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A comparison of different treatment approaches for vascular age related macular degeneration
The treatment of choroidal neovascularisation (CNV) in age related macular degeneration (AMD) has changed enormously during the last decade.1 While 10 years ago there was only argon laser coagulation, today we have several treatment options for classic, occult, and mixed subtypes available: classic CNV responds well to photodynamic therapy (PDT) with “off label” triamcinolone, while occult CNV can be treated by PDT, transpupillary thermotherapy (TTT), subretinal surgery, macular translocation, and antiangiostatic therapy. The choice often depends on a variety of personal and environmental circumstances. Firstly, increased age and reduced health status of the patient may exclude them from surgery. Secondly, while first eyes may benefit from subretinal surgery, second eyes may be eligible for macular translocation. Thirdly, the initial visual acuity (VA) and the type of lesion often limit the success in PDT and also the financial coverage by medical insurance.
The beneficial results were initially presented by the Macular Photocoagulation Study (MPS), with laser reducing severe visual loss in extrafoveal and juxtafoveal CNV. As the mechanism of conventional photocoagulation relies on thermal damage to the neuroretina, through an estimated temperature rise to 42°C, severe central scotomas and recurrent CNV are often experienced in patients with subfoveal lesions.2 This treatment is currently used only in selected cases with small extrafoveal lesions. This limitation of photocoagulation led to an increase in new treatments.
Transpupillary thermotherapy (TTT) is a subthreshold photocoagulation delivering moderate heat to the choroid and retinal pigment epithelium (RPE) using a diode laser (810 nm). The goal is to achieve relative sparing of the overlying neuroretina by a limited temperature elevation of approximately 10°C.3 However, it might be difficult to deliver an appropriate irradiation in every case, as a standardised measure of …