Treatment of age-related macular degeneration

Influence of background on image recognition in normal vision and age-related macular degeneration

PURPOSE

The influence of background attenuation on the spatial frequency bandwidth requirements for image recognition was assessed in normal young and older groups and in a group with age-related macular degeneration (AMD). Bandwidth requirements were also assessed in the visual periphery of young normal observers.

METHODS

In Experiment 1, each observer was presented with 20 series of images. Each series consisted of a sequence of progressively low-pass filtered images, presented in an order of increasing bandwidth, i.e., according to an ascending method of limits. For half of the series, the background of the base image was selectively darkened by 80% of its original luminance. Three measures were analyzed: (1) the critical bandwidth defined as the bandwidth in cycles/image (cpi) at which 50% of the images were recognized, (2) the minimal bandwidth, defined as the minimal bandwidth at which images were recognized and (3) the proportion of images recognized at full bandwidth. In Experiment 2, young normal observers were similarly tested in central vision and at 5.5° eccentricity (superior or inferior visual field). A third background attenuation condition was included, as well, in which the background was low-pass filtered.

RESULTS

The critical bandwidth for image recognition was significantly reduced by darkening the image background for normal young and old and the AMD groups. This improvement was found to be contrast dependent for the darkened background. In addition, AMD observers tended to recognize more images at full bandwidth if the background was darkened. For normal young observers, making the background low-pass was ineffective in lowering the critical bandwidth in the fovea. Fewer images were recognized at full bandwidth at 5.5° eccentricity for a low-pass background and marginally fewer for a darkened background.

CONCLUSIONS

Selective attenuation of the image background can lead to reductions in the bandwidth requirements for image recognition in AMD. However, performance of young normal observers for images presented in the periphery was unlike AMD performance under the conditions investigated. These results have interesting implications for the design of image enhancement algorithms to aid low vision observers.

Enhanced bioavailability of zeaxanthin in a milk-based formulation of wolfberry (Gou Qi Zi; Fructus barbarum L.)

The carotenoid zeaxanthin is concentrated within the macula. Increased macular zeaxanthin is suggested to lower the risk of age-related macular degeneration. The small red berry, wolfberry (Fructus barbarum L.; Gou Qi Zi and Kei Tze), is one of the richest natural sources of zeaxanthin. However, carotenoid bioavailability is low, and food-based products with enhanced bioavailability are of interest. The present study investigated zeaxanthin bioavailability from three wolfberry formulations. Berries were homogenised in hot (80 degrees C) water, warm (40 degrees C) skimmed milk and hot (80 degrees C) skimmed milk, with freeze drying of each preparation into a powdered form. A zeaxanthin-standardised dose (15 mg) of each was consumed, in randomised order, together with a standardised breakfast by twelve healthy, consenting subjects in a cross-over trial, with a 3-5-week washout period between treatments. Blood samples were taken via a venous cannula immediately before (fasting) and 2, 4, 6, 7, 8 and 10 h post-ingestion. Zeaxanthin concentration in the triacylglycerol-rich lipoprotein fraction of plasma was measured by HPLC. Results showed that triacylglycerol-rich lipoprotein zeaxanthin peaked at 6 h post-ingestion for all formulations. Zeaxanthin bioavailability from the hot milk formulation was significantly higher (P < 0.001) than from the others. Mean area under the curve (n 12) results were 9.73 (sem 2.45), 3.24 (sem 0.72) and 3.14 (sem 1.09) nmol x h/l for the hot milk, warm milk and hot water formulations, respectively. Results showed clearly that homogenisation of wolfberry in hot skimmed milk results in a formulation that has a 3-fold enhanced bioavailability of zeaxanthin compared with both the 'classical' hot water and warm skimmed milk treatment of the berries.

Fasting plasma zeaxanthin response to Fructus barbarum L. (wolfberry; Kei Tze) in a food-based human supplementation trial

Age-related macular degeneration (AMD) is a common disorder that causes irreversible loss of central vision. Increased intake of foods containing zeaxanthin may be effective in preventing AMD because the macula accumulates zeaxanthin and lutein, oxygenated carotenoids with antioxidant and blue light-absorbing properties. Lycium barbarum L. is a small red berry known as Fructus lycii and wolfberry in the West, and Kei Tze and Gou Qi Zi in Asia. Wolfberry is rich in zeaxanthin dipalmitate, and is valued in Chinese culture for being good for vision. The aim of this study, which was a single-blinded, placebo-controlled, human intervention trial of parallel design, was to provide data on how fasting plasma zeaxanthin concentration changes as a result of dietary supplementation with whole wolfberries. Fasting blood was collected from healthy, consenting subjects; fourteen subjects took 15 g/d wolfberry (estimated to contain almost 3 mg zeaxanthin) for 28 d. Repeat fasting blood was collected on day 29. Age- and sex-matched controls (n 13) took no wolfberry. Responses in the two groups were compared using the Mann-Whitney test. After supplementation, plasma zeaxanthin increased 2.5-fold: mean values on day 1 and 29 were 0.038 (sem 0.003) and 0.096 (sem 0.009) micromol/l (P<0.01), respectively, for the supplementation group; and 0.038 (sem 0.003) and 0.043 (sem 0.003) micromol/l (P>0.05), respectively, for the control group. This human supplementation trial shows that zeaxanthin in whole wolfberries is bioavailable and that intake of a modest daily amount markedly increases fasting plasma zeaxanthin levels. These new data will support further study of dietary strategies to maintain macular pigment density.

Preventive versus treatment effect of AG3340, a potent matrix metalloproteinase inhibitor in a rat model of choroidal neovascularization

PURPOSE

AG3340 (prinomastat) is a nonpeptidic, small-molecular-weight, synthetic matrix metalloproteinase inhibitor (MMPI) with selective inhibitory action of MMP-2, MMP-9, MMP-3, and MT-MMP1. We evaluated AG3340 injected intravitreally to treat choroidal neovascularization in a laser induced rat CNV model.

METHODS

In the pretreatment group, the drug was injected the same day after induction of choroidal neovascularization by diode laser. In the treatment group, the drug was injected 2 weeks after induction of choroidal neovascularization (CNV). Fluorescein and indocyanine green angiography were performed to evaluate CNV. ERG recordings and histology were performed to assess toxicity and the CNV lesions.

RESULTS

When used at the time of CNV induction, 62.8% of lesions in control versus 22.8% of the laser lesions in treated eyes developed CNV (p < 0.0001). The invading fibrovascular complex was thicker in the control eyes than that in the treated eyes. No signs of toxicity were detected. When used to treat established CNV, the percentage of leakage in treated and control eyes were 54.1% and 58.9% respectively (p > 0.05). Prinomastat was effective when given at the time of induction of CNV in the rat model. Administration of prinomastat 2 weeks after laser induction did not show efficacy.

CONCLUSION

Prinomastat was active in the earliest stages of experimental CNV. It might be best used in combination with photodynamic therapy to inhibit recurrence of CNV from temporarily closed new vessels.

Verteporfin : a review of its use in the management of subfoveal choroidal neovascularisation

Verteporfin (Visudyne) therapy (photodynamic therapy with intravenous liposomal verteporfin) is the first treatment to effectively prevent the loss of visual acuity in patients with subfoveal choroidal neovascularisation (CNV) secondary to age-related macular degeneration (AMD), pathological myopia or presumed ocular histoplasmosis syndrome (POHS). In adult patients with classic subfoveal CNV or occult with no classic subfoveal CNV secondary to AMD, or subfoveal CNV secondary to pathological myopia or POHS, verteporfin therapy slows or prevents loss of visual acuity. In well designed clinical trials, verteporfin therapy was superior to placebo in patients with subfoveal classic-containing CNV and occult with no classic CNV secondary to AMD at 12 and/or 24 months (Treatment of Age-related macular degeneration with Photodynamic therapy [TAP] Investigation and Verteporfin In Photodynamic therapy [VIP-AMD] trial) and in patients with pathological myopia at 12 months (Verteporfin In Photodynamic therapy [VIP-PM] trial). Limited data suggest that verteporfin therapy also prevents loss of visual acuity in patients with subfoveal CNV secondary to POHS. Verteporfin therapy was generally well tolerated in clinical trials; most adverse events were mild to moderate in intensity and transient. The most frequently reported verteporfin therapy-related adverse events (incidence >2%) were visual disturbance, injection-site reactions, photosensitivity reactions and infusion-related back pain. Approximately 5% of patients with occult with no classic subfoveal CNV secondary to AMD reported severe vision decrease within 7 days of treatment in clinical trials; 3 months later, several patients had recovered some of this loss.

CONCLUSION

Photodynamic therapy with verteporfin, the first photosensitiser approved for the treatment of subfoveal CNV, is a well tolerated treatment that stabilises or slows visual acuity loss in adult patients with predominantly classic or occult with no classic subfoveal CNV secondary to AMD, and subfoveal CNV secondary to pathological myopia or POHS. Thus, verteporfin therapy provides a valuable option for the management of these patients for whom treatment options are few, and should be considered as a first-line therapy in these difficult-to-manage conditions.