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MACULAR DEGENERATION: THE LATEST IN CURRENT SURGICAL MANAGEMENT

V itreoretinal surgery for the treatment of neovascular age-related macular degeneration (ARMD) has a relatively short history of less than 20 years. In 1988, de Juan and Machemer reported early beneficial results from removal of blood and fibrosis from beneath the retina in patients with neovascular ARMD.1 In 1991 and 1993 the Macular Photocoagulation Study Group reported decrease in central vision after laser treatment of subfoveal choroidal neovascularization (CNV) and recommended laser photocoagulation for small subfoveal CNV associated with severe vision loss in patients with ARMD.2,3 In 1992, Berger and Kaplan, and separately Thomas et al, proposed submacular surgery with removal of CNV as an alternate treatment for some subfoveal CNV.4,5 From early experience with submacular surgery for CNV, surgery was thought to be of likely benefit for ocular histoplasmosis and possible benefit in stabilizing vision in ARMD. These reports provided much of the initial impetus for surgical therapies for ARMD. In the following dozen years the Submacular Surgery Trials were completed and alternate techniques were developed and tested for the treatment of subfoveal CNV and blood. The techniques addressed here include submacular surgery, displacement of submacular hemorrhage, and macular translocation surgery, recognizing the limited information to date on alternate techniques for transplantation of retinal pigment epithelium (RPE) cells and choroid beneath the fovea. The Submacular Surgery Trials (SST) consist of three randomized clinical trials sponsored by the National Eye Institute of the National Institutes of Health. The SST addressed the study question “Does submacular surgery increase the chances of stable or improved visual acuity at two years after randomization when compared to observation?” The enrolled patients were randomized 50:50 to submacular surgery or to observation. Two of the SST trials addressed ARMD, with one trial (Group N study) of patients with new subfoveal CNV from ARMD with evidence of classic CNV but no prior treatment,6 and the second ARMD group (Group B study) of patients with predominantly hemorrhagic subfoveal lesion with the area of blood 50% of the area of the entire lesion.7 In each surgery, the treatment included pars plana vitrectomy with surgical detachment of the posterior hyaloid, a small retinotomy, and removal of the subretinal CNV, subretinal scar including laser scar, and blood if present. In Group B, a small amount of subretinal tissue plasminogen activator (tPA) could also be injected beneath the retina 40 minutes before lesion removal, to aid in fibrinolysis before the removal of the subretinal complex.7 In Group N (patients with new subfoveal CNV), when patients were assessed for the percentage with loss of two or more lines of visual acuity (eight letters on the Bailey-Lovey chart), there was no significant difference between the treated patients and observation at any of the time points, 1, 2, 3, or 4 years after surgery.6 When evaluated in subgroups and when other outcomes were assessed, including reading speed and contrast sensitivity, surgery did not appear to benefit visual function for any of the subgroups. Thus for the Group N study, there was no clinical evidence of benefit from submacular surgery, although, from quality-of-life interviews of patients, there was a small perceived benefit in patient-perceived visual function in the surgery group when compared to observation.6,8 In the SST Group B, also looking at the percentage From Duke University Eye Center, Durham, North Carolina. Dr. Toth receives royalties for technology licensed to Alcon Laboratories by Duke University, following the patent policy for Duke University Medical Center. Reprint requests: Cynthia A. Toth, MD, Box 3802, Wadsworth Bldg/Erwin Road, Duke University Eye Center, Durham, NC 27710; e-mail: cynthia.toth@duke.edu