Fluorescein angiographic abnormalities after prophylactic macular photocoagulation for high-risk age-related maculopathy

doi:10.1016/S0002-9394(99)00043-4

American Journal of Ophthalmology

Volume 127, Issue 6, June 1999, Pages 681-687

https://doi.org/10.1016/S0002-9394(99)00043-4 Get rights and content

Abstract

PURPOSE:

Initial studies suggest that drusen associated with age-related maculopathy resolve in response to laser photocoagulation; there are conflicting reports regarding whether this treatment might prevent neovascular complications and blindness. The goal of the Drusen Laser Study is to maintain good visual acuity in eyes at the highest risk for neovascular complications of age-related maculopathy. In this report, we alert the ophthalmic community to possible laser-induced complications in patients treated within the context of this clinical trial.

METHODS:

A double-masked, randomized, controlled clinical trial of prophylactic macular photocoagulation for high-risk age-related maculopathy is in progress. Patients randomly assigned to treatment received a ring-type distribution of 12 light spots of argon laser photocoagulation. Drusen were treated directly only if they were present at the protocol treatment locations. Fluorescein angiography was performed in all patients at yearly review, and at nonprotocol visits if symptoms or clinical examination were suggestive of choroidal neovascularization.

RESULTS:

Fluorescein angiographic abnormalities suggestive of choroidal neovascularization have been seen in treated eyes only: one patient in the pilot study and six patients in the Drusen Laser Study. No fluorescein angiographic abnormalities were seen in eyes of control subjects.

CONCLUSIONS:

Laser photocoagulation in high-risk age-related maculopathy may induce choroidal neovascularization and, therefore, is not recommended outside the context of a randomized, controlled clinical trial.

Section snippets

Methods

The goals of the study are twofold: to assess drusen characteristics in response to macular photocoagulation and to determine whether scatter macular photocoagulation reduces the risk of visual acuity loss from neovascular complications compared with control subjects.

The following is a brief overview of eligibility criteria for patients in the Drusen Laser Study: (1A) Unilateral group: soft drusen with or without focal retinal pigment epithelial hyperpigmentation in one eye and an end-stage

Results

In one patient in the Pilot Study and six patients in the Drusen Laser Study, fluorescein angiographic abnormalities were identified after laser treatment that implied the presence of choroidal neovascularization. In three the leakage was related to a laser spot, and in three visual acuity was reduced as a consequence. In no case could these new angiographic abnormalities be related to any feature of the angiogram before photocoagulation. The clinical data regarding these patients are

Discussion

The patient in the Drusen Laser Pilot Study had a good visual outcome despite features of occult choroidal neovascularization postphotocoagulation. We had 15 months of review in this case before faced with the clinical management of a second such affected patient. The favorable visual outcome in the pilot study patient served as the framework for our conservative approach to subsequent patients.

The ill-defined hyperfluorescence occurring after photocoagulation described in this report is highly

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Cited by (20)

Orientation-independent Feature Matching (OIFM) for Multimodal Retinal Image Registration
2020, Biomedical Signal Processing and Control
Citation Excerpt :
Moreover, the use of multimodal retinal images can also benefit surgical treatments. For instance, in laser photocoagulation [11,12], pretreatment angiographic images are used to determine the region of neovascularization based on the leakage of fluorescein, and RF images are used to evaluate the effectiveness of the treatment during post-treatment follow-up. Therefore, combining RF and FA images has the potential to improve photocoagulation treatment.
The analysis of fundus images in ophthalmology can be greatly facilitated by data integration of multimodal retinal images, which can be achieved via image registration based on the matching of keypoints represented by certain descriptors. However, the matching results offered by conventional feature descriptors may be substantially compromised due to their inconsistent estimates of the main orientation for keypoints in multimodal images. In this paper, we propose an orientation-independent feature matching (OIFM) method for better matching of feature points in multimodal retinal images. The keypoints detected in the images are firstly represented with a new circular neighborhood-based feature descriptor, allowing for the rotation of the neighborhood around the keypoints can be achieved by circularly shifting the elements in the descriptor. Then, the proposed feature descriptor is applied for the matching of keypoints, whose distance is measured after the compensation of the orientation discrepancy. The proposed OIFM method has two distinct characteristics. First, the feature descriptor no longer relies on the calculation of main orientations, and instead it is formulated by stacking the feature vectors of the keypoint neighborhood in a circular order with a conveniently assigned reference. Second, orientation independence is achieved during the matching stage where the feature points are aligned in a global manner, leading the OIFM method more robust to rotation and content variations among multimodal retinal images. Experimental results on a total of 160 pairs of multimodal retinal images show that the proposed OIFM method outperforms the conventional algorithms in terms of registration accuracy and robustness.
Prophylactic laser treatment hastens choroidal neovascularization in unilateral age-related maculopathy: Final results of the Drusen Laser Study
2006, American Journal of Ophthalmology
Citation Excerpt :
The goals of the study were to assess drusen response after prophylactic macular laser photocoagulation and reduce the risk of visual acuity loss from neovascular complications. Initial clinical observations from the DLS at Moorfields and an interim analysis of pooled data were reported previously.5,6 The complete protocol was reviewed and approved by the ethics and research committees of all participating hospitals before patient recruitment was begun.
The Drusen Laser Study evaluated macular laser to prevent choroidal neovascularization (CNV) and vision loss in high-risk age-related maculopathy (ARM).
Prospective, interventional, randomized, controlled clinical trial in five hospital centers.
Patients in the unilateral group had neovascular ARM and drusen in the study eye. Study eyes were randomized to laser-treated or no-laser groups. For patients in the bilateral drusen group, eyes were randomized to right eye, laser or no laser; and left eye, alternative. Laser treatment comprised 12 argon spots. Outcome was best-corrected visual acuity and CNV signs, which were monitored for 3 years.
In the unilateral group, vision loss occurred in 21 (28.8%) of 73 patients in laser vs 13 (19.7%) of 66 no-laser patients (P = .214). Incidence of CNV was 27 (29.7%) of 91 in laser vs 15 (17.65%) of 85 no-laser patients (P = .061). CNV onset was approximately 6 months earlier in laser-treated compared with no-laser patients (P = .05). In the bilateral group, vision loss occurred in six (8.3%) of 72 laser-treated vs 10 (13.9%) of 72 fellow eyes (P = .3877). CNV incidence was 12 (11.6%) of 103 in laser-treated vs seven (6.8%) of 103 fellow eyes (P = .225). There was no difference in onset of CNV.
Results do not support prophylactic laser of the fellow eye of patients with neovascular ARM. Its role in patients with bilateral drusen remains unclear.
Age-Related Macular Degeneration: Nonneovascular Early AMD, Intermediate AMD, and Geographic Atrophy
2005, Retina: Fourth Edition
Laser prophylaxis for age-related macular degeneration
2005, Canadian Journal of Ophthalmology
Background: Age-related macular degeneration (AMD) is the most common cause of severe and irreversible vision loss among people 50 years of age or older in many Western countries. Most of the available treatments for AMD are intended for the late stage, specifically for choroidal neovascularization (CNV). Effective preventive treatments could have an even greater impact on the vision of the millions of people at risk for vision loss from AMD. Drusen are typically the earliest lesions seen in patients with AMD and precede the development of CNV. In 1973, Gass noted the disappearance of drusen in eyes that received laser photocoagulation, which led to the hypothesis that laser-induced drusen reduction could alter the natural course of AMD.
Methods: We reviewed relevant articles found through a search of MEDLINE through February 2005 by means of the following key words, alone or in combination: drusen, laser, photocoagulation, age-related macular degeneration, macula and choroidal neovascularization.
Results: Reports ranging from individual cases and case series to randomized controlled pilot studies have described various laser treatment protocols and their effects on eyes with high-risk drusen but no neovascular changes. These reports provide evidence that laser photocoagulation can induce drusen reduction. Although some investigators have reported a corresponding improvement in visual function, others have found no change or even worsening.The results in several of the larger randomized controlled studies suggest that CNV may occur at an increased rate in laser-treated eyes with high-risk drusen in patients who have neovascular AMD in the other eye. The long-term effects of laser treatment in patients with high-risk drusen in both eyes and no neovascular changes have yet to be determined.
Interpretation: The outcome of clinical trials such as the Prophylactic Treatment of Age-Related Macular Degeneration and the Complications of Age-Related Macular Degeneration Prevention Trial will help to determine the role of laser prophylaxis in patients with AMD.
Contexte: La dégénérescence maculaire liée à l’âge (DMLA) est la cause la plus répandue de perte grave et irréversible de la vue chez les personnes de 50 ans et plus dans beaucoup de pays occidentaux. Les traitements disponibles s’adressent pour la plupart aux dernières étapes de la maladie, plus précisément à la néovascularisation choroïdienne (NVC). Des traitements préventifs efficaces pourraient avoir un impact encore plus grand sur la vue de millions de personnes à risque de perte de la vue à cause de la DMLA. Les drusens sont typiquement les toutes premières lésions qu’on découvre chez les patients atteints de DMLA avant le développement de la NVC. En 1973, Gass avait remarqué que les drusens disparaissaient des yeux après une photocoagulation au laser, ce qui suggéra l’hypothèse que la réduction des drusens induite par laser pourrait altérer l’évolution naturelle de la DMLA.
Méthodes: Nous avons examiné les articles pertinents que nous avons trouvés dans MEDLINE jusqu’à la fin de février 2005 avec les mots clés suivants: drusen, laser, photocoagulation, age-related macular degeneration, macula et choroidal neovascularization.
Résultats: Les comptes rendus, allant de cas individuels ou en séries aux études pilotes randomisées, décrivent divers protocoles de traitement au laser et leurs effets sur les yeux avec drusens à risque élevé mais sans changements néovasculaires. Ils démontrent que la photocoagulation peut introduire une réduction des drusens. Si certains chercheurs ont signalé une amélioration correspondante de la fonction visuelle, d’autres n’ont trouvé aucun changement ni même d’aggravation. Les résultats de plusieurs essais comparatifs plus étendus et randomisés indiquent que la NVC peut survenir à un rythme accru dans les yeux avec drusens à risque élevé traités au laser chez les patients qui ont une DMLA néovasculaire dans l’autre œil. Les effets à long terme du traitement au laser chez les patients avec drusens à risque élevé dans les 2 yeux mais sans changements néovasculaires restent à déterminer.
Interprétation: Le résultat d’essais cliniques comme ceux portant sur le traitement prophylactique et la prévention des complications de la DMLA (Prophylactic Treatment of Age-Related Macular Degeneration et Complications of Age-Related Macular Degeneration Prevention Trial) aideront à établir le rôle de la prophylaxie au laser chez les patients atteints de DMLA.
Fundus autofluorescence in patients with age-related macular degeneration and high risk of visual loss
2002, American Journal of Ophthalmology
Citation Excerpt :
Patients were recruited from the Medical Retina clinics at Moorfields Eye Hospital. Twenty-nine patients prospectively enrolled in the DLS34 who had serial AF recording for 1 year or longer were included in this study. Patients with media opacities at baseline that prevented adequate imaging of fundus AF were not included in this study.
PURPOSE: To describe fundus autofluorescence (AF) patterns and their change over time in patients with age-related macular degeneration (AMD) and high risk of visual loss participating in the drusen laser study (DLS).
DESIGN: Randomized clinical trial.
METHODS: The study population consisted of 29 patients (35 eyes) participating in the DLS, which is a prospective, randomized, controlled clinical trial of prophylactic laser therapy in patients with AMD and high risk of neovascular complications. The intervention consisted of 16 eyes having prophylactic laser and 19 receiving no treatment. The main outcome measures were changes in the distribution of drusen and AF. Patients were reviewed for a median follow-up or 24 months (range 12–36 months).
RESULTS: At baseline, four patterns of fundus AF were recognized: focal increased AF (n = 18), reticular AF (n = 3), combined focal and reticular AF (n = 2), and homogeneous AF (n = 12). At last follow-up, fundus AF remained unchanged in 15 untreated (78%) and in seven treated (43%) eyes. In only one untreated eye, focal areas of increased AF returned to background levels and were no longer detectable at last follow-up, compared with six treated eyes. This difference was statistically significant (P = .03). Only large foveal soft drusen (drusenoid pigment epithelium detachments) consistently corresponded with focal changes in AF, whereas no obvious correspondence was found between small soft drusen located elsewhere and changes in AF.
CONCLUSION: The lack of obvious correspondence between the distribution of drusen and of AF found in this study appears to indicate that drusen and AF represent independent measures of aging in the posterior pole.
Treatments targeting autophagy ameliorate the age-related macular degeneration phenotype in mice lacking APOE (apolipoprotein E)
2022, Autophagy

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Original ArticlesFluorescein angiographic abnormalities after prophylactic macular photocoagulation for high-risk age-related maculopathy

Abstract

Section snippets

Methods

Results

Discussion

Surv Ophthalmol

Am J Ophthalmol

Ophthalmology

Ophthalmology

Am J Ophthalmol

Ophthalmology

Ophthalmology

Am J Ophthalmol

Subfoveal choroidal neovascular membranes in age-related macular degenerationvisual prognosis with good initial visual acuity

Arch Ophthalmol

Laser photocoagulation of subfoveal neovascular lesions in age-related macular degenerationresults of a randomized clinical trial

Arch Ophthalmol

Visual outcome after laser photocoagulation for subfoveal choroidal neovascularization secondary to age-related macular degenerationthe influence of initial lesion size and initial visual acuity

Arch Ophthalmol

The Framingham eye study. I. Outline and major prevalence findings

Am J Epidemiol

Relationship of drusen and abnormalities of the retinal pigment epithelium to the prognosis of neovascular macular degeneration

Arch Ophthalmol

Five-year incidence and disappearance of drusen and retinal pigment epithelial abnormalitiesWaterman study

Arch Ophthalmol

Original Articles
Fluorescein angiographic abnormalities after prophylactic macular photocoagulation for high-risk age-related maculopathy