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Evolving European guidance on the medical management of neovascular age related macular degeneration
  1. U Chakravarthy1,
  2. G Soubrane2,
  3. F Bandello3,
  4. V Chong4,
  5. C Creuzot-Garcher5,
  6. S A Dimitrakos II6,
  7. J-F Korobelnik7,
  8. M Larsen8,
  9. J Monés9,
  10. D Pauleikhoff10,
  11. C J Pournaras11,
  12. G Staurenghi12,
  13. G Virgili13,
  14. S Wolf14
  1. 1Queen’s University and Royal Victoria Hospitals, Belfast, UK
  2. 2Department of Ophthalmology, University of Créteil-Paris XII, France
  3. 3Department of Ophthalmology, University of Udine, Italy
  4. 4King’s College Hospital, University of London, UK
  5. 5Service d’Ophtalmologie, Université de Bourgogne, Dijon, France
  6. 6Department of Ophthalmology, Aristotle University of Thessaloniki, Greece
  7. 7Service d’Ophtalmologie, Hôpital Pellegrin, Bordeaux, France
  8. 8Herlev Hospital, University of Copenhagen, Denmark
  9. 9Instituto de Microcirugia Ocular de Barcelona, Spain
  10. 10St. Franziskus Hospital, Münster, Germany
  11. 11Geneva University Hospital, Switzerland
  12. 12Eye Clinic, University of Milan, Italy
  13. 13Eye Clinic, University of Florence, Italy
  14. 14University Ophthalmology Clinic, Inselspital, Bern, Switzerland
  1. Correspondence to: Gisèle Soubrane Department of Ophthalmology, University-Paris XII-Créteil, 40 Avenue de Verdun, Créteil, France 94010; gisele.soubrane{at}chicreteil.fr

Abstract

Background: Until recently, only two options were available for the treatment of choroidal neovascularisation (CNV) associated with age related macular degeneration (AMD)—thermal laser photocoagulation and photodynamic therapy with verteporfin (PDT-V). However, new treatments for CNV are in development, and data from phase III clinical trials of some of these pharmacological interventions are now available. In light of these new data, expert guidance is required to enable retina specialists with expertise in the management of AMD to select and use the most appropriate therapies for the treatment of neovascular AMD.

Methods: Consensus from a round table of European retina specialists was obtained based on best available scientific data. Data rated at evidence levels 1 and 2 were evaluated for laser photocoagulation, PDT-V, pegaptanib sodium, and ranibizumab. Other treatments discussed are anecortave acetate, triamcinolone acetonide, bevacizumab, rostaporfin (SnET2), squalamine, and transpupillary thermotherapy.

Results: PDT-V is currently recommended for subfoveal lesions with predominantly classic CNV, or with occult with no classic CNV with evidence of recent disease progression and a lesion size ⩽4 Macular Photocoagulation Study (MPS) disc areas (DA). The new classes of anti-angiogenic agents—namely, pegaptanib sodium and ranibizumab (the latter when peer reviewed phase III data become available) are recommended for subfoveal lesions with any proportion of classic CNV or occult with no classic CNV. For juxtafoveal classic CNV, PDT-V or anti-angiogenic therapy should be considered if the new vessels are so close to the fovea that laser photocoagulation would almost certainly extend under the centre of the foveal avascular zone. For all other well demarcated juxtafoveal lesions and for extrafoveal classic lesions, laser photocoagulation remains the standard treatment. Therapy should be undertaken within 1 week of the fluorescein angiogram on which the clinical decision to treat is based. At each follow up, fluorescein angiography should be performed and best corrected visual acuity measured as a minimum requirement.

Conclusions: These recommendations provide evidence based guidance for the choice and use of non-surgical therapies for the management of neovascular AMD. Revisions of the recommendations may be required as new data become available.

  • AMD, age related macular degeneration
  • CNV, choroidal neovascularisation
  • DA, disc areas
  • EMEA, European Agency for the Evaluation of Medical Products
  • FDA, Food and Drug Administration
  • ICG, indocyanine green
  • IVTA, intravitreal TA
  • MPS, Macular Photocoagulation Study
  • OCT, optical coherence tomography
  • PDT, photodynamic therapy
  • PDT-V, photocoagulation and photodynamic therapy with verteporfin
  • RPE, retinal pigment epithelium
  • TA, triamcinolone acetonide
  • TTT, transpupillary thermotherapy
  • VEGF, vascular endothelial growth factor
  • age related macular degeneration
  • European guidelines
  • AMD, age related macular degeneration
  • CNV, choroidal neovascularisation
  • DA, disc areas
  • EMEA, European Agency for the Evaluation of Medical Products
  • FDA, Food and Drug Administration
  • ICG, indocyanine green
  • IVTA, intravitreal TA
  • MPS, Macular Photocoagulation Study
  • OCT, optical coherence tomography
  • PDT, photodynamic therapy
  • PDT-V, photocoagulation and photodynamic therapy with verteporfin
  • RPE, retinal pigment epithelium
  • TA, triamcinolone acetonide
  • TTT, transpupillary thermotherapy
  • VEGF, vascular endothelial growth factor
  • age related macular degeneration
  • European guidelines

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Footnotes

  • Competing interests: Usha Chakravarthy has been an investigator in the VISION study and has been a paid consultant in expert advisory boards for Novartis Pharma AG and Pfizer Inc. Gisèle Soubrane has participated in multiple expert advisory boards and has been reimbursed by Eyetech Pharmaceuticals, Inc, Novartis Pharma AG, Alcon, Inc, Pfizer Inc, Genaera Corporation and Allergan, Inc for attending several conferences and for running educational programmes. Francesco Bandello has been reimbursed by Novartis Pharma AG, Alcon, Inc, and Pfizer Inc for attending several conferences. Victor Chong has been reimbursed by Novartis Pharma AG for attending several conferences, and has received funds for a member of staff and fees for consultation. Catherine Creuzot-Garcher has declared no competing interests. Stavros A Dimitrakos has been reimbursed by Novartis Pharma AG for attending a meeting. Jean-François Korobelnik is a paid consultant for Pfizer Inc and has been paid by Alcon, Inc for running educational programmes. Michael Larsen has been reimbursed by Novartis Pharma AG and Pfizer Inc for speaking at symposia and for consulting services. Jordi Monés has has participated in multiple expert advisory boards and has been reimbursed by Eyetech Pharmaceuticals, Inc, Novartis Pharma AG, Pfizer Inc, Allergan Inc, Genaera Corporation. Daniel Pauleikhoff has participated in multiple expert advisory boards and has been reimbursed by Pfizer Inc. Constantin J Pournaras has declared no competing interests. Giovanni Staurenghi has declared no competing interests. Gianni Virgili has been reimbursed by Novartis Pharma AG for attending several conferences and speaking at one conference. Sebastian Wolf has been reimbursed by Novartis Pharma AG, Pfizer Inc, and Alcon, Inc for attending several conferences, and has received research grants and consultancy fees from Novartis Pharma AG and Pfizer Inc.

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