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Steal syndrome versus aberrant wound healing?
In this issue of the BJO, Sarks and co-workers (p 442) report that progressive retinal pigment epithelium (RPE) atrophy develops around the perimeter of disciform scars in patients with age related macular degeneration (AMD). As noted by the authors, the progressive RPE atrophy seems to be caused by the presence of the disciform scar and seems to be distinct from AMD associated geographic atrophy (see, for example, table 2 in their paper). Sarks and co-workers postulate the existence of a “steal” syndrome in which: (1) active choroidal neovascularisation induces remodelling of the adjacent choroidal circulation with reduced blood flow to smaller choroidal vessels; and (2) secondary attenuation and, ultimately, atrophy of the RPE occurs adjacent to disciform scars.
The study was executed carefully. On the basis of fundus photographs alone, it is difficult to judge the presence of RPE atrophy versus RPE depigmentation with reduced but not completely atrophic overlying photoreceptors.1 Thus, as the authors recognise, there may be some degree of overestimation of the extent of atrophy in those 18 patients in whom pathological material was …