Dear Editor

We read with interest the article by Aisenbrey et al [1] who have described the results of surgical treatment of peripapillary choroidal neovascularisation in eight patients.

As reported, peripapillary choroidal neovascularisation is a relatively uncommon entity that can be a variant of macular choroidal neovascularisation in elderly patients. Accordingly to the MPSG[2], early small peripapillary choroidal neovascularisation should be first treated with red thermal laser photocoagulation. If applied by an experienced specialist the risk of burning the interpapillomacular bundle is limited. However, the therapeutical approach is more delicate for laser resistant, extended and/or very exsudative peripapillary choroidal neovascularisation.

In their study, Aisenbrey et al report good clinical outcome after surgical treatment. Nevertheless, as published by Rosenblatt et al [3], photodynamic therapy with Verteporfin can also be a good option because of its efficacy and very limited risk. This is also our clinical experience.

Figure 1 shows the left eye of a male patient in his early seventies with very exsudative peripapillary choroidal neovascularisation before and one year after one photodynamic therapy with Verteporfin. The current parameters for choroidal neovascularisation and a spot of 4200 µ covering a great part of the optic nerve were used. This case looks very similar to the illustrated case of Aisenbrey et al, except the fact that we first unsuccessfully tried to treat the lesion with thermal laser.

Figure 1: left eye of a male patient in his early seventies with very exsudative peripapillary choroidal neovascularisation before (a) and one year after one photodynamic therapy with Verteporfin (b).

Figure 1a

Figure 1b

In our experience with Verteporfin we have never noted any clinical damage to the optic nerve after partial exposition and it has been shown by Schmidt-Erfurth et al [4] that optic nerve can be exposed to a light dose twice as high as conventionally used without showing histopathological alterations.

Regarding the potential major risks of the surgical approach of peripapillary choroidal neovascularisation we suggest that PDT could be the first therapeutical choice in these cases.

References

1. Aisenbrey S, Gelisken F, Szurman P, et al. Surgical treatment of peripapillary choroidal neovascularisation. Br J Ophthalmol 2007;91:1027- 1030.

2. The Macular Photocoagulation Study Group. Laser photocoagulation for neovascular lesions nasal to the fovea. Results from clinical trials for lesions secondary to ocular histoplasmosis or idiopathic causes. Macular Photocoagulation Study Group. Arch. Ophthalmol. 1995; 113:56-61.

3. Rosenblatt BJ, Shah GK, Blinder K. Photodynamic therapy with verteporfin for peripapillary choroidal neovascularisation. Retina. 2005; 25:33-37.

4. Schmidt-Erfurth U, Laqua H, Schlotzer-Schrehard U, et al. Histopathological changes following photodynamic therapy in human eyes. Arch. Ophthalmol. 2002 Jun; 120(6):835-44.