LIGHTSITE III: 13-Month Efficacy and Safety Evaluation of Multiwavelength Photobiomodulation in Nonexudative (Dry) Age-Related Macular Degeneration Using the Lumithera Valeda Light Delivery System

PURPOSE

The LIGHTSITE III study evaluated multiwavelength photobiomodulation (PBM) therapy in nonexudative (dry) age-related macular degeneration (AMD) using the LumiThera Valeda Light Delivery System.

METHODS

LIGHTSITE III is a randomized, controlled trial to assess the safety and effectiveness of PBM in dry AMD. Subjects were given multiwavelength PBM (590, 660, and 850 nm) or Sham treatment delivered in a series of nine sessions over 3 to 5 weeks every four months over 24 months. Subjects were assessed for efficacy and safety outcomes. Data from the 13-month analysis are presented in this report.

RESULTS

A total of 100 subjects (148 eyes) with dry AMD were randomized. LIGHTSITE III met the primary efficacy best-corrected visual acuity endpoint with a significant difference between PBM (n = 91 eyes) and Sham (n = 54 eyes) groups (Between group difference: 2.4 letters (SE 1.15), CI: -4.7 to -0.1, P = 0.02) (PBM alone: 5.4 letters (SE 0.96), CI: 3.5 to 7.3, P < 0.0001; Sham alone: 3.0 letters (SE 1.13), CI: 0.7-5.2, P < 0.0001). The PBM group showed a significant decrease in new onset geographic atrophy ( P = 0.024, Fisher exact test, odds ratio 9.4). A favorable safety profile was observed.

CONCLUSION

LIGHTSITE III provides a prospective, randomized, controlled trial showing improved clinical and anatomical outcomes in intermediate dry AMD following PBM therapy.

Photobiomodulation for non-exudative age-related macular degeneration

BACKGROUND

Age-related macular degeneration (AMD) is one of the leading causes of blindness in high-income countries. The majority of cases of AMD are of the non-exudative type. Experts have proposed photobiomodulation (PBM) therapy as a non-invasive procedure to restore mitochondrial function, upregulate cytoprotective factors and prevent apoptotic cell death in retinal tissue affected by AMD.

OBJECTIVES

To assess the effectiveness and safety of PBM compared to standard care, no treatment or sham treatment for people with non-exudative AMD.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (Issue 5, 2020), Ovid MEDLINE, Embase, ISRCTN, ClinicalTrials.gov and the WHO ICTRP to 11 May 2020 with no language restrictions.

SELECTION CRITERIA

The review included randomised controlled trials (RCTs) on participants receiving any type of PBM therapy for non-exudative AMD compared to standard care, sham treatment or no treatment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We considered the following outcome measures at 12 months: best-corrected visual acuity (BCVA) ; contrast sensitivity; near vision; low luminance density score; reading speed; vision-related quality of life score; and adverse events such as progression of AMD and conversion to exudative AMD. We graded the certainty of the evidence using GRADE.

MAIN RESULTS

We included two published RCTs from single centres in the UK and Canada, which recruited 60 participants (60 eyes) and 30 participants (46 eyes) respectively. Participants in these trials were people with non-exudative AMD with Age-Related Eye Disease Study (AREDS) categories 2 to 4. One study compared single wavelength PBM with no treatment. This study was at risk of performance bias because the study was not masked, and there was attrition bias. One study compared multi-wavelength PBM with sham treatment and conflicts of interest were reported by study investigators. We also identified three eligible ongoing RCTs from searching the clinical trials database. When comparing PBM with sham treatment or no treatment for non-exudative AMD, there was no evidence of any meaningful clinical difference in BCVA at 12 months (mean difference (MD) 0.02 logMAR, 95% confidence interval (CI) -0.02 to 0.05; 2 RCTs, 90 eyes; low-certainty evidence). One study comparing multi-wavelength PBM with sham treatment showed an improvement in contrast sensitivity at Level E (18 cycles/degree) at 12 months (MD 0.29 LogCS, 95% CI 0.23 to 0.35; 1 RCT, 46 eyes; low-certainty evidence). Visual function and health-related quality of life scores were comparable between single wavelength PBM and no treatment groups at 12 months (VFQ-48 score MD 0.43, 95% CI -0.17 to 1.03; P = 0.16; 1 RCT, 47 eyes; low-certainty evidence). When comparing PBM with sham treatment or no treatment for non-exudative AMD, there was no evidence of any meaningful clinical difference in conversion to exudative AMD (risk ratio (RR) 0.97, 95% CI 0.17 to 5.44; 2 RCTs, 96 eyes; very low-certainty evidence) at 12 months. There was inconclusive evidence that single wavelength PBM prevents the progression of AMD (RR 0.79, 95% CI 0.41 to 1.53; P = 0.48; 1 RCT, 50 eyes; low-certainty evidence). Disease progression was defined as the development of advanced AMD or significant increase in drusen volume. No included study reported near vision, low luminance vision or reading speed outcomes.

AUTHORS' CONCLUSIONS

Currently there remains uncertainty whether PBM treatment is beneficial in slowing progression of non-exudative macular degeneration. There is a need for further well-designed controlled trials assessing dosimetry, powered for both effectiveness and safety outcomes. Consideration should be given to the adoption of agreed clinical outcome measures and patient-based outcome measures for AMD.

Radiotherapy for neovascular age-related macular degeneration

BACKGROUND

Radiotherapy has been proposed as a treatment for new vessel growth in people with neovascular age-related macular degeneration (AMD).

OBJECTIVES

To examine the effects of radiotherapy on neovascular AMD.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, LILACS and three trials registers and checked references of included studies. We last searched the databases on 4 May 2020.  SELECTION CRITERIA: We included all randomised controlled trials in which radiotherapy was compared to another treatment, sham treatment, low dosage irradiation or no treatment in people with choroidal neovascularisation (CNV) secondary to AMD.

DATA COLLECTION AND ANALYSIS

We used standard procedures expected by Cochrane. We graded the certainty of the evidence using GRADE. We considered the following outcomes at 12 months: best-corrected visual acuity (BCVA) (loss of 3 or more lines, change in visual acuity), contrast sensitivity, new vessel growth, quality of life and adverse effects at any time point.  MAIN RESULTS: We included 18 studies (n = 2430 people, 2432 eyes) of radiation therapy with dosages ranging from 7.5 to 24 Gy. These studies mainly took place in Europe and North America but two studies were from Japan and one multicentre study included sites in South America. Three of these studies investigated brachytherapy (plaque and epimacular), the rest were studies of external beam radiotherapy (EBM) including one trial of stereotactic radiotherapy. Four studies compared radiotherapy combined with anti-vascular endothelial growth factor (anti-VEGF) with anti-VEGF alone. Eleven studies gave no radiotherapy treatment to the control group; five studies used sham irradiation; and one study used very low-dose irradiation (1 Gy). One study used a mixture of sham irradiation and no treatment. Fifteen studies were judged to be at high risk of bias in one or more domains. Radiotherapy versus no radiotherapy There may be little or no difference in loss of 3 lines of vision at 12 months in eyes treated with radiotherapy compared with no radiotherapy (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.64 to 1.04, 811 eyes, 8 studies, I² = 66%, low-certainty evidence). Low-certainty evidence suggests a small benefit in change in visual acuity (mean difference (MD) -0.10 logMAR, 95% CI -0.17 to -0.03; eyes = 883; studies = 10) and average contrast sensitivity at 12 months (MD 0.15 log units, 95% CI 0.05 to 0.25; eyes = 267; studies = 2). Growth of new vessels (largely change in CNV size) was variably reported and It was not possible to produce a summary estimate of this outcome. The studies were small with imprecise estimates and there was no consistent pattern to the study results (very low-certainty evidence). Quality of life was only reported in one study of 199 people; there was no clear difference between treatment and control groups (low-certainty evidence). Low-certainty evidence was available on adverse effects from eight of 14 studies. Seven studies reported on radiation retinopathy and/or neuropathy. Five of these studies reported no radiation-associated adverse effects. One study of 88 eyes reported one case of possible radiation retinopathy. One study of 74 eyes graded retinal abnormalities in some detail and found that 72% of participants who had radiation compared with 71% of participants in the control group had retinal abnormalities resembling radiation retinopathy or choroidopathy. Four studies reported cataract surgery or progression: events were generally few with no consistent evidence of any increased occurrence in the radiation group. One study noted transient disturbance of the precorneal tear film but there was no evidence from the other two studies that reported dry eye of any increased risk with radiation therapy. None of the participants received anti-VEGF injections. Radiotherapy combined with anti-VEGF versus anti-VEGF alone People receiving radiotherapy/anti-VEGF were probably more likely to lose 3 or more lines of BCVA at 12 months compared with anti-VEGF alone (RR 2.11, 95% CI 1.40 to 3.17, 1050 eyes, 3 studies, moderate-certainty). Most of the data for this outcome come from two studies of epimacular brachytherapy (114 events) compared with 20 events from the one trial of EBM. Data on change in BCVA were heterogenous (I² = 82%). Individual study results ranged from a small difference of -0.03 logMAR in favour of radiotherapy/anti-VEGF to a difference of 0.13 logMAR in favour of anti-VEGF alone (low-certainty evidence). The effect differed depending on how the radiotherapy was delivered (test for interaction P = 0.0007). Epimacular brachytherapy was associated with worse visual outcomes (MD 0.10 logMAR, 95% CI 0.05 to 0.15, 820 eyes, 2 studies) compared with EBM (MD -0.03 logMAR, 95% CI -0.09 to 0.03, 252 eyes, 2 studies). None of the included studies reported contrast sensitivity or quality of life. Growth of new vessels (largely change in CNV size) was variably reported in three studies (803 eyes). It was not possible to produce a summary estimate and there was no consistent pattern to the study results (very low-certainty evidence). For adverse outcomes, variable results were reported in the four studies. In three studies reports of adverse events were low and no radiation-associated adverse events were reported. In one study of epimacular brachytherapy there was a higher proportion of ocular adverse events (54%) compared to the anti-VEGF alone (18%). The majority of these adverse events were cataract. Overall 5% of the treatment group had radiation device-related adverse events (17 cases); 10 of these cases were radiation retinopathy. There were differences in average number of injections given between the four studies (1072 eyes). In three of the four studies, the anti-VEGF alone group on average received more injections (moderate-certainty evidence).

AUTHORS' CONCLUSIONS

The evidence is uncertain regarding the use of radiotherapy for neovascular AMD. Most studies took place before the routine use of anti-VEGF, and before the development of modern radiotherapy techniques such as stereotactic radiotherapy. Visual outcomes with epimacular brachytherapy are likely to be worse, with an increased risk of adverse events,  probably related to vitrectomy. The role of stereotactic radiotherapy combined with anti-VEGF is currently uncertain. Further research on radiotherapy for neovascular AMD may not be justified until current ongoing studies have reported their results.

Radiation Therapy for Benign Disease: Keloids, Macular Degeneration, Orbital Pseudotumor, Pterygium, Peyronie Disease, Trigeminal Neuralgia

Although the use of ionizing radiation on malignant conditions has been well established, its application on benign conditions has not been fully accepted and has been inadequately recognized by health care providers outside of radiation therapy. Most frequently, radiation therapy in these benign conditions is used along with other treatment modalities, such as surgery, when the condition causes significant disability or could even lead to death. Radiation therapy can be helpful for inflammatory/proliferative disorders. This article discusses the present use of radiation therapy for some of the most common benign conditions.

Subfoveal Choroidal Thickness as a Potential Predictor of Clinical Response to Stereotactic Radiotherapy for Neovascular Age-Related Macular Degeneration

BACKGROUND AND OBJECTIVE

Stereotactic radiotherapy (SRT) is a new adjuvant treatment modality that has been shown to reduce the need for repetitive intravitreal injections (IVIs) in patients with neovascular age-related macular degeneration (nAMD). The authors aimed to determine baseline predictors of clinical response to SRT.

PATIENTS AND METHODS

This was a retrospective, observational case series of patients with nAMD who underwent SRT and subsequently had at least 12 months of complete follow-up. After SRT and one mandatory IVI, patients were examined every 4 weeks and received further treatment on a pro re nata basis. Examination included enhanced depth imaging spectral-domain optical coherence tomography (SD-OCT) to measure subfoveal choroidal thickness (SFCT) and central macular thickness (CMT). Patients' data were retrieved from medical records and included demographics, disease duration, lesion size, best-corrected visual acuity (BCVA), previous number of IVIs, and type of drug applied.

RESULTS

A total of 35 eyes of 35 patients (76.23 years ± 7.05 years) were included, and 21 eyes (60%) responded well to SRT. The annual injection rate decreased from 6.86 before SRT to 3.46 afterward, whereas BCVA improved from 0.49 logMAR at baseline to 0.37 logMAR at final follow-up. From a morphologic point of view, CMT and SFCT decreased by 71 μm and 37 μm, respectively, at 12-month follow-up compared to baseline. Of all investigated parameters, only SFCT proved to be significant, as a higher baseline SFCT was found to be a strong negative predictor for the number of IVIs needed after SRT (regression coefficient: -0.678; P < .001).

CONCLUSIONS

Baseline SFCT may help predict which patients with nAMD will respond more favorably to SRT. The authors found eyes with a thicker baseline SFCT needed fewer IVIs after SRT. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:320-328.].

Grading Choroidal Neovascular Membrane Regression after Strontium Plaque Radiotherapy; Masked Subjective Evaluation vs Planimetry

Purpose

To analyze angiographic changes in choroidal neovascular membranes (CNVM) after strontium-plaque (90Sr) irradiation for exudative age-related macular degeneration (AMD) using masked measurement of the CNVM areas and a masked subjective comparison of CNVM size and leakage.

Methods

We studied the baseline, 3, 6, and 12-month angiograms of 19 eyes treated with 90Sr-plaque irradiation for exudative AMD. The area of CNVM-related hyperfluorescence was measured quantitatively, and the angiograms were subjectively evaluated by a masked grader.

Results

In 7 of the 19 eyes the CNVM-related hyperfluorescence was too scattered to be analyzed by planimetry but masked subjective grading correlated with the clinical response to irradiation. In the remaining 12 eyes, the CNVM decreased in size in 67% of the eyes and showed leakage in 67%. Planimetry and subjective assessment of the size and leakage of the CNVMs similarly reflected the regression after irradiation.

Conclusions

CNVM size and leakage frequently diminish after 90Sr-plaque irradiation. Quantitative measurement of the CNVM areas, or a grading system based on masked subjective assessment, give similar results for evaluating these changes. Masked subjective grading can be used even in cases where the CNVM is too scattered to be outlined for planimetry.

Stereotactic radiotherapy in neovascular age-related macular degeneration: Real-life efficacy and morphological evaluation of the outer retina-choroid complex

Stereotactic radiotherapy (SRT) is a new approach to treat neovascular age-related macular degeneration (nAMD). The INTREPID trial suggested that SRT could reduce the frequency of regular intravitreal injections (IVIs) with antivascular endothelial growth factor drugs, which are necessary to control disease activity. However, the efficacy of SRT in nAMD and resulting morphological changes have not been validated under real-life circumstances, an issue, which we would like to address in this retrospective analysis.Patients who met the INTREPID criteria for best responders were eligible for SRT. A total of 32 eyes of 32 patients were treated. Thereafter, patients were examined monthly for 12 months and received pro re nata IVI of aflibercept or ranibizumab. Outcome measures were: mean number of injections, best-corrected visual acuity, and morphological changes of the outer retina-choroid complex as well as patient safety.Mean number of IVI decreased by almost 50% during the 12 months after SRT compared to the year before, whereas visual acuity increased by one line (logMAR). Morphological evaluation showed that most changes affect outer retinal layers.Stereotactic radiotherapy significantly reduced IVI retreatment in nAMD patients under real-life circumstances. Therefore, SRT might be the first step to stop visual loss as a result of IVI undertreatment, which is a major risk.

Mitochondrial decline precedes phenotype development in the complement factor H mouse model of retinal degeneration but can be corrected by near infrared light

Mitochondria produce adenosine triphosphate (ATP), critical for cellular metabolism. ATP declines with age, which is associated with inflammation. Here, we measure retinal and brain ATP in normal C57BL/6 and complement factor H knockout mice (Cfh(-/-)), which are proposed as a model of age-related macular degeneration. We show a significant premature 30% decline in retinal ATP in Cfh(-/-) mice and a subsequent shift in expression of a heat shock protein that is predominantly mitochondrial (Hsp60). Changes in Hsp60 are associated with stress and neuroprotection. We find no differences in brain ATP between C57BL/6 and Cfh(-/-) mice. Near infrared (NIR) increases ATP and reduces inflammation. ATP decline in Cfh(-/-) mice was corrected with NIR which also shifted Hsp60 labeling patterns. ATP decline in Cfh(-/-) mice occurs before inflammation becomes established and photoreceptor loss occurs and may relate to disease etiology. However, ATP levels were corrected with NIR. In summary, we provide evidence for a mitochondrial basis for this disease in mice and correct this with simple light exposure known to improve mitochondrial function.

Pre-exposure to low-power diode laser irradiation promotes cytoprotection in the rat retina

The aim of this study was to investigate whether pre-exposure to low-power laser irradiation can provoke an effect on cellular protection in the rat retina. The right eyes of 40 rats were exposed to a 3-mm diode laser beam for 1 min in different light intensities and different experimental sets: group A low power of 60 mW (34.27 J/cm(2) on the retina in consideration of the energy losses along the optical pathway) prior to high power of 80 mW (44.88 J/cm(2) on the retina in consideration of the energy losses along the optical pathway), group B high power, group C low power, group D (the left eyes from the counterpart of group A) and group E (untreated rat eyes) as controls. Morphological retinal change retinas were assessed using light microscopy and/or transmission electron microscopy. Heat shock protein (Hsp) 70 and cleaved caspase 3 protein expression were analyzed by immunohistochemical staining and Western blot. Cellular injury was assessed by terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL) assay. Hsp 70 expression in the inner plexiform layer and the outer plexiform layer in group A were 73.09 ± 6.49 and 78.03 ± 3.05%, respectively, which was significantly higher (P < 0.05) than those observed in group B (59.07 ± 1.40 and 32.25 ± 4.26%, respectively). The Hsp70/β-actin ratio was 0.49 ± 0.06 in group C, which was significantly higher (P < 0.05) than that of group B (0.27 ± 0.04). Cleaved caspase 3 expression in group C both was significantly lower than that observed in group B. TUNEL staining showed that positive cells in the outer nuclear layer and inner nuclear layer in group A were significantly lower than those of group B. Pre-exposure to a 60-mW (34.27 J/cm(2) on the retina) power laser irradiation stimulates a hyperexpression of Hsp70 together with a hypoexpression of cleaved caspase 3 in rat retina, which may suggest a cellular protective effect.

Radiation therapy for neovascular age-related macular degeneration

In the enormity of the public health burden imposed by age-related macular degeneration (ARMD), much effort has been directed toward identifying effective and efficient treatments. Currently, anti-vascular endothelial growth factor (VEGF) injections have demonstrated considerably efficacy in treating neovascular ARMD, but patients require frequent treatment to fully benefit. Here, we review the rationale and evidence for radiation therapy of ARMD. The results of early photon external beam radiation therapy are included to provide a framework for the sequential discussion of evidence for the usage of stereotactic radiation therapy, proton therapy, and brachytherapy. The evidence suggests that these 3 modern modalities can provide a dose-dependent benefit in the treatment of ARMD. Most importantly, preliminary data suggest that all 3 can be used in conjunction with anti-VEGF therapeutics, thereby reducing the frequency of anti-VEGF injections required to maintain visual acuity.

[Long-term outcome of radiation therapy for exudative age-related macular degeneration in Japan]

PURPOSE

To evaluate the long-term outcome of radiation therapy in eyes with exudative age-related macular degeneration (AMD).

METHODS

Eighty eyes of 80 patients (54 men and 26 women) with exudative AMD, which underwent radiation therapy with a photon beam of 20 Gy (2 Gy per day for 10 days) between 1998 and 2003, were retrospectively reviewed. Average age was 69 +/- 8.1 and follow-up period was 66 months. Best-corrected visual acuity (BCVA), additional therapies and complications were assessed.

RESULTS

Mean duration till the best value of postoperative BCVA could be reached was 10 months. The best BCVA was improved in 20 eyes (25.0%), stabilized in 56 eyes (70.0%), and deteriorated in 4 eyes (5.0%). On the final visit visual improvement was observed in 9 (11.3%), stabilization in 25 (31.3%), and deterioration in 46 eyes (57.5%). Additional therapies for exudative AMD were performed in 24 eyes (30.0%). Severe subretinal hemorrhage was observed in 9 eyes (11.3%), which resulted in severe vision loss despite additional vitrectomy.

CONCLUSIONS

Low-dose radiation therapy for exudative AMD achieved short-term efficacy but seemed less effective in the long-term.

Radiotherapy for neovascular age-related macular degeneration

BACKGROUND

Radiotherapy has been proposed as a treatment to prevent new vessel growth in people with neovascular age-related macular degeneration (AMD).

OBJECTIVES

The aim of this review was to examine the effects of radiotherapy on neovascular AMD.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) in The Cochrane Library Issue 3, 2010, MEDLINE (January 1950 to March 2010), EMBASE (January 1980 to March 2010), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to March 2010), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) (March 2010) and ClinicalTrials.gov (http://clinicaltrials.gov) (March 2010). There were no language or date restrictions in the search for trials. The electronic databases were last searched on 23 March 2010. We also wrote to investigators of trials included in the review to ask if they were aware of any other studies.

SELECTION CRITERIA

We included all randomised controlled trials in which radiotherapy was compared to another treatment, sham treatment, low dosage irradiation or no treatment in people with choroidal neovascularisation secondary to AMD.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data. We combined relative risks using a random-effects model. We estimated the percentage of the variability in effect estimates that was due to heterogeneity, rather than sampling error, using I(2).

MAIN RESULTS

Thirteen trials (n=1154) investigated external beam radiotherapy with dosages ranging from 7.5 to 24 Gy; one additional trial (n=88) used plaque brachytherapy (15Gy at 1.75mm for 54 minutes/12.6 Gy at 4mm for 11 minutes). Most studies found effects (not always significant) that favoured treatment. Overall there was a small statistically significant reduction in risk of visual acuity loss in the treatment group. There was considerable inconsistency between trials and the trials were considered to be at risk of bias, in particular because of the lack of masking of treatment group. Subgroup analyses did not reveal any significant interactions, however, there were small numbers of trials in each subgroup (range three to five). There was some indication that trials with no sham irradiation in the control group reported a greater effect of treatment. The incidence of adverse events was low in all trials; there were no reported cases of radiation retinopathy, optic neuropathy or malignancy. Three trials found non-significant higher rates of cataract progression in the treatment group.

AUTHORS' CONCLUSIONS

This review currently does not provide convincing evidence that radiotherapy is an effective treatment for neovascular AMD. If further trials are to be considered to evaluate radiotherapy in AMD then adequate masking of the control group must be considered.

[Radiotherapy of age-related macular degeneration. Case reports]

The radiotherapy is worth to remember in the most progression causes of AMD, when there is no possibility for application the modern methods of the treatment. We present cause of patient with bilateral advanced changes and low visual acuity in course AMD, who had applied rtg therapy and laser fotocoagulation. The right eye was radiated with foton beam energy 10 MeV using linear accelerator. Dosage of 9 Gy was delivered in 3 fractions through 5 days. In right eye we observed increase of visual acuity from 2/50 before treatment to 3/50 after 12 months, and 0.1 after the 48 months of radiation. The visual acuity in the left eye decreased from 0.2 to 2/50 after the 48 months. The improvement of acuity vision after rtg therapy allowed the patient self-dependence life.

Apport de la photothérapie dynamique dans la qualité de vie des patients atteints de dégénérescence maculaire exsudative

PURPOSE

To analyze the benefit of photodynamic therapy in terms of quality of life in patients with wet age-related macular degeneration.

METHODS

A retrospective study was conducted on 33 patients with subretinal neovascularization receiving visual rehabilitation in a low vision clinic (ARAMAV, Nîmes) in southern France. Twenty had been treated with photodynamic therapy (PDT group) and 13 had not (non-PDT group). In the non-PDT group, the patients had been treated with thermal photocoagulation, transpupillary thermotherapy, or external radiotherapy, or had not received any treatment. Visual acuity, reading speed, reading endurance, and quality of life were compared. Two quality-of-life scales were employed: the VF-14 and NEI-VFQ-25.

RESULTS

A significant difference between the two groups in terms of quality of life was observed. The VF-14 score (p<0.01) and two parameters (near activities and distant activities) of the NEI VFQ-25 were significantly higher (both p<0.01) in the PDT group. Visual acuity, reading speed, and reading endurance were similar in both groups.

CONCLUSION

Although no difference in terms of functional parameters was observed, photodynamic therapy could preserve the central retina and thus enable a better use of the residual visual function, which could explain the better quality of life perceived by the patients in the PDT group.

[Therapeutic options in age-related exudative macular degeneration]

The age-related macular disease (AMD) is the most frequent cause for blindness over 65 years in the developed countries. The incidence of this pathology (Framingham study) is: 2% (52-64 old), 11 %(65-74 old), 28%(>75 old). Our paper wants to review the therapeutic armamentarium during the last twenty years for treating Wet AMD--the most serious form of this disease.

The role of radiation therapy in benign diseases

Although adequate prospective data are lacking, radiation therapy seems to be effective for many benign diseases and remains one of the treatment modalities in the armamentarium of medical professionals. Just as medication has potential adverse effects, and surgery has attendant morbidity, irradiation sometimes can be associated with acute and chronic sequelae. In selecting the mode of treatment, most radiation oncologists consider the particular problem to be addressed and the goal of therapy in the individual patient. It is the careful and judicial use of any therapy that identifies the professional. With an understanding of the current clinical data, treatment techniques, cost, and potential detriment, the goal is to provide long-term control of the disease while minimizing unnecessary treatment and potential risks of side effects. The art lies in balancing benefits against risks.

A phase I trial of stereotactic external beam radiation for subfoveal choroidal neovascular membranes in age-related macular degeneration

Effective treatment for neovascular age-related macular degeneration (AMD) is currently limited. Radiation therapy, a therapeutic approach with known antiangiogenic properties, has been investigated as a modality to prevent severe visual loss in AMD. Most of the studies using external beam radiation employed <25 Gy to the whole eye, which is below the dose of radiation that is toxic to the retina and optic nerve ( approximately 50 Gy and approximately 59 Gy, respectively). Stereotactic fractionated external beam radiation (St-EBR) is a method that allows radiation to be delivered to a small, defined area. We investigated the effects of St-EBR in incremental doses up to 40 Gy on neovascular AMD. Patients with clinical signs and fluorescein angiography demonstrating neovascular AMD, visual acuity (VA) better than 20/400 and ineligible for laser treatment (MPS criteria) or who refused to have laser photocoagulation were enrolled in the study. Each patient was treated with radiation at incremental dosages from 20 Gy to 40 Gy. After completion of the radiation course, all patients were followed-up at 3 and 7 weeks and 3, 6, and 12 months. Best-corrected VA (ETDRS), slit-lamp and fluorescein angiographic evaluations were performed at each visit. 94 eyes of 89 patients were treated from October 1997 to April 2000. The VA was 0.82+/-0.35 before treatment, 0.83+/-0.36 at 6 months, and 0.89+/-0.33 at 12 months. No patients suffered any significant acute side effects. No significant benefits in either VA or in membrane size were derived from increasing the doses of radiation. Our results are consistent with trends of a palliative benefit of radiotherapy in neovascular AMD and support further investigation of radiotherapy. Since there is no evidence that therapeutic effectiveness is dose dependent, our data provide no justification for potentially dangerous escalations in radiation dosage for treating neovascular AMD.

[Electroretinoraphic findings in age-related macular degeneration (ARMD) before and after radiotherapy]

Standard ERG examinations were performed in 61 patients with ARMD before and after radiotherapy. Before the radiotherapy, a significant decrease in the cone b- wave amplitude and a significant reduction of the sum of oscillatory potentials (OP1-OP4) were found. At 24 months after the first dose of radiotherapy, a significant decrease in the rod response and 30-Hz flicker response were described. A possible explanation for the findings is an influence of radiotherapy onto primary circulatory disturbances in the whole retina in ARMD.

[The results of radiotherapy 24 months after treatment by patients with age-related macular degeneration]

The authors evaluate results of the radiotherapy by age- related macular degeneration. 114 patients (123 eyes) were examined. According to the total dose, we have divided the patients in 3 groups. Group A (12 Gy) consisted of 68 patients (74 eyes) and group B consisted of 46 patients (49 eyes), group C was designated as a control group, consisting of 21 patients (22 eyes). They have been performed in Department of Ophthalmology of Teaching Hospital of Charles University in Hradec Králové from February 1999 to April 2003. All examinations were performed before and at 24 months- follow up the radiotherapy. Radiotherapy seems to be a very promising and efficient method for treatment of the wet form of ARMD.

Strontium Plaque Brachytherapy for Exudative Age-Related Macular DegenerationThree-year results of a randomized study

OBJECTIVE

To determine the efficacy of strontium plaque (Sr90) brachytherapy for age-related macular degeneration (AMD) with subfoveal choroidal neovascularization (CNV).

DESIGN

Randomized clinical trial.

PARTICIPANTS

Eighty-eight eyes of 86 patients with subfoveal CNV secondary to AMD were randomized either to plaque radiotherapy or to observation.

INTERVENTION

Radiotherapy was given as episcleral brachytherapy using Sr90 plaques. Two different plaque types were used. Plaque I had a diameter of 8 mm and delivered a dose of 15 Gy at a depth of 1.75 mm in 54 minutes. With plaque II, the corresponding values were 4 mm, 12.6 Gy, and 11 minutes. The control group was observed without any treatment.

MAIN OUTCOME MEASURES

The primary outcome measure was visual acuity at 6, 12, 24, and 36 months. Other outcome variables were contrast sensitivity, fluorescein angiographic, and clinically evaluated changes in the macula.

RESULTS

Eighty-two patients (84 eyes [95%]) completed the 1-year follow-up, and 80 (93%) and 74 (86%) patients completed the 2- and 3-year follow-ups, respectively. At 6 months, visual loss of > or =3 lines occurred in 20% of treated patients and 42% of control patients (P = 0.031). At 12 months, a visual loss of > or =3 lines occurred in 45% (treated) and 56% (controls) (P = 0.325); at 24 months, in 73% and 71% (P = 0.914); and at 36 months, in 80% and 84% of patients (P = 0.591), respectively. Patients irradiated with plaque I had better results: a visual loss of > or =3 lines occurred in 6% at 6 months (P = 0.008, relative to controls), in 18% at 12 months (P = 0.007), in 59% at 24 months (P = 0.348), and in 71% at 36 months (P = 0.212). In patients treated with plaque II, the corresponding values were 29% (P = 0.032), 65% (P = 0.459), 83% (P = 0.317), and 80% (P = 0.687) at 6, 12, 24, and 36 months, respectively.

CONCLUSIONS

The short-term clinical course of exudative AMD is affected by Sr90 brachytherapy, but by 12 months, there was no treatment benefit. This article contains additional online-only material available at http://www.ophsource.org/periodicals/ophtha.

Verteporfin photodynamic therapy for the treatment of persistent subfoveal choroidal neovascularization after external beam radiotherapy: one-year results

PURPOSE

To determine the safety and efficacy of verteporfin photodynamic therapy (PDT) for the treatment of persistent choroidal neovascularization (CNV) previously treated with external beam radiotherapy (EBRT).

DESIGN

Retrospective case series.

METHODS

Verteporfin PDT was performed on 14 eyes of 13 patients with symptomatic leakage from CNV previously treated by EBRT. Principal outcome measures were: comparison of visual acuity at 12 months post-PDT with baseline and the recording of any ocular or systemic adverse events.

RESULTS

At baseline, the mean logMAR (+/-SD) VA was 0.81 +/- 0.33, whereas at the 12-month point it was 0.89 +/- 0.43 (P = .326). At the 12-month examination 10 eyes had lost less than 3 lines of VA, and 8 eyes had lost less than 1.5 lines. During this time, there were 2.1 PDT treatment sessions per eye on average (range = 1 to 4). There were no ocular or systemic adverse events recorded.

CONCLUSIONS

This short-term study shows that verteporfin PDT is safe after EBRT and may be of benefit for recalcitrant CNV.

Effect of irradiation on neovascularization in rat skinfold chambers: implications for clinical trials of low-dose radiotherapy for wet-type age-related macular degeneration

PURPOSE

Wet-type age-related macular degeneration is a refractory eye disease that involves choroidal neovascularization. Randomized controlled trials of low-dose radiotherapy for this disease performed in Japan showed that, at 12 months of follow-up, visual acuity was significantly well preserved and the neovascular membrane size decreased. Because understanding the effect of irradiation on new vascular networks is an important prerequisite for clinical trials, we used a rat skinfold chamber technique to investigate X-ray-induced changes in neovasculature microcirculation.

METHODS AND MATERIALS

Neovascularization was induced in rat skinfold chambers via polyvinyl chloride resin plates. Neovessels were irradiated in a single 10-Gy dose, after which, changes in vascular density, blood velocity, tissue blood flow, and interstitial fluid pressure (IFP), were measured.

RESULTS

Vascular density, tissue blood flow, and IFP measurements in resin-induced inflammatory tissue were much higher than those measurements in normal tissue. Although overall blood velocity was low and sluggish or blood-flow stasis occurred in the neovascular network, after a single 10-Gy dose of radiation, the velocity increased, stasis improved markedly, and many dilated vessels narrowed. Thereafter, vascular density, blood flow, and IFP significantly decreased and approached normal values.

CONCLUSION

These findings may help explain clinical results related to radiotherapy-induced changes in neovascular membranes in age-related macular degeneration. Both vascular morphology and vascular function in inflammatory tissue returned to normal, without vessel destruction, after an appropriate radiation dose.

External-beam radiation therapy for age-related macular degeneration: two years' follow-up results at a total dose of 20 Gy in 10 fractions

PURPOSE

The efficacy of external-beam radiation therapy (RT) was evaluated in the treatment of eyes with subfoveal or juxtafoveal choroidal neovascularization in age-related macular degeneration (ARMD).

MATERIALS AND METHODS

Twenty-one eyes of 18 patients with occult or mixed-type ARMD received a total dose of 20 Gy of 6 MV X-rays in 10 fractions. The follow-up time was 24 months. Fifteen non-treated eyes of 13 patients who had been followed served as a control.

RESULTS

In the RT group, visual acuity was improved in three eyes, maintained in 14 eyes, and worsened in four eyes. In the control group, it was not improved in any eyes, was maintained in six eyes, and worsened in nine eyes. The improved or maintained rate in visual acuity was 81% in the RT group and 40% in the control group (p=0.0342). In the RT group, fundoscopic and angiographic findings were improved in five eyes, unchanged in seven eyes, and worsened in nine eyes, while they were not improved in any eyes, unchanged in two eyes, and worsened in 13 eyes in the control group(p=0.0342).

CONCLUSION

RT at a total dose of 20 Gy in 10 fractions is effective for ARMD for at least two years. RT may be effective treatment for occult or mixed-type ARMD compared with the classic type.

The age-related macular degeneration radiotherapy trial (AMDRT): one year results from a pilot study

PURPOSE

To assess the short-term safety and efficacy of treating subfoveal choroidal neovascularization (CNV) with external beam radiation delivered in 5 x 4 Gy fractions among patients having age-related macular degeneration (AMD).

DESIGN

A multicenter prospective randomized controlled pilot study.

METHODS

Eighty-eight patients were enrolled through 10 sites and were randomized to radiotherapy (20 Gy delivered in 5 daily fractions of 4 Gy each; 6 MV [N = 41]) or no radiotherapy (sham radiotherapy [N = 22] or observation [N = 25]). Eligibility criteria included visual acuity of at least 20/320 and subfoveal CNV not amenable to treatment. Randomization was stratified by lesion type (new or recurrent CNV) and blood (<50% or >/=50% of the lesion [N = 13]). The primary outcome measure was loss of >/=3 lines of visual acuity. Secondary outcome measures were angiographic response and side effects.

RESULTS

At baseline, patient and ocular characteristics were similar between treatment groups. At six months, 9 radiated eyes (26%) and 17 eyes not radiated (49%) lost >/=3 lines of visual acuity (P = .04; stratified chi(2) test). At 12 months, 13 radiated eyes (42%) and 9 observed eyes (49%) lost >/=3 visual acuity lines (P = .60). The radiated group demonstrated smaller lesions and less fibrosis than the nonradiated group (P = .05 and .004, respectively) at 12 months. Radiation-induced complications were not observed except for one radiated eye with numerous cotton wool spots and possible radiation retinopathy.

CONCLUSIONS

External beam radiation at 5 x 4 Gy may have a modest and short-lived (six month) benefit in preserving visual acuity.

Results of radiotherapy of subfoveal neovascularization with 16 and 20 Gy

PURPOSE

In a nonrandomized, prospective study the efficacy of radiotherapy with 16 and 20 Gray (Gy) for subfoveal neovascularization in age-related macular degeneration (ARMD) was analysed.

MATERIAL AND METHODS

From 1996 to 1998, 63 eyes were irradiated with 16 Gy and 38 eyes with 20 Gy for exudative ARMD. A total of 12 eyes had classic ARMD, 89 eyes occult ARMD, median baseline visual acuity (VA) was 6/30 (range: 3/60-6/9.5), median age was 78 years. Risk factors (type of ARMD, baseline VA) were evenly distributed in both groups. Median follow-up was 1.3 years (range: 4 months-4.7 years). VA of +/-1 line or better and unchanged size and activity of the membrane in fluorescein angiography were defined as stable. Actuarial methods were used.

RESULTS

Median loss of VA was -3 lines (range: -14 to +5), neovascularization remained unchanged or decreased in size and activity in 35 eyes. At 18 months, the probability of stabilized VA was 0.4 (95% confidence interval (CI): 0.3-0.5), at 24 months 0.3 (95% CI: 0.2-0.4). Radiation dose, type of ARMD or baseline VA had no significant impact on outcome of VA and membrane size and activity (P>0.05). Side effects were mild and transient increased tearing.

CONCLUSION

In this study, the results after radiotherapy were comparable to the natural course of the disease. An impact of radiation dose (16 vs 20 Gy) on stabilizing visual acuity and subfoveal neovascularization could not be shown. The results of studies on dose escalation using very small fields and high radiation doses should be awaited.

Radiotherapy for neovascular age-related macular degeneration

BACKGROUND

Radiotherapy has been proposed as a treatment to prevent new vessel growth in people with neovascular age-related macular degeneration (AMD).

OBJECTIVES

The aim of this review was to examine the effects of radiotherapy on neovascular AMD.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group trials register) on The Cochrane Library Issue 2, 2004, MEDLINE (1966 to May 2004), EMBASE (1980 to June 2004) and LILACS (Latin American and Caribbean Health Sciences Literature Database) (May 2004). We also wrote to investigators of trials included in the review to ask if they were aware of any other studies.

SELECTION CRITERIA

We included all randomised controlled trials in which radiotherapy was compared to another treatment, sham treatment, low dosage irradiation or no treatment in people with subfoveal choroidal neovascularisation secondary to AMD.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted the data. Relative risks were combined using a random effects model. The percentage of the variability in effect estimates that was due to heterogeneity, rather than sampling error, was estimated using I2.

MAIN RESULTS

Eleven trials randomising a total of 1078 people were included in this review. All trials used a similar method of delivering the radiotherapy treatment (external beam). Dosage ranged from 7.5 to 24 Gy. Most trials found effects (not always significant) that favoured treatment. However, there was considerable inconsistency in the results between trials (I2 > 50%). As only 11 trials were included in the review and only some of these trials provided data for each outcome our ability to determine the causes of the heterogeneity between trials was limited. Subgroup analyses did not reveal any statistically significant interactions although with small numbers of trials in each subgroup (range two to four) this was not surprising. There was some indication that trials with no sham irradiation reported a greater effect of treatment as did trials with a greater percentage of participants with classic choroidal neovascularisation.

REVIEWERS' CONCLUSIONS

This review currently does not provide evidence that external beam radiotherapy is an effective treatment for neovascular AMD. If further trials are to be considered to evaluate radiotherapy in AMD then adequate masking of the control group must be considered. Given the recent evidence that most lesions are amenable to treatment with photodynamic therapy if identified at a small lesion size, trials evaluating radiotherapy against photodynamic therapy are warranted.

Long-term results after external radiotherapy in age-related macular degeneration. A prospective study

PURPOSE

To prospectively evaluate the short- and long-term efficacy of external radiotherapy (RT) in patients with age-related macular degeneration (AMD) by comparing two different dose schedules.

PATIENTS AND METHODS

In this prospective, nonrandomized, comparative study including 80 patients, the efficacy of external RT with a total dose of 14.4 Gy (group A, n = 40) and 25.2 Gy (group B, n = 40) was compared. Patients of group A were irradiated between September 1995 and July 1996, patients of group B between August 1996 and November 1997. 67 patients presented with occult choroidal neovascularization (CNV), 13 with classic subfoveal lesions. Complete ophthalmologic investigation was performed before RT, at intervals of 3 months during the 1st year after RT, and of 6 months thereafter.

RESULTS

12 months after RT, vision deteriorated in 85% (14.4 Gy) and 65% (25.2 Gy) of patients. Central visual field decreased with both dose schedules. There was no morphological benefit in neovascular changes. After 48 months, complete follow-up was possible in 46 patients who showed a significant loss of vision similar to the natural course of AMD.

CONCLUSION

External RT of AMD with 14.4 Gy as well as with the escalated dose of 25.2 Gy showed a poor beneficial outcome after 6 and 12 months, respectively. After a follow-up of 4 years, visual outcome in irradiated patients was similar to the natural course of the disease. A conspicuous efficacy of RT in prevention of blindness could not be demonstrated.

Palladium-103 plaque radiation therapy for macular degeneration: results of a 7 year study

AIM

To report 7 year results of ophthalmic plaque radiotherapy for exudative macular degeneration.

METHODS

In a phase I clinical trial, 30 patients (31 eyes) were treated with ophthalmic plaque irradiation for subfoveal exudative macular degeneration. Radiation was delivered to a mean 2 mm from the inner sclera (range 1.2-2.4) prescription point calculated along the central axis of the plaque. The mean prescription dose was 17.62 Gy (range 12.5-24) delivered over 34 hours (range 18-65). Early Treatment Diabetic Retinopathy Study (ETDRS) type standardised visual acuity determinations, ophthalmic examinations, and angiography were performed before and after treatment. Clinical evaluations were performed in a non-randomised and unmasked fashion.

RESULTS

At 33.3 months (range 3-4), 17 of 31 (55%) eyes had lost 3 or more lines of vision on the ETDRS chart, five (16%) had improved 3 or more lines, and the remaining nine (29%) were within 2 lines of their pretreatment visual acuity measurement. Overall, 45% of patients were within or improved more than 2 lines of their initial visual acuity. Five eyes developed macular scars, eight developed subsequent neovascularisation or haemorrhage, and three progressed through therapy. Two patients were lost to follow up. The most common finding of patients followed for 6 or more months (n=18 of 29 (62%)) was regression or stabilisation of the exudative process. No radiation retinopathy, optic neuropathy, or cataracts could be attributed to irradiation.

CONCLUSION

Ophthalmic plaque radiation can be used to treat exudative macular degeneration. At the dose and dose rates employed, most patients experienced decreased exudation or stabilisation of their maculas. No sight limiting radiation complications were noted during 7 year follow up. Owing to the variable natural course of this disease, a prospective randomised clinical trial should be performed to evaluate the efficacy of plaque radiation therapy for exudative macular degeneration.

Current and Future Treatment Options for Nonexudative and Exudative Age-Related Macular Degeneration

Age-related macular degeneration (AMD) is the leading cause of irreversible visual loss in the industrialised world. Although relatively simple to diagnose through direct visualisation augmented with rapid sequence fluorescein angiography, treatment has presented a far greater challenge because the true aetiology of AMD is largely unknown. Within the past decade, researchers have introduced many new, potentially promising treatment and prevention options in an attempt to minimise the damage imparted from AMD. They capitalise on many of the theoretical and known factors contributing to AMD progression. A high-dose of an orally administered combination of the antioxidants ascorbic acid (vitamin C), tocopherol (vitamin E) and beta-carotene, in addition to copper and zinc, is the only widely accepted preventive therapy. Thermal laser photocoagulation and verteporfin photodynamic therapy are the only standard treatment options available based on large scale, randomised, prospective, placebo-controlled trials; however, efficacy is limited and only a minority of patients who present with AMD are eligible for these treatments. Many other preventive and treatment options are in all phases of clinical studies and expected to change the entire approach to AMD management in the near future. For example, alternative antioxidants, drusen ablation, apheresis and HMG-CoA reductase inhibitors have shown promise in some studies by preventing or slowing the progression of certain forms of AMD. In addition, alternative photodynamic therapies, low-intensity laser, antiangiogenic medications, radiation treatment and surgery have demonstrated the ability, albeit to differing degrees, to inhibit or possibly even reverse the severe vision loss often associated with AMD characterised by choroidal neovascularisation.

Review Article. New treatments in age-related macular degeneration

Age-related macular degeneration (AMD) is the leading cause of legal blindness in individuals 50 years and older in the developed world. Choroidal neovascularization (CNV) in exudative AMD is responsible for the majority of severe vision loss. Until recently, laser photocoagulation was the only well-established and widely accepted treatment for CNV. However, it is beneficial only for a small subset of patients, has a high rate of CNV persistence and recurrence and results in iatrogenic, collateral damage to the overlying retina. These issues make it difficult to recommend in the case of subfoveal lesions. Consequently, numerous experimental therapeutic interventions are under investigation with the common objective of destroying the CNV but leaving the foveal neurosensory retina intact. Treatment modalities can be grouped into five major categories: photodynamic therapy; radiotherapy; transpupillary thermotherapy; anti-angiogenic and angiostatic agents; and surgical intervention. The present review aims to explain the rationale behind these new treatments, analyse the evidence for their safety and efficacy, determine their stage of development and indicate in which patients they are potentially useful.

Prophylactic laser treatment in early age-related maculopathy: an 8-year follow-up in a randomized pilot study shows a reduced incidence of exudative complications

PURPOSE

To study the effect of mild laser treatment on the incidence of exudative complications in patients with soft drusen maculopathy in a longterm perspective.

METHODS

In a prospective study, 38 patients with early age-related maculopathy and good visual acuity (VA) were randomized either to laser treatment using an argon green laser or to observation. At 8 years, 29 patients remained in the study, 16 in the control group and 13 in the treatment group.

RESULTS

During follow-up, mean VA decreased significantly in both groups, to 0.53 in the treatment group (p < 0.05) and to 0.25 in the control group (p < 0.001). At 8 years, 9/16 in the control group showed exudative complications, whereas only 2/13 in the treatment group developed such changes (p < 0.03).

CONCLUSION

In this randomized pilot study, mild laser treatment of soft drusen maculopathy significantly reduced the rate of exudative complications in a longterm perspective. As the study is small, the results should be viewed with caution.

Visual acuity and contrast sensitivity in patients with neovascular age-related macular degeneration

BACKGROUND

Patients with advanced age-related macular degeneration (AMD) suffer not only from impairment in central visual acuity (VA), but also from reduction in contrast sensitivity (CS). We examined VA and CS changes over time in patients with subfoveal choroidal neovascularizations (CNV) as well as the correlation between the two parameters.

METHODS

VA was determined according to a standardized protocol with the Early Treatment Diabetic Retinopathy (ETDRS) chart. CS was measured with Pelli-Robson charts. The angiographic characteristics of CNV and the presence of CNV in the fellow eye as well as gender and age were evaluated as possible prognostic factors of VA and CS progression. Two hundred and five patients with neovascular AMD were recruited within the Radiation Therapy for Age-Related Macular Degeneration (RAD) Study and were reviewed over 2 years. The treatment and control groups showed no significant difference for VA or for CS ( P>0.05), and both groups were considered together.

RESULTS

At baseline, mean VA was 55.6+/-14.5 SD letters (EDTRS chart), and mean CS was 22.8+/-6.9 letters (Pelli-Robson chart). Spearman Correlation Coefficient ( r(s)) between VA and CS was r(s)=0.60, P=0.0001. Over 2 years the mean VA loss was 23.6+/-21.4 letters and mean CS reduction was 9.0+/-9.7 letters. Agreement between change of VA and change of CS was moderate ( r(s)=0.65, P=0.0001; kappa coefficient (grouped into VA loss < or =15, >15, >30 letters; CS loss < or =6, >6, >15 letters) kappa=0.43, 95% CI [0.32;0.54]). Proportional hazard models did not show any apparent influence of type of CNV, or CNV in the fellow eye, on change in VA and CS.

CONCLUSION

The results indicate that VA and CS do not always show the same progression in visual function loss although they show a moderate correlation in eyes with neovascular AMD. Both parameters provide important information about visual disability and should be evaluated as outcome in interventional studies.

Idiopathic and radiation-induced ocular telangiectasia: the involvement of the ATM gene

PURPOSE

To investigate whether individuals, with no family history of ataxia telangiectasia (AT), in whom idiopathic or radiation-induced ocular telangiectasia developed are carriers of ATM gene mutations.

METHODS

The ATM cDNA from lymphoblastoid cell lines established from 16 patients with idiopathic retinal or choroidal telangiectasia and 14 patients with radiation-induced telangiectasia after radiotherapy for age-related macular degeneration (AMD) was screened using the restriction endonuclease fingerprinting technique. The frequency of each detected variant was determined in the French population by either a mass spectrometry-based technique or variant-specific endonuclease digestion.

RESULTS

Twenty-one ATM missense alterations, at 10 different sites, 8 of which would result in an amino acid substitution at a conserved position in the ATM protein were found. Four were novel changes, three of which were not detected in the 128 French control subjects screened. Eleven of 16 of the individuals with either idiopathic polypoidal choroidal vasculopathy or juxtafoveolar retinal telangiectasis and 6 of 14 individuals that had choroidal telangiectasis after radiotherapy for AMD carried ATM sequence variants. These latter six individuals had a significantly shorter delay time before the presentation of this vasculopathy compared with those individuals who had a wild-type ATM (11.8 +/- 3.4 months vs. 17.5 +/- 4.5 months, P = 0.024). They had also received a lower average dose of X-rays, although this difference did not reach statistical significance (18.7 +/- 3.9 Gy vs. 23.7 +/- 5.6 Gy, P = 0.09).

CONCLUSIONS

ATM missense variants could confer an AT-like phenotype and influence the formation of retinal and choroidal vascular abnormalities.

[The results of randomized controlled trial of low-dose radiation for wet-type age-related macular degeneration on a 1 year term basis]

OBJECT

Evaluation of low dose radiation therapy to the wet-type age-related macular degeneration (AMD) located at the fovea centralis.

CASES AND METHODS

Patients were irradiated with 10 fractions of 2 Gy external beam or just observed. Between the treated(39) and untreated (31) cases, there was no significant difference in gender, age, initial visual acuity, or size of the neovascular membrane.

RESULTS

With the follow-up of 12 months, the visual acuity was significantly well preserved and the size of the neovascular membrane was decreased.

CONCLUSION

These results indicate that low dose irradiation is effective for the wet-type AMD of the stage we treated in the present study.

Clinicopathological correlation of choroidal neovascularization after external beam radiotherapy in age-related macular degeneration

PURPOSE

To analyze the histopathology of choroidal neovascularization after external beam radiotherapy in age-related macular degeneration.

METHODS

A retrospective non-case-matched comparative histopathologic study. The histoarchitecture of nine surgically removed subretinal specimens from nine patients that had undergone external beam radiotherapy for exudative age-related macular degeneration was studied. Seven patients had received 20 Gy in 10 fractions and two 15 Gy in 5 fractions with an average time interval between radiotherapy and surgical extraction of 14 months (range 3-28). A consecutive series of classic, mixed and occult choroidal neovascular membranes served as controls.

RESULTS

Clinical findings. Radiation-associated choroidal neovasculopathy was angiographically suspected in four patients: a coarse net of vessels on fluorescein angiography developing at the border of previously irradiated choroidal neovascularization was observed in three patients; blebs at the margin of a plaque on indocyanine green angiography were observed in two patients. Pathological findings. Diffuse drusen as well as intra-Bruch's fibrovascular tissue was found in all irradiated specimens. In four specimens an edematous vascularized layer was seen between diffuse drusen and normal-appearing intra-Bruch's fibrovascular tissue. This lesion was not found in the control specimens. A particular correlation for the bleb lesion was not recognized.

CONCLUSION

The appearance of an edematous subretinal pigment epithelial vascularized layer between diffuse drusen and normal-appearing fibrovascular tissue in four of nine irradiated membranes may be secondary to previous irradiation. It may correlate with the unusual exudative manifestations observed after external beam radiotherapy.

Beta irradiation: new uses for an old treatment: a review

Beta radiation has a long history as a treatment modality in ophthalmology. It is a convenient and practical method of applying radiation and has the advantage of minimal tissue penetration. There has been a recent resurgence in the use of beta radiation in other areas in medicine, such as the prevention of restenosis after coronary artery stenting. Beta radiation has been shown in vitro and in vivo to inhibit proliferation of human Tenon's fibroblasts, which enter a period of growth arrest but do not die. Effects on the cell cycle controller p53 have been shown to be important in this process. In ophthalmology, beta radiation has been used widely for the treatment of pterygium and is under evaluation for treatment of age-related macular degeneration and for controlling wound healing after glaucoma drainage surgery. In this latter role, beta radiation may be particularly appropriate for use in developing countries to improve the results of trabeculectomy while potentially avoiding some of the side effects of other antimetabolites.

Use of radiation in the treatment of age-related macular degeneration

In this century, macular degeneration is likely to reach epidemic proportions. New treatment modalities are being evaluated for wet or neovascular age-related macular degeneration (AMD) and include radiation treatment. Radiation is known to potentially destroy vascular tissue, and low-dose radiation has been shown to inhibit new blood vessel growth. Potential advantages to radiation therapy in treating AMD include the absence of iatrogenic mechanical or laser damage, the absence of systemic side effects, and the absence of local side effects caused by periocular and intraocular injection. An additional advantage is that eyes with primarily large, occult choroidal neovascularization are potentially eligible for treatment, and only one treatment would be necessary. The major potential side effect is radiation retinopathy, which is dose dependent.

Proton therapy for exudative age-related macular degeneration: a randomized, sham-controlled clinical trial

PURPOSE

To examine the effect of proton beam irradiation on subfoveal choroidal neovascular membranes (CNVM) associated with age-related macular degeneration (AMD).Randomized, prospective, sham-controlled, double-masked treatment trial.

METHODS

Thirty-seven subjects with subfoveal CNVM due to AMD were randomly assigned to 16-Gy proton irradiation delivered in two fractions 24 hours apart or to sham control treatment. Recruitment was halted at 37 subjects for ethical reasons regarding randomization to sham treatment when Food and Drug Administration approval of Visudyne was anticipated.

RESULTS

Proton irradiation was associated with a trend toward stabilization of visual acuity, but this association did not reach statistical significance. No correlations were found within the fluorescein angiography data, including greatest linear dimension of CNVM total size, area of active leakage, area of associated subretinal hemorrhage, and intensity.

CONCLUSIONS

With the acceptance of photodynamic therapy, future studies will require more complex design and larger sample size to determine whether radiation can play either a primary or adjunctive role in treating these lesions.

Visual outcomes in the subfoveal radiotherapy study: a randomized controlled trial of teletherapy for age-related macular degeneration

OBJECTIVE

To determine whether teletherapy with 6-mV photons can reduce visual loss in patients with subfoveal choroidal neovascularization in age-related macular degeneration.

DESIGN

A multicenter, single-masked, randomized controlled trial of 12 Gy of external beam radiation therapy delivered to the macula of an affected eye vs observation only.

SETTING

Three United Kingdom-based hospital units.

PARTICIPANTS

Patients with age-related macular degeneration, aged 60 years and older, who had subfoveal choroidal neovascularization and a visual acuity of 20/200 (logMAR 1.0) or better.

METHODS

Two hundred three patients were randomly assigned to radiotherapy or observation. Treatment was undertaken at designated radiotherapy centers, and patients assigned to the treatment group received a total dosage of 12 Gy of 6-mV photons in 6 fractions. Follow-up was scheduled at 3, 6, 12, and 24 months. After excluding protocol violators, the data from 199 patients were analyzed.

MAIN OUTCOME MEASURES

The primary outcome measure was mean loss of distance visual acuity in the study eye at 12 and 24 months. Other outcome variables analyzed were near visual acuity and contrast sensitivity. The proportions of patients losing 3 or more or 6 or more lines of distance and near acuity and 0.3 or more or 0.6 or more log units of contrast sensitivity at each follow-up were also analyzed.

RESULTS

At all time points, mean distance visual acuity was better in the radiotherapy-treated group than in the control group, but the differences did not reach statistical significance. At 24 months, analysis of the proportions of patients with loss of 3 or more (moderate) (P =.08) or 6 or more (severe) (P =.29) lines of distance vision showed that fewer treated patients had severe losses, but there was no statistically significant difference between groups. For near visual acuity, although there was no evidence of treatment benefit at 12 and 24 months, a significant difference in favor of treatment was present at 6 months (P =.048). When analyzed by the proportions of patients losing 3 lines of contrast sensitivity, there was a significant difference in favor of treatment at 24 months (P =.02). No adverse retinal effects were observed during the study, but transient disturbance of the precorneal tear film was noted in treated patients.

CONCLUSION

The results of the present trial do not support the routine clinical use of external beam radiation therapy in subjects with subfoveal choroidal neovascularization in age-related macular degeneration.

Radiotherapy for age-related macular degeneration: is there a benefit for classic CNV?

AIM

To evaluate the efficacy of radiotherapy in the treatment of subfoveal classic and occult choroidal neovascularization (CNV) in age-related macular degeneration (AMD) under strict fixation control.

METHODS

Twenty-seven eyes of 27 patients with subfoveal CNV as a result of AMD were treated with a total dose of 20 Gy in 10 fractions (10 well-defined, 17 occult). Fixation monitoring was achieved by installing a TV camera with an attached fixation light 3 cm from the cornea of the eye being treated. Visual acuity and fluorescein angiography were obtained before and 6 months after treatment. Fifteen eyes of 15 patients served as controls (4 well-defined, 11 occult).

RESULTS

After 6 months the treated group showed an average decrease in visual acuity of 27%; the control group experienced a decrease of 31%. Membrane size increased by 56% in the treated group and by 28% in the control group. There was no statistically significant difference. Within the subgroup analysis, however, patients with classic CNV suffered significantly less visual loss than in the control group.

CONCLUSION

Radiation therapy under optimized treatment conditions by fixation monitoring failed to control further growth in membrane size in both classic and occult CNV. Regarding visual acuity, however, patients with classic CNV seem to benefit from radiation treatment compared to the natural course.

Side effects after radiotherapy of age-related macular degeneration with the Nijmegen technique

BACKGROUND

In a randomized trial concerning radiotherapy for age-related macular degeneration, fluorescein angiograms were taken of controls and patients. In this study the frequency of side effects in eyes receiving radiotherapy with the Nijmegen technique is compared with the findings in the eyes of controls.

METHODS

Patients receiving treatment were irradiated by two isocentric photon beams in four fractions of 6 Gy that were directed to the macular area at 30 degrees and -30 degrees with regard to the optical axis. The most recent fluorescein angiograms of the randomized eyes (32 treated and 31 control eyes) were scored by two independent researchers, using a scoring form with nine features of radiation retinopathy: nonperfusion, macular edema, microaneurysms, retinal hemorrhages, cotton-wool spots, perifoveal telangiectasis, vascular sheathing, retinal neovascularization, and radiation-associated choroidal neovasculopathy. The results were graded as: no retinopathy (grade 0), mild retinopathy (grade 1), moderate retinopathy (grade 2), and severe retinopathy (grade 3).

RESULTS

In the treated group 6 patients (18.8%) were grade 1, 10 patients (31.2%) were grade 2 and 7 patients (21.9%) were grade 3. In the control group 9 patients (29.0%) were grade 1, 11 patients (35.5%)were grade 2 and 2 patients (6.5%) were grade 3. There were no patients with retinal neovascularization.

CONCLUSION

With the Nijmegen technique a relatively high dose of radiation can be applied to a small retinal area. In only a minority of cases does some evidence of radiation retinopathy occur.