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Drug Therapy
A L A S T A I R J . J . W O O D , M. D. , Editor
A GE -R ELATED
M ACULAR D EGENERATION
STUART L. FINE, M.D., JEFFREY W. BERGER, M.D., PH.D.,
MAUREEN G. MAGUIRE, PH.D., AND ALLEN C. HO, M.D.
CLINICAL FEATURES
AND CLASSIFICATION
From the Department of Ophthalmology, Scheie Eye Institute, University of Pennsylvania Health System (S.L.F., J.W.B., M.G.M.), and the Department of Ophthalmology, Wills Eye Hospital, Thomas Jefferson University (A.C.H.) both in Philadelphia. Address reprint requests to Dr.
Fine at the Scheie Eye Institute, University of Pennsylvania Health System,
51 N. 39th St., Philadelphia, PA 19104-2689.
2000, Massachusetts Medical Society.
Figure 2. Early Age-Related Macular Degeneration, Characterized by Large Drusen (Arrows) and Clumps of Pigment (Arrowheads) in the Macula.
This eye has normal visual acuity but is at risk for late agerelated macular degeneration and loss of vision.
ed with minimal visual impairment and is characterized by large drusen and pigmentary abnormalities
in the macula (Fig. 2).4 Drusen are accumulations of
acellular, amorphous debris subjacent to the basement
membrane of the retinal pigment epithelium (Fig.
3).5 Nearly all people over the age of 50 years have
at least one small druse (63 m) in one or both
eyes.6 Only eyes with large drusen (>63 m) are at
risk for late age-related macular degeneration.7
There are two forms of late age-related macular
degeneration: the atrophic form and the neovascular,
exudative form. The atrophic form typically involves
the choriocapillaris, retinal pigment epithelium, and
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B
Figure 3. Cross Section of Normal Retina (Panel A) and Retina
with Drusen (Panel B) (Hematoxylin and Eosin).
The asterisks in Panel A identify photoreceptors, and the arrowheads point to retinal pigment epithelium (100). The asterisks
in Panel B identify drusen, or accumulations of eosinophilic
acellular debris subjacent to the basement membrane of retinal
pigment epithelium (400). Panel B was provided by J.D.M.
Gass, Vanderbilt University.
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B
Figure 4. Fundus Photographs Showing Progression of Atrophy
(Arrows) over a Period of Three Years.
In Panel A, atrophy of the retinal pigment epithelium and choriocapillaries makes the subjacent choroidal vessels appear
more prominent. The surrounding fundus is otherwise normal.
Three years later, these features are more pronounced (Panel
B), and the central atrophy is severe enough that reading can
only be accomplished if the text is magnified.
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Sensory retina
Subretinal<
fluid
Choroidal neovascularization
B
Figure 6. Choroidal Neovascularization.
Panel A shows choroidal neovascularization (asterisks) temporal to the fovea, surrounded by subretinal blood. In Panel B,
fluorescein dye fills the new blood vessels (asterisks) above the
avascular zone of the fovea.
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Choroidal neovascularization may progress rapidly, and therefore, any sudden change in central vision in a patient with drusen in one or both eyes requires a prompt ophthalmoscopic examination after
dilation of the eyes. The purpose of this evaluation
is to determine whether this sudden loss of vision is
due to leakage from new blood vessels that might be
amenable to treatment with laser photocoagulation
or photodynamic therapy.
Laser Photocoagulation Therapy
Between 1979 and 1994, the Macular Photocoagulation Study Group conducted a number of clinical
Female sex
Light-colored iris
Cardiovascular disease
Increased exposure to
sunlight
Percentage of Patients
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100
90
80
70
60
50
40
30
20
10
0
87
53
44
25
7
trials supported by the National Eye Institute that enrolled patients with neovascular lesions of one or both
eyes. Each affected eye was randomly assigned to either
laser treatment or observation. For eligible eyes with
neovascularization in extrafoveal locations (200 m
or more from the center of the macula), juxtafoveal
locations (more than 1 m but less than 200 m
from the foveal center), and subfoveal locations, laser treatment reduced the risk of severe visual loss.32-34
Laser photocoagulation, as performed in the Macular Photocoagulation Study, is the only treatment for
age-related macular degeneration with proven longterm benefit. To identify patients eligible for laser
treatment, intravenous fluorescein angiography is performed. Well-circumscribed new blood vessels identified on the fluorescein angiogram (Fig. 6B) are
treated with laser photocoagulation after topical or
local (retrobulbar or peribulbar) anesthesia. Figure
10 shows the effects of laser photocoagulation immediately after treatment and six months later.
There are three major limitations of laser photocoagulation treatment. First, not more than 10 to 15
percent of all neovascular lesions are small enough
and sufficiently delineated by fluorescein angiography
to be eligible for laser treatment. Second, even if laser
treatment is initially successful that is, the new
blood vessels appear closed on fluorescein angiography there is at least a 50 percent chance that leakage will recur during the next two years. Fortunately, many recurrences are amenable to additional laser
treatment if detected early, thus mandating careful
monitoring after laser treatment. Third, at least half
the patients with sufficiently well-circumscribed neovascular lesions have some initial leakage beneath the
center of the fovea. Laser treatment leads to an immediate reduction in central vision. Even so, with sufVol ume 342
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Figure 10. Choroidal Neovascularization in the Absence of and after Laser Treatment.
In Panel A, choroidal neovascularization (asterisks) has caused new blood vessels to penetrate Bruchs membrane (arrowheads).
The arrows identify the retinal pigment epithelium (periodic acidSchiff, 775). In Panel B, immediately after laser treatment, there
is opacification of the normally clear retina over the treated area. In Panel C, six months after treatment, there is a circumscribed
laser scar with no accompanying blood or subretinal fluid. In Panel D, a fluorescein angiogram obtained six months after treatment
shows no leakage from the treated blood vessels. Panel A was provided by W.R. Green, Wilmer Eye Institute, Johns Hopkins Medical
Institution. Panel B was reprinted from Bressler et al.10 with the permission of the publisher.
Photodynamic therapy is a nonthermal process leading to the localized production of reactive oxygen
species, including singlet oxygen, superoxide anions,
and hydroxyl radicals, which may mediate local cellular, vascular, and immunologic injury, and ultimately result in the partially selective destruction of new
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Although preliminary data in animals and anecdotal reports in humans had suggested that interferon alfa-2a was beneficial in patients with choroidal
neovascularization, the results of a large, multicenter,
international trial of interferon alfa-2a were negative.38 Indeed, patients treated with high-dose interferon alfa-2a had more rapid loss of vision than did
those given placebo.
INVESTIGATIONAL TREATMENTS
Submacular Surgery
Advances in microsurgical techniques have permitted the development and refinement of surgical methods for the treatment of age-related macular degeneration. Areas of choroidal neovascularization can be
excised and blood extracted from the subretinal space
by means of vitreous surgery. The efficacy of this procedure is now being evaluated in a trial supported by
the National Eye Institute.39
External-Beam Radiation Therapy
External-beam radiation therapy is being considered as a treatment for the neovascular lesions in patients with age-related macular degeneration because
of the radiosensitivity of vascular endothelial cells,
especially proliferating vascular endothelial cells. Since
1993, when the results of the first series were published,40 many large studies have been conducted, but
none included a control group. A recent small, randomized clinical trial in the Netherlands found that
patients who received external-beam radiation therapy had a smaller decrease in visual acuity than did
untreated patients one year after enrollment.41
Thalidomide
Although laser photocoagulation as guided by fluorescein angiography is the only treatment of proven
long-term benefit for age-related macular degeneration, several other imaging methods are contributing to our understanding of the structure, function,
natural history, and response to treatment of eyes
with this disorder. One such approach is indocyanine
green angiography. Indocyanine green differs from
fluorescein in that it absorbs and fluoresces in the
near-infrared portion of the spectrum and is more
completely bound to plasma proteins, potentially conferring advantages for the study of choroidal circulation.43 Several groups have attempted to use indocyanine green angiography to guide treatment of
choroidal neovascularization in patients whose eyes
are deemed ineligible for treatment on the basis of
fluorescein angiography.44,45 The usefulness of this
technique awaits validation.
Retinal Transplantation and Transplantation of Retinal
Pigment Epithelium
Retinal transplantation and transplantation of retinal pigment epithelium are still many years away from
clinical use. However, investigators are now attempting to transplant photoreceptor elements and retinal
pigment epithelium cells as a means of restoring visual function or at least slowing the progression of
visual loss resulting from processes potentiated in
part by abnormal retinal and retinal pigment epithelium cells.46
Retinal Translocation
Surgical innovators are exploring the potential benefits and complications of translocating the retina
with respect to the retinal pigment epithelium and
choroid.47,48 The goal of one experimental procedure
is to move otherwise functional sensory retina away
from subfoveal areas of choroidal neovascularization
so that laser photocoagulation can obliterate the new
blood vessels without destroying the overlying retina.
Early reports have described both successes with this
approach and adverse effects, including retinal detachment with loss of vision. With experience, advanced
methods of vitreoretinal surgery may prove effective.
Perhaps the optimal approach is to combine techniques; for example, excision of subfoveal areas of
choroidal neovascularization could be combined with
transplantation of retinal pigment epithelium or photoreceptors and possibly with the intravitreal instillation of a suitable drug to inhibit further choroidal
neovascularization.
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Retinal Prosthesis
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Perhaps the most promising approach for the future is prophylactic treatment. Even if the rate of efficacy of prophylaxis were only 30 percent, such a response would still reduce by half the rate of legal
blindness from age-related macular degeneration.56
On the basis of the encouraging results of pilot studies in the United States and elsewhere,57-61 the National Eye Institute recently funded a clinical trial to
evaluate the effect of low-intensity laser application
as prophylaxis in high-risk patients with numerous
large drusen in both eyes the Complications of
Age-Related Macular Degeneration Prevention Trial.
In each patient in this study, one eye will be randomly
assigned to receive laser photocoagulation of the macula in a grid pattern and the other eye to observation. Patients will be followed for at least five years.
In addition, an industry-sponsored, clinical trial of
prophylaxis with the infrared diode laser is being conducted in patients with bilateral drusen and patients
who already have choroidal neovascularization in one
eye and in whom the other eye is at risk.
Although prophylactic laser treatment can promote the resolution of drusen and, in some patients,
improve visual function moderately, it is not clear
whether the ophthalmoscopic resolution of drusen is
accompanied by a reduction in the risk of severe visual loss from atrophy or neovascularization.56 In fact,
in a pilot study of moderate-intensity laser treatment
(the Choroidal Neovascularization Prevention Trial), which was conducted from 1994 to 1999 to prepare for the large-scale study, the risk of choroidal
neovascularization in prophylactically treated fellow
eyes was increased.57
Nutrition and Dietary Supplements
Nutritional factors have been a subject of great interest among patients with age-related macular degeneration and their physicians. In casecontrol studies, subjects who habitually consumed large quantities
of leafy green vegetables and other foods containing
antioxidant vitamins had a decreased risk of age-related macular degeneration.62 Can people who begin to
consume antioxidant vitamins in their 60s and 70s
alter their risk of age-related macular degeneration?
For the past decade, the National Eye Institute has
supported the Age-Related Eye Disease Study, which
is assessing whether supplementation with antioxidant vitamins alone or in combination with zinc can
D RUG TH ERA PY
In the next few years, we anticipate that many genetic mutations will be discovered in patients with
the various forms of macular degeneration. In some
instances, it may be possible to modify environmental factors, such as diet, in carriers of a mutation before macular degeneration develops. Even if the onset
of age-related macular degeneration could be delayed
by only 5 to 10 years, such a delay could profoundly
decrease the rate of blindness, because some patients
would not survive long enough to lose their vision.
Although effective treatment is currently limited, research being conducted in many areas, including
prophylaxis, offers hope for the future to the many
affected patients and their offspring.
Supported in part by an unrestricted grant from Research to Prevent
Blindness (to Drs. Fine, Berger, Maguire, and Ho), a Career Development
Award from Research to Prevent Blindness (to Dr. Berger), and a grant
from the Paul and Evanina Bell Mackall Foundation Trust (to Drs. Fine,
Berger, Maguire, and Ho). Drs. Fine, Maguire, and Ho have received a grant
from Entremed, and Dr. Ho has received grants from CibaVision and Pharmacia & Upjohn and served as a consultant for Nexstar Pharmaceuticals.
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