Quality of life in a prospective, randomised pilot-trial of photodynamic therapy versus full macular translocation in treatment of neovascular age-related macular degeneration--a report of 1 year results

Impact of age-related macular degeneration on vision-specific quality of life: Follow-up from the 10-year and 15-year visits of the Study of Osteoporotic Fractures

PURPOSE

To assess vision-specific quality of life (QOL), based on abbreviated surveys derived from the National Eye Institute Visual Function Questionnaire (NEI-VFQ), in a cohort of United States women who participated in the Study of Osteoporotic Fractures.

DESIGN

Prospective, observational cohort study.

METHODS

Age-related macular degeneration (AMD) status, based on a 3-level classification (no AMD, early AMD, late AMD), and vision-specific QOL, based on abbreviated NEI-VFQ surveys, were calculated for 1674 women enrolled in the Study of Osteoporotic Fractures at 4 centers within the United States who had gradable fundus photographs at both the 10-year and 15-year follow-up visits. The associations among 5-year changes in NEI-VFQ composite scores, change in AMD status, and distance visual acuity were examined.

RESULTS

Compared with study participants without AMD at both visits, study participants with late AMD at both visits and those who progressed from early AMD to late AMD demonstrated the greatest declines in adjusted NEI-VFQ composite scores, up to a mean decrease of 16.2 from a scale of 100. Visual acuity declines also were most prominent for patients with late AMD at both visits and for those who progressed from early AMD to late AMD. Change in visual acuity was found to correlate significantly with change in vision-specific QOL.

CONCLUSIONS

The abbreviated NEI-VFQ surveys provide reliable assessments of vision-specific QOL in AMD patients. The decline in vision-specific QOL associated with the progression of AMD is clinically meaningful.

Surgical management of subfoveal choroidal neovascular membranes in age-related macular degeneration by macular relocation: experiences of an early-stopped randomised clinical trial (MARAN Study)

RATIONALE

The MARAN (Macular Relocation in Age-related Neovascular disease) trial was planned to assess the effectiveness of full macular relocation (MR) in patients with neovascular age-related macular degeneration (AMD).

DESIGN

Randomised, prospective, controlled clinical trial.

METHODS

Patients suffering from visual loss because of AMD were randomised to either surgery or a control group receiving standard treatment (observation or photodynamic therapy (PDT)). The primary end point was the change of visual acuity (VA) (ETDRS) 52 weeks after randomisation compared with initial VA, and secondary end points included reading performance, contrast sensitivity, stability of fixation, eye-specific quality of life, and the absolute number of letters read correctly at 52 weeks compared with initial examination.

RESULTS

Owing to early determination, only 28 patients were included in the study. The study did not show a difference between the two groups with respect to the final visual result or any of the secondary outcomes measured. The study was limited by the low recruitment that was, at least in part, attributed to the inherent risks for those patients randomised to the surgical arm of the study as well as to the emerging new treatments for AMD.

CONCLUSION

The results of the MARAN trial failed to recruit a sufficient number of patients and a superiority of surgery over observation or PDT in patients with exudative AMD was not shown. There was a trend that the reading function was superior after surgery. In the light of the new pharmacological treatments, surgical options such as MR will be an option for only selected cases.

Full macular translocation (FMT) versus photodynamic therapy (PDT) with verteporfin in the treatment of neovascular age-related macular degeneration: 2-year results of a prospective, controlled, randomised pilot trial (FMT-PDT)

BACKGROUND

To report the outcome of best-corrected visual acuity (BCVA), near visual acuity (NVA), contrast sensitivity (CS) and vision-related quality of life (VRQOL) in patients 2 years after undergoing photodynamic therapy (PDT) or full macular translocation (FMT) for the treatment of neovascular age-related macular degeneration (AMD).

METHODS

Fifty patients with predominantly classic subfoveal choroidal neovascularisation (CNV) secondary to AMD were randomized to PDT or FMT. BCVA was determined according a standardized protocol with ETDRS charts. NVA were calculated after testing with SNAB (Swiss National Association of and for the Blind) visual acuity cards. CS was measured with Pelli-Robson charts. The 39-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25 plus supplement) was performed. Primary end points were the changes of BCVA, NVA, CS and VRQOL at 24-month examination.

RESULTS

A stabilisation of BCVA (+0.3 letters) was found in the FMT group, whereas a decrease of more than 12 letters (-12.6 letters) was found in the PDT group (p = 0.052). Mean NVA improved by 7.0 letters in the FMT group and was superior to the PDT group (-9.6 letters, p = 0.036), while mean CS showed a time-dependent decrease in both treatment groups (FMT: -3.3 letters, PDT: -3.8 letters, p = 0.726). Considering the results of the VRQOL scores, the improvement of the subscales scores for general vision (p = 0.015), mental health (p = 0.028) and near activity (p = 0.020) were significantly higher in the FMT group.

CONCLUSIONS

FMT can stabilise BCVA and improve NVA over a period of 2 years in patients with subfoveal classic CNV secondary to neovascular AMD, whereas a decrease of BCVA and NVA was found in the PDT group. CS did not differ between FMT and PDT. A significant increase of VRQOL scores was only found in the FMT group and not in the PDT group. FMT seems to be a therapeutic approach that can increase visual function resulting in an improvement of patient's VRQOL, but exhibits a higher number of severe complications compared to PDT.

Macular translocation for neovascular age-related macular degeneration

BACKGROUND

Macular translocation has been proposed by vitreoretinal surgeons to displace the neuroretinal tissue onto healthy retinal pigment epithelium and choroid when the macula has been invaded by subretinal neovascularisation.

OBJECTIVES

This review aims at assessing the effectiveness of macular translocation for preserving or improving vision in patients with neovascular age-related macular degeneration (AMD).

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE and Caribbean Literature on Health Sciences (LILACS). There were no language or date restrictions in the search for trials.The electronic databases were last searched on 21 July 2008.

SELECTION CRITERIA

We included randomised or quasi randomised controlled trials comparing macular translocation with any other treatment or observation.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted the data. The risk ratio (RR) of visual loss and visual gain was estimated at one year after treatment.

MAIN RESULTS

Only one small unblinded study on 50 people compared full macular translocation with photodynamic therapy (PDT) in AMD patients with predominantly classic subfoveal choroidal neovascularisation (CNV). At the last examination, performed in most of the cases after one year, there was no difference in the rate of visual loss of 3 or more lines (translocation versus PDT: RR 0.56, 95% confidence interval (CI) 0.22 to 1.43), as well as in the mean change of contrast sensitivity (1 letter favouring translocation; 95% CI -3.51 to 5.51) and the rate of recurrence of CNV (translocation versus PDT: RR 1.56, 95% CI 0.83 to 2.91). Other outcomes significantly favoured translocation, such as the gain of 3 or more ETDRS lines (RR 21, 95% CI 1.30 to 340.02), the mean change of visual acuity (mean difference (MD) 14.60, 95% CI 5.39 to 23.81) and the mean change of near visual acuity score (MD 17.80, 95% CI 3.98 to 31.62) which is obtained with an algorithm. Serious complications reported after macular translocation were retinal detachment in 6/25 patients and diplopia requiring prismatic correction in 5/25 patients.

AUTHORS' CONCLUSIONS

There is insufficient evidence from randomised controlled trials on the effectiveness of macular translocation, which is also not free of important risks. Furthermore, this technique is difficult to perform and a long surgical training is required. Future studies might include patients with small neovascular lesions that failed to respond to current pharmacological therapies and are willing to accept the risks associated with surgery to try to improve visual acuity.

Time-dependent effects on contrast sensitivity, near and distance acuity: difference in functional parameters? (Prospective, randomized pilot trial of photodynamic therapy versus full macular translocation)

PURPOSE

To report the change of contrast sensitivity (CS) after photodynamic therapy (PDT) vs full macular translocation (FMT) for neovascular age-related macular degeneration (AMD), and to relate this to other measures of visual function (distance and near acuity).

METHODS

Fifty patients (50 eyes) with predominantly classic subfoveal choroidal neovascularisation (CNV) secondary to AMD were randomized to PDT or FMT. CS was measured with Pelli-Robson charts. Acuity scores of near visual function (NVS) were calculated after testing with visual acuity cards of the Swiss National Association of and for the Blind (SNAB). Best corrected distance visual acuity (DVA) was determined according to a standardized protocol with EDTRS charts. Primary end point was the change of CS at 12-month examination from baseline. The interaction of the CS with NVS and DVA was analysed.

RESULTS

Mean CS showed a decrease in both treatment groups (FMT: -2 letters, PDT: -3 letters, p=0.969) at 12-month examination from baseline. While mean NVS improved by seven letters in the FMT group, a decrease of more than ten letters was seen in the PDT group (p<0.05). We found no agreement between CS and high-contrast acuity (NVS, DVA). In FMT patients, the parameters at baseline (CS, NVS, DVA) correlated poorly with the corresponding 12-month results, therefore providing no informative basis to predict the later functional development. In contrast, PDT patients showed strong baseline-to-outcome coherence with baseline measures also associated with better final values.

CONCLUSIONS

Although FMT can initiate recovery of near and distance acuity over the period of 1 year in selected patients with classic CNV, CS did not differ between FMT and PDT. We found no close connection of CS with DVA or NVS, especially after FMT. Knowledge about the unequal variation of visual parameters can provide more comprehensive information when advising patients on different therapeutic options. That also applies in particular to vascular endothelial growth factor inhibitors, which seem to promise an even higher extent of gain in CS and to reach the peak of recovery at an earlier time.