Exudative age-related macular degeneration

Abstract

The exudative form of AMD is the major cause of visual blindness in patients with AMD. Increased age, Caucasian race, and smoking are closely linked to development of CNV. Large drusen (>5), confluent drusen, hyperpigmentation, and hypertension are associated with an increased risk of CNV in fellow eyes of patients with CNV. Symptoms may be absent in the presence of CNV. Amsler grid testing of patients at risk of CNV may help to detect problems earlier. Prompt evaluation of symptomatic patients is essential for preventing visual loss. Fluorescein angiography is required to characterize the location (extrafoveal, juxtafoveal, subfoveal), type of CNV (classic, occult—FVPED, LLUS), and extent of CNV. Extrafoveal CNV (classic or well-demarcated forms) should be treated with laser photocoagulation as per the MPS guidelines. Conventional laser photocoagulation (either confluent or scatter) is not of benefit for eyes with occult CNV and AMD. ICG is useful for evaluating eyes with occult CNV or PEDs, or subretinal hemorrhage. Occult CNV has a better natural history than that of classic CNV. When classic CNV develops in occult CNV, the visual prognosis is worse than for occult only eyes. Photodynamic therapy is useful: (1) for eyes with subfoveal CNV that are at least 50% or more classic in composition and (2) for eyes with occult CNV with visual acuity less than 20/50 and lesion size less than four MPS disk areas. Persistent and recurrent CNV risk is high for extrafoveal and juxtafoveal CNV treated with thermal laser. Most of these are on the foveal side of the laser treatment. Alternative treatments under investigation include thermotherapy, radiation therapy, antiangiogenesis inhibitors, submacular surgery, RPE transplantation surgery, and translocation surgery.