provide a much clearer picture of the relevant cellular events, genetic factors, and biochemical processes associated with early AMD. Recently, compelling evidence has emerged that the innate immune system and, more specifically, uncontrolled regulation of the complement alternative pathway plays a central role in the pathobiology of AMD. The complement Factor H gene--which encodes the major inhibitor of the complement alternative pathway--is the first gene identified in multiple independent studies that confers a significant genetic risk for the development of AMD. The emergence of this new paradigm of AMD pathogenesis should hasten the development of novel diagnostic and therapeutic approaches for this disease that will dramatically improve the quality of our prolonged lifespan.
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Affiliation(s)
- Karen M Gehrs
- Department of Ophthalmology and Visual Sciences, The University of Iowa, Iowa City, IA 52240, USA
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