Surgery may help improve vision when anti-VEGF therapy ineffective

June 25, 2008

Surgical therapy for age-related macular degeneration in the form of macular translocation, injection of tissue plasminogen activator, and gas tamponade provides some improvements in visual acuity for patients whose conditions do not respond to the anti-vascular endothelial growth factor drugs.

Surgical therapy for age-related macular degeneration (AMD) provides some improvements in visual acuity (VA) for patients whose conditions do not respond to anti-vascular endothelial growth factor (VEGF) drugs, according to Claus Eckardt, MD, professor of ophthalmology, Staedtische Kliniken Frankfurt am Main-Hoechst, Frankfurt, Germany.

"There is agreement today that, in the anti-VEGF drug era, macular surgery is indicated only in cases in which no improvement is expected with administration of ranibizumab [Lucentis, Novartis] or bevacizumab [Avastin, Genentech], such as in eyes with tears in the retinal pigment epithelium [RPE], large subretinal hemorrhages, or in eyes in which the VA has decreased despite the use of anti-VEGF therapy," he said.

Vitrectomy with removal of subretinal hemorrhage, macular translocation, injection of tissue plasminogen activator (tPA) and gas tamponade, and the still-experimental translocation of the choroid and RPE are the macular surgeries currently performed, Dr. Eckardt said.

Three approaches

He provided examples of the former three approaches. In the case of an eye in which a large tear in the RPE developed 15 days after the patient had received an injection of bevacizumab, Dr. Eckardt relayed, near vision was adversely affected, but distance vision remained intact. Two additional injections of the drug did not restore reading vision, so the patient underwent macular translocation surgery. Seven months postoperatively, VA improved to 0.5, and near vision returned. In another patient, VA was 0.2. After translocation surgery, VA increased to 0.8 and has remained stable for 4 years.

"I am not aware of another surgery other than translocation surgery that would be more successful to repair rips in the RPE," he said.

A report of eight cases published by Yusuke Oshima, MD, PhD, and colleagues from the Osaka University Graduate School of Medicine and Faculty of Medicine in Japan described how the authors drained the liquid blood from eyes 24 hours after the injection of tPA. They drained the blood through two small peripheral retinotomies by injecting perfluorocarbon liquid onto the retina. VA had improved significantly in all eyes except one by 2 years after the procedure, Dr. Eckardt said. He recounted that his group performs a large peripheral retinotomy (~250º). They then reflect the retina to remove the blood and fibrovascular proliferation. In the presence of a small RPE defect, the retinotomy is enlarged to 360º, and macular rotation is performed.

The procedure is easy to perform if the hemorrhage is not fluid, Dr. Eckardt said; if the hemorrhage is fluid, then performing the retinotomy can be difficult because the blood can obscure visualization.

Read the complete article in the June 15, 2008 issue of Ophthalmology Times.