Exudative ARMD Workup

  • Author: F Ryan Prall, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: May 8, 2012
 

Laboratory Studies

No laboratory studies assist in the diagnosis of AMD.

Next

Imaging Studies

After a thorough dilated examination of the fundus with slit lamp biomicroscopy, stereo color photography of the fundus, rapid-sequence fluorescein angiography (FA), and optical coherence tomography (OCT) are performed on many patients with signs and symptoms of exudative AMD.

FA is an office-based procedure to help identify and confirm the source of the CNV. During the procedure, fluorescein dye is injected intravenously and serial photographs of the retina are taken to document the progression of the dye through the choroidal and retinal vasculature. Abnormalities are identified in areas where the dye collects (hyperfluorescence) or is absent (hypofluorescence).

Findings on FA consistent with exudative AMD include the following: increasing hyperfluorescence secondary to dye leakage from the CNV and hypofluorescent blockage from subretinal hemorrhage. Additional findings consistent with any form of AMD include the following: hyperfluorescence of drusen and RPE atrophy and hypofluorescence from RPE hypertrophy. See the images below.

Color photograph of the fundus shows nonexudative Color photograph of the fundus shows nonexudative age-related macular degeneration (AMD) with geographic atrophy of the retinal pigment epithelium (RPE) and drusen. Absolute atrophy of the RPE occupies the foveal region in this case of nonexudative AMD. The central atrophic region causes a corresponding central scotoma. Note the large choroidal vessels, which are visible through the RPE defect. Drusen surround the region of geographic atrophy. Photo by Tim Steffens. Late-frame fluorescein angiogram shows nonexudativLate-frame fluorescein angiogram shows nonexudative age-related macular degeneration (AMD) with geographic atrophy of the retinal pigment epithelium (RPE) and drusen from the case of geographic atrophy illustrated in the image above. Geographic atrophy stains intensely with distinct borders, but no leakage is present to suggest a choroidal neovascular membrane (CNVM). Stain highlights the large choroidal vessels in the region of atrophy well. Photo by Tim Steffens. Midframe from the fluorescein angiogram of the casMidframe from the fluorescein angiogram of the case in the image above reveals the discrete region of hyperfluorescence, which is characteristic of a classic choroidal neovascular membrane (CNVM). Late frames of the angiogram (not shown) revealed intense leakage from the CNVM. Subretinal hemorrhage is more commonly due to classic CNVM than occult CNVM and typically occurs along the peripheral aspect of the CNVM. Photo by Tim Steffens. Color photograph of the fundus shows a retinal pigColor photograph of the fundus shows a retinal pigment epithelium (RPE) tear. The RPE has torn from the nasal portion of the macula and assumed a scrolled, redundant configuration in the temporal portion of the macula. Associated sub-RPE and subretinal hemorrhage is present, as are hard exudates and subretinal fluid. Courtesy of Albert R. Frederick, Jr, MD. Early-frame fluorescein angiogram shows a retinal Early-frame fluorescein angiogram shows a retinal pigment epithelium (RPE) tear. Fluorescein angiogram from the case illustrated in the image above temporally shows blockage of the choroidal flush by the redundant, scrolled RPE. Stained areas represent where the RPE was torn. Later frames of the angiogram (not shown) also showed leakage due to the associated choroidal neovascular membrane (CNVM). Courtesy of Albert R. Frederick, Jr, MD.

A disciform scar, which is the end stage of exudative AMD, is hyperfluorescent from fluorescein staining. Depending on the distance from the foveal avascular zone, the leakage is classified as subfoveal, juxtafoveal (1-199 µm), or extrafoveal (200-250 µm). CNV is sometimes defined as classic or occult based on the FA leakage pattern.

Classic CNV results in discrete and early hyperfluorescence with late leakage of fluorescein dye into the surrounding interstitial spaces. See the images below.

Color photograph of the fundus shows classic choroColor photograph of the fundus shows classic choroidal neovascular membrane (CNVM) causing subretinal hemorrhage. Subretinal hemorrhage, which resulted from a classic CNVM, occupies the foveal region, causing a dense central scotoma. The subretinal hemorrhage can be large, mimicking a choroidal melanoma. On occasion, the subretinal hemorrhage can break through the retina, causing a vitreous hemorrhage. Patients who present with vitreous hemorrhage and evidence of age-related macular degeneration (AMD) in the other eye should be thought to have a CNVM, especially if they have no history of diabetes or other causes of vitreous hemorrhage. Photo by Tim Steffens. Late-frame fluorescein angiogram. Classic choroidaLate-frame fluorescein angiogram. Classic choroidal neovascular membrane (CNVM) before laser photocoagulation shows classic CNVM, which manifests as a discrete, early focus of hyperfluorescence with late leakage. Associated subretinal hemorrhage at the peripheral edge of the CNVM blocks the underlying choroidal flush. Photo by Tim Steffens. Early-frame fluorescein angiogram shows classic chEarly-frame fluorescein angiogram shows classic choroidal neovascular membrane (CNVM) after laser photocoagulation. Classic CNVM illustrated in the image above was photocoagulated. The patient underwent repeat fluorescein angiography (image shown here) 2 weeks later to rule out persistence. Note nonperfusion of the choriocapillaris and CNVM in the laser scar. Photo by Tim Steffens.

Occult CNV is categorized into 2 basic forms, as follows: late leakage of undetermined source or fibrovascular PED. Both forms manifest as a region of ill-defined leakage in the early and late frames without a distinct source of leakage. See the images below.

Midframe fluorescein angiogram shows classic plus Midframe fluorescein angiogram shows classic plus occult choroidal neovascular membrane (CNVM). Temporal to the foveal region, image reveals a discrete region of hyperfluorescence that is suggestive of a classic CNVM. Photo by Tim Steffens. Late-frame fluorescein angiogram shows classic pluLate-frame fluorescein angiogram shows classic plus occult choroidal neovascular membrane (CNVM). Late frames of the angiogram from the case in the image above show leakage from the discrete focus (seen in early frames). This finding is characteristic of the classic component. The surrounding late-stippled leakage is characteristic of the occult component. Photo by Tim Steffens.

When a treatment other than a vascular endothelial growth factor (VEGF) inhibitor is planned, angiography is customarily performed within 72 hours of treatment because the morphology and resulting treatment parameters can evolve rapidly.

Indocyanine green (ICG) angiography can be performed as an adjunctive study in patients with subretinal hemorrhage, suspected retinal angiomatous proliferation, or polypoidal choroidal vasculopathy.

The near-infrared light (795-810 nm) absorbed by ICG tends to penetrate hemorrhage and RPE better than the shorter wavelength that is absorbed by fluorescein.

Unlike fluorescein, ICG is strongly bound to plasma proteins, which prevents diffusion of the compound through the normally fenestrated choroidal capillaries and improves delineation of choroidal detail.[50]

Optical coherence tomography (OCT) is a useful noninvasive adjunct for identifying retinal and subretinal pathology secondary to CNV. OCT provides a cross-sectional view of the retina with an axial resolution of about 4 µm. OCT can identify soft drusen, RPE detachments, subretinal and intraretinal fluid, CNV, cystoid macular edema, as well as the integrity of the photoreceptor and RPE layers.[51, 52, 53, 54] OCT is useful for monitoring therapeutic response.[53, 55, 56]

Previous
Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

F Ryan Prall, MD  Assistant Professor of Ophthalmology, Indiana University School of Medicine

F Ryan Prall, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Coauthor(s)

Thomas Ciulla, MD  Retina Specialist, Midwest Eye Institute, Indianapolis, Indiana

Thomas Ciulla, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Mark H Criswell, PhD  Adjunct Assistant Research Professor, Department of Ophthalmology, Indiana University School of Medicine

Mark H Criswell, PhD is a member of the following medical societies: Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Alon Harris, PhD  Lois Letzter Professor, Director of Glaucoma Research and Diagnostic Center, Department of Ophthalmology, Indiana University School of Medicine

Alon Harris, PhD is a member of the following medical societies: American College of Sports Medicine, American Physiological Society, American Society for Laser Medicine and Surgery, and New York Academy of Sciences

Disclosure: Nothing to disclose.

Specialty Editor Board

Brian A Phillpotts, MD  Former Vitreo-Retinal Service Director, Former Program Director, Clinical Assistant Professor, Department of Ophthalmology, Howard University College of Medicine

Brian A Phillpotts, MD is a member of the following medical societies: American Academy of Ophthalmology, American Diabetes Association, American Medical Association, and National Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Steve Charles, MD  Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine; Adjunct Professor of Ophthalmology, Columbia College of Physicians and Surgeons; Clinical Professor Ophthalmology, Chinese University of Hong Kong

Steve Charles, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Club Jules Gonin, Macula Society, and Retina Society

Disclosure: Alcon Laboratories Consulting fee Consulting; OptiMedica Ownership interest Other; Topcon Medical Lasers Consulting fee Consulting

Lance L Brown, OD, MD  Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD  Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Grant M Comer, MD, to the development and writing of this article.

References

  1. Kahn HA, Leibowitz HM, Ganley JP, Kini MM, Colton T, Nickerson RS, et al. The Framingham Eye Study. I. Outline and major prevalence findings. Am J Epidemiol. Jul 1977;106(1):17-32. [Medline].

  2. Attebo K, Mitchell P, Smith W. Visual acuity and the causes of visual loss in Australia. The Blue Mountains Eye Study. Ophthalmology. Mar 1996;103(3):357-64. [Medline].

  3. Klaver CC, Wolfs RC, Vingerling JR, Hofman A, de Jong PT. Age-specific prevalence and causes of blindness and visual impairment in an older population: the Rotterdam Study. Arch Ophthalmol. May 1998;116(5):653-8. [Medline].

  4. Tielsch JM, Javitt JC, Coleman A, Katz J, Sommer A. The prevalence of blindness and visual impairment among nursing home residents in Baltimore. N Engl J Med. May 4 1995;332(18):1205-9. [Medline].

  5. Friedman DS, O'Colmain BJ, Munoz B, Tomany SC, McCarty C, de Jong PT, et al. Prevalence of age-related macular degeneration in the United States. Arch Ophthalmol. Apr 2004;122(4):564-72. [Medline].

  6. Klein R, Davis MD, Magli YL, Segal P, Klein BE, Hubbard L. The Wisconsin age-related maculopathy grading system. Ophthalmology. Jul 1991;98(7):1128-34. [Medline].

  7. Davis MD, Gangnon RE, Lee LY, Hubbard LD, Klein BE, Klein R, et al. The Age-Related Eye Disease Study severity scale for age-related macular degeneration: AREDS Report No. 17. Arch Ophthalmol. Nov 2005;123(11):1484-98. [Medline]. [Full Text].

  8. Klein ML, Francis PJ, Ferris FL 3rd, Hamon SC, Clemons TE. Risk assessment model for development of advanced age-related macular degeneration. Arch Ophthalmol. Dec 2011;129(12):1543-50. [Medline].

  9. Bird AC, Bressler NM, Bressler SB, Chisholm IH, Coscas G, Davis MD, et al. An international classification and grading system for age-related maculopathy and age-related macular degeneration. The International ARM Epidemiological Study Group. Surv Ophthalmol. Mar-Apr 1995;39(5):367-74. [Medline].

  10. Davis MD, Gangnon RE, Lee LY, Hubbard LD, Klein BE, Klein R, et al. The Age-Related Eye Disease Study severity scale for age-related macular degeneration: AREDS Report No. 17. Arch Ophthalmol. Nov 2005;123(11):1484-98. [Medline].

  11. Klein R, Peto T, Bird A, Vannewkirk MR. The epidemiology of age-related macular degeneration. Am J Ophthalmol. Mar 2004;137(3):486-95. [Medline].

  12. Mares-Perlman JA, Brady WE, Klein R, VandenLangenberg GM, Klein BE, Palta M. Dietary fat and age-related maculopathy. Arch Ophthalmol. Jun 1995;113(6):743-8. [Medline].

  13. Chong EW, Kreis AJ, Wong TY, Simpson JA, Guymer RH. Dietary omega-3 fatty acid and fish intake in the primary prevention of age-related macular degeneration: a systematic review and meta-analysis. Arch Ophthalmol. Jun 2008;126(6):826-33. [Medline].

  14. Seddon JM, Rosner B, Sperduto RD, Yannuzzi L, Haller JA, Blair NP, et al. Dietary fat and risk for advanced age-related macular degeneration. Arch Ophthalmol. Aug 2001;119(8):1191-9. [Medline].

  15. Chong EW, Robman LD, Simpson JA, Hodge AM, Aung KZ, Dolphin TK, et al. Fat consumption and its association with age-related macular degeneration. Arch Ophthalmol. May 2009;127(5):674-80. [Medline].

  16. Chua B, Flood V, Rochtchina E, Wang JJ, Smith W, Mitchell P. Dietary fatty acids and the 5-year incidence of age-related maculopathy. Arch Ophthalmol. Jul 2006;124(7):981-6. [Medline].

  17. Seddon JM, Cote J, Davis N, Rosner B. Progression of age-related macular degeneration: association with body mass index, waist circumference, and waist-hip ratio. Arch Ophthalmol. Jun 2003;121(6):785-92. [Medline].

  18. Okubo A, Rosa RH, Fan JT, et al. RPE residual body content, autofluorescence and aging. Invest Ophthalmol Vis Sci. 1996;37(suppl):380.

  19. von Ruckmann A, Fitzke FW, Bird AC. In vivo fundus autofluorescence in age-related macular degeneration. Invest Ophthalmol Vis Sci. 1997;38:478-86.

  20. Edwards AO, Ritter R 3rd, Abel KJ, Manning A, Panhuysen C, Farrer LA. Complement factor H polymorphism and age-related macular degeneration. Science. Apr 15 2005;308(5720):421-4. [Medline].

  21. Haines JL, Hauser MA, Schmidt S, Scott WK, Olson LM, Gallins P, et al. Complement factor H variant increases the risk of age-related macular degeneration. Science. Apr 15 2005;308(5720):419-21. [Medline].

  22. Hageman GS, Anderson DH, Johnson LV. A common haplotype in the complement regulatory gene factor H (HF1/CFH) predisposes individuals to age-related macular degeneration. Proc Natl Acad Sci USA. 2005;102:7227-32.

  23. Jakobsdottir J, Conley YP, Weeks DE, Mah TS, Ferrell RE, Gorin MB. Susceptibility genes for age-related maculopathy on chromosome 10q26. Am J Hum Genet. Sep 2005;77(3):389-407. [Medline].

  24. Gold B, Merriam JE, Zernant J. Variation in factor B (BF) and complement component 2 (C2)genes is associated with age-related macular degeneration. Nat Genet. 2006;38:458-62.

  25. Johnson LV, Leitner WP, Staples MK, Anderson DH. Complement activation and inflammatory processes in Drusen formation and age related macular degeneration. Exp Eye Res. Dec 2001;73(6):887-96. [Medline].

  26. Esparza-Gordillo J, Soria JM, Buil A, Almasy L, Blangero J, Fontcuberta J. Genetic and environmental factors influencing the human factor H plasma levels. Immunogenetics. May 2004;56(2):77-82. [Medline].

  27. Sepp T, Khan JC, Thurlby DA, Shahid H, Clayton DG, Moore AT, et al. Complement factor H variant Y402H is a major risk determinant for geographic atrophy and choroidal neovascularization in smokers and nonsmokers. Invest Ophthalmol Vis Sci. Feb 2006;47(2):536-40. [Medline].

  28. Bressler NM, Bressler SB, Congdon NG, Ferris FL 3rd, Friedman DS, et al. Potential public health impact of Age-Related Eye Disease Study results: AREDS report no. 11. Arch Ophthalmol. Nov 2003;121(11):1621-4. [Medline].

  29. Thylefors B. A global initiative for the elimination of avoidable blindness. Am J Ophthalmol. Jan 1998;125(1):90-3. [Medline].

  30. Brody BL, Gamst AC, Williams RA, et al. Depression, visual acuity, comorbidity, and disability associated with age-related macular degeneration. Ophthalmology. Oct 2001;108(10):1893-900; discussion 1900-1. [Medline].

  31. Casten RJ, Rovner BW, Tasman W. Age-related macular degeneration and depression: a review of recent research. Curr Opin Ophthalmol. Jun 2004;15(3):181-3. [Medline].

  32. Coleman AL, Stone K, Ewing SK, Nevitt M, Cummings S, Cauley JA, et al. Higher risk of multiple falls among elderly women who lose visual acuity. Ophthalmology. May 2004;111(5):857-62. [Medline].

  33. Dong LM, Childs AL, Mangione CM, Bass EB, Bressler NM, Hawkins BS, et al. Health- and vision-related quality of life among patients with choroidal neovascularization secondary to age-related macular degeneration at enrollment in randomized trials of submacular surgery: SST report no. 4. Am J Ophthalmol. Jul 2004;138(1):91-108. [Medline].

  34. Vision and quality-of-life. Brown GC. Trans Am Ophthalmol Soc. 1999;97:473-511.

  35. Sommer A, Tielsch JM, Katz J, Quigley HA, Gottsch JD, Javitt JC, et al. Racial differences in the cause-specific prevalence of blindness in east Baltimore. N Engl J Med. Nov 14 1991;325(20):1412-7. [Medline].

  36. Cruickshanks KJ, Klein R, Klein BE. Sunlight and age-related macular degeneration. The Beaver Dam Eye Study. Arch Ophthalmol. Apr 1993;111(4):514-8. [Medline].

  37. Das BN, Thompson JR, Patel R, Rosenthal AR. The prevalence of eye disease in Leicester: a comparison of adults of Asian and European descent. J R Soc Med. Apr 1994;87(4):219-22. [Medline].

  38. Miyazaki M, Nakamura H, Kubo M, Kiyohara Y, Oshima Y, Ishibashi T, et al. Risk factors for age related maculopathy in a Japanese population: the Hisayama study. Br J Ophthalmol. Apr 2003;87(4):469-72. [Medline].

  39. Klein R, Klein BE, Linton KL. Prevalence of age-related maculopathy. The Beaver Dam Eye Study. Ophthalmology. Jun 1992;99(6):933-43. [Medline].

  40. Klein R, Rowland ML, Harris MI. Racial/ethnic differences in age-related maculopathy. Third National Health and Nutrition Examination Survey. Ophthalmology. Mar 1995;102(3):371-81. [Medline].

  41. Kini MM, Leibowitz HM, Colton T, Nickerson RJ, Ganley J, Dawber TR. Prevalence of senile cataract, diabetic retinopathy, senile macular degeneration, and open-angle glaucoma in the Framingham eye study. Am J Ophthalmol. Jan 1978;85(1):28-34. [Medline].

  42. Leibowitz HM, Krueger DE, Maunder LR, Milton RC, Kini MM, Kahn HA, et al. The Framingham Eye Study monograph: An ophthalmological and epidemiological study of cataract, glaucoma, diabetic retinopathy, macular degeneration, and visual acuity in a general population of 2631 adults, 1973-1975. Surv Ophthalmol. May-Jun 1980;24:335-610. [Medline].

  43. Klein R, Klein BE, Jensen SC, Meuer SM. The five-year incidence and progression of age-related maculopathy: the Beaver Dam Eye Study. Ophthalmology. Jan 1997;104(1):7-21. [Medline].

  44. Seddon JM, Cote J, Davis N, Rosner B. Progression of age-related macular degeneration: association with body mass index, waist circumference, and waist-hip ratio. Arch Ophthalmol. Jun 2003;121(6):785-92. [Medline].

  45. Seddon JM, Ajani UA, Mitchell BD. Familial aggregation of age-related maculopathy. Am J Ophthalmol. Feb 1997;123(2):199-206. [Medline].

  46. Seddon JM, Willett WC, Speizer FE, Hankinson SE. A prospective study of cigarette smoking and age-related macular degeneration in women. JAMA. Oct 9 1996;276(14):1141-6. [Medline].

  47. Christen WG, Glynn RJ, Manson JE, Ajani UA, Buring JE. A prospective study of cigarette smoking and risk of age-related macular degeneration in men. JAMA. Oct 9 1996;276(14):1147-51. [Medline].

  48. Christen WG, Schaumberg DA, Glynn RJ, Buring JE. Dietary {omega}-3 Fatty Acid and Fish Intake and Incident Age-Related Macular Degeneration in Women. Arch Ophthalmol. Jul 2011;129(7):921-9. [Medline]. [Full Text].

  49. Seddon JM, George S, Rosner B. Cigarette smoking, fish consumption, omega-3 fatty acid intake, and associations with age-related macular degeneration: the US Twin Study of Age-Related Macular Degeneration. Arch Ophthalmol. Jul 2006;124(7):995-1001. [Medline].

  50. Yannuzzi LA. Indocyanine green angiography: a perspective on use in the clinical setting. Am J Ophthalmol. May 2011;151(5):745-751.e1. [Medline].

  51. Hee MR, Baumal CR, Puliafito CA, Duker JS, Reichel E, Wilkins JR, et al. Optical coherence tomography of age-related macular degeneration and choroidal neovascularization. Ophthalmology. Aug 1996;103(8):1260-70. [Medline].

  52. Ting TD, Oh M, Cox TA, Meyer CH, Toth CA. Decreased visual acuity associated with cystoid macular edema in neovascular age-related macular degeneration. Arch Ophthalmol. Jun 2002;120(6):731-7. [Medline].

  53. Sahni J, Stanga P, Wong D, Harding S. Optical coherence tomography in photodynamic therapy for subfoveal choroidal neovascularisation secondary to age related macular degeneration: a cross sectional study. Br J Ophthalmol. Mar 2005;89(3):316-20. [Medline].

  54. Piccolino FC, de la Longrais RR, Ravera G, Eandi CM, Ventre L, Abdollahi A, et al. The foveal photoreceptor layer and visual acuity loss in central serous chorioretinopathy. Am J Ophthalmol. Jan 2005;139(1):87-99. [Medline].

  55. Rogers AH, Martidis A, Greenberg PB, Puliafito CA. Optical coherence tomography findings following photodynamic therapy of choroidal neovascularization. Am J Ophthalmol. Oct 2002;134(4):566-76. [Medline].

  56. Rosenfeld P, Rich RM, Lalwani GA. Ranibizumab: Phase II clinical trial results. Ophthalmology Clinics of North America. 2006;19:361-72.

  57. Tolentino MJ, Brucker AJ, Fosnot J, Ying GS, Wu IH, Malik G, et al. Intravitreal injection of vascular endothelial growth factor small interfering RNA inhibits growth and leakage in a nonhuman primate, laser-induced model of choroidal neovascularization. Retina. Feb 2004;24(1):132-8. [Medline].

  58. Tolentino MJ, Husain D, Theodosiadis P, Gragoudas ES, Connolly E, Kahn J, et al. Angiography of fluoresceinated anti-vascular endothelial growth factor antibody and dextrans in experimental choroidal neovascularization. Arch Ophthalmol. Jan 2000;118(1):78-84. [Medline].

  59. Gragoudas ES, Adamis AP, Cunningham ET Jr, Feinsod M, Guyer DR. Pegaptanib for neovascular age-related macular degeneration. N Engl J Med. Dec 30 2004;351(27):2805-16. [Medline].

  60. Eyetech Pharmaceuticals. Eyetech announces launch date for Macugen (pegaptanib sodium injection) [Eyetech Web site]. January 20, 2005. Available at: http://media.corporate-ir.net/media_files/irol/13/134799/newspdfs/1-20-05.pdf. Accessed June 27, 2005. [Full Text].

  61. Eyetech Pharmaceuticals. Pfizer and Eyetech provide regulatory update on Macugen (pegaptanib sodium injection) [Eyetech Web site]. September 20, 2004. Available at: http://media.corporate-ir.net/media_files/irol/13/134799/newspdfs/9-20-04-Update.pdf. Accessed October 12, 2004. [Full Text].

  62. Brown DM, Kaiser PK, Michels M, Soubrane G, Heier JS, Kim RY. Ranibizumab versus verteporfin for neovascular age-related macular degeneration. N Engl J Med. Oct 5 2006;355(14):1432-44. [Medline].

  63. Genetech Press Release. Preliminary Results from a Phase IIIb Study Showed Patients with Wet AMD Treated with Lucentis Quarterly Experienced a 16-Letter Benefit over the Control Group at One Year. Available at http://www.gene.com/gene/news/press-releases/display.do?method=detail&id=9747. Accessed 2/21/2008.

  64. Singer MA, Awh CC, Sadda S, Freeman WR, Antoszyk AN, Wong P, et al. HORIZON: An Open-Label Extension Trial of Ranibizumab for Choroidal Neovascularization Secondary to Age-Related Macular Degeneration. Ophthalmology. Feb 4 2012;[Medline].

  65. Schmidt-Erfurth U, Eldem B, Guymer R, Korobelnik JF, Schlingemann RO, Axer-Siegel R, et al. Efficacy and Safety of Monthly versus Quarterly Ranibizumab Treatment in Neovascular Age-related Macular Degeneration: The EXCITE Study. Ophthalmology. May 2011;118(5):831-9. [Medline].

  66. Fung AE, Lalwani GA, Rosenfeld PJ, Dubovy SR, Michels S, Feuer WJ. An optical coherence tomography-guided, variable dosing regimen with intravitreal ranibizumab (Lucentis) for neovascular age-related macular degeneration. Am J Ophthalmol. Apr 2007;143(4):566-83. [Medline].

  67. Holz FG, Korobelnik JF, Lanzetta P, Mitchell P, Schmidt-Erfurth U, Wolf S, et al. The effects of a flexible visual acuity-driven ranibizumab treatment regimen in age-related macular degeneration: outcomes of a drug and disease model. Invest Ophthalmol Vis Sci. Jan 2010;51(1):405-12. [Medline].

  68. Spaide R. Ranibizumab according to need: a treatment for age-related macular degeneration. Am J Ophthalmol. Apr 2007;143(4):679-80. [Medline].

  69. Brown DM, Regillo CD. Anti-VEGF agents in the treatment of neovascular age-related macular degeneration: applying clinical trial results to the treatment of everyday patients. Am J Ophthalmol. Oct 2007;144(4):627-37. [Medline].

  70. Gupta OP, Shienbaum G, Patel AH, et al. A treat and extend regimen using ranibizumab for neovascular age-related macular degeneration clinical and economic impact. Ophthalmology. 2010;117:2134-2140.

  71. Shienbaum G, Gupta OP, Fecarotta C, et al. Management of neovascular age- related macular degeneration using bevacizumab with the treat and extend regimen: clinical results and economic impact. In: ARVO; Fort Lauderdale, Florida; 2010.

  72. Genentech. Avastin [Genentech Web site]. Available at: http://www.gene.com/gene/products/information/oncology/avastin/index.jsp. Accessed June 28, 2005. [Full Text].

  73. Michels S, Rosenfeld PJ, Puliafito CA, et al. Systemic bevacizumab (Avastin) therapy for neovascular age-related macular degeneration twelve-week results of an uncontrolled open-label clinical study. Ophthalmology. Jun 2005;112(6):1035-47. [Medline].

  74. Rosenfeld PJ, Moshfeghi AA, Puliafito CA. Optical coherence tomography findings after an intravitreal injection of bevacizumab (avastin) for neovascular age-related macular degeneration. Ophthalmic Surg Lasers Imaging. Jul-Aug 2005;36(4):331-5. [Medline].

  75. Yoganathan P, Deramo VA, Lai JC, Tibrewala RK, Fastenberg DM. Visual improvement following intravitreal bevacizumab (Avastin) in exudative age-related macular degeneration. Retina. Nov-Dec 2006;26(9):994-8. [Medline].

  76. Emerson MV, Lauer AK, Flaxel CJ, Wilson DJ, Francis PJ, Stout JT. Intravitreal bevacizumab (Avastin) treatment of neovascular age-related macular degeneration. Retina. Apr-May 2007;27(4):439-44. [Medline].

  77. Abraham-Marin ML, Cortes-Luna CF, Alvarez-Rivera G, Hernandez-Rojas M, Quiroz-Mercado H, Morales-Canton V. Intravitreal bevacizumab therapy for neovascular age-related macular degeneration: a pilot study. Graefes Arch Clin Exp Ophthalmol. May 2007;245(5):651-5. [Medline].

  78. Bashshur ZF, Schakal A, Hamam RN, El Haibi CP, Jaafar RF, Noureddin BN. Intravitreal bevacizumab vs verteporfin photodynamic therapy for neovascular age-related macular degeneration. Arch Ophthalmol. Oct 2007;125(10):1357-61. [Medline].

  79. Lazic R, Gabric N. Verteporfin therapy and intravitreal bevacizumab combined and alone in choroidal neovascularization due to age-related macular degeneration. Ophthalmology. Jun 2007;114(6):1179-85. [Medline].

  80. Martin DF, Maguire MG, Ying GS, Grunwald JE, Fine SL, Jaffe GJ. Ranibizumab and bevacizumab for neovascular age-related macular degeneration. N Engl J Med. May 19 2011;364(20):1897-908. [Medline].

  81. Martin DF, Maguire MG, Fine SL, Ying GS, Jaffe GJ, Grunwald JE, et al. Ranibizumab and Bevacizumab for Treatment of Neovascular Age-Related Macular Degeneration: Two-Year Results. Ophthalmology. Apr 26 2012;[Medline].

  82. Cavalcante LL, Cavalcante ML, Murray TG, et al. Intravitreal injection analysis at the Bascom Palmer Eye Institute: evaluation of clinical indications for the treatment and incidence rates of endophthalmitis. Clin Ophthalmol. May 25 2010;4:519-24. [Medline]. [Full Text].

  83. Mason JO 3rd, White MF, Feist RM, et al. Incidence of acute onset endophthalmitis following intravitreal bevacizumab (Avastin) injection. Retina. Apr 2008;28(4):564-7. [Medline].

  84. Fintak DR, Shah GK, Blinder KJ, et al. Incidence of endophthalmitis related to intravitreal injection of bevacizumab and ranibizumab. Retina. Nov-Dec 2008;28(10):1395-9. [Medline].

  85. Pilli S, Kotsolis A, Spaide RF, et al. Endophthalmitis associated with intravitreal anti-vascular endothelial growth factor therapy injections in an office setting. Am J Ophthalmol. May 2008;145(5):879-82. [Medline].

  86. Diago T, McCannel CA, Bakri SJ, et al. Infectious endophthalmitis after intravitreal injection of antiangiogenic agents. Retina. May 2009;29(5):601-5. [Medline].

  87. McCannel CA. Meta-analysis of endophthalmitis after intravitreal injection of anti-vascular endothelial growth factor agents: causative organisms and possible prevention strategies. Retina. Apr 2011;31(4):654-61. [Medline].

  88. Wen JC, McCannel CA, Mochon AB, Garner OB. Bacterial dispersal associated with speech in the setting of intravitreous injections. Arch Ophthalmol. Dec 2011;129(12):1551-4. [Medline].

  89. US Food and Drug Administration. FDA alerts health care professionals of infection risk from repackaged Avastin intravitreal injections. Available at http://www.fda.gov/Drugs/DrugSafety/ucm270296.htm. Accessed August 31, 2011.

  90. Dixon JA, Oliver SC, Olson JL, Mandava N. VEGF Trap-Eye for the treatment of neovascular age-related macular degeneration. Expert Opin Investig Drugs. Oct 2009;18(10):1573-80. [Medline].

  91. Regeneron announces FDA approval of Eylea™ (aflibercept) injection for the treatment of wet age-related macular degeneration; 18 November 2011. Available at http://www.multivu.com/mnr/51268-eylea-aflibercept-wet-age-related-macular-degeneration-AMD-FDA-approval. Accessed 22 November 2011.

  92. Brown DM, Heier JS, Ciulla T, Benz M, Abraham P, Yancopoulos G, et al. Primary Endpoint Results of a Phase II Study of Vascular Endothelial Growth Factor Trap-Eye in Wet Age-related Macular Degeneration. Ophthalmology. Jun 2011;118(6):1089-97. [Medline].

  93. Heier JS, Boyer D, Nguyen QD, Marcus D, Roth DB, Yancopoulos G, et al. The 1-year Results of CLEAR-IT 2, a Phase 2 Study of Vascular Endothelial Growth Factor Trap-Eye Dosed As-needed After 12-week Fixed Dosing. Ophthalmology. Jun 2011;118(6):1098-106. [Medline].

  94. Gehlbach P, Li T, Hatef E. Statins for age-related macular degeneration. Cochrane Database Syst Rev. Jul 8 2009;CD006927. [Medline].

  95. Chuo JY, Wiens M, Etminan M, Maberley DA. Use of lipid-lowering agents for the prevention of age-related macular degeneration: a meta-analysis of observational studies. Ophthalmic Epidemiol. Nov-Dec 2007;14(6):367-74. [Medline].

  96. MPS Group. Macular Photocoagulation Study Group. Argon laser photocoagulation for senile macular degeneration. Results of a randomized clinical trial. Arch Ophthalmol. Jun 1982;100(6):912-8. [Medline].

  97. MPS Group. Macular Photocoagulation Study Group. Argon laser photocoagulation for neovascular maculopathy. Three-year results from randomized clinical trials. Arch Ophthalmol. May 1986;104(5):694-701. [Medline].

  98. MPS Group. Argon laser photocoagulation for neovascular maculopathy. Five-year results from randomized clinical trials. Macular Photocoagulation Study Group. Arch Ophthalmol. Aug 1991;109(8):1109-14. [Medline].

  99. MPS Group. Macular Photocoagulation Study Group. Five-year follow-up of fellow eyes of patients with age-related macular degeneration and unilateral extrafoveal choroidal neovascularization. Arch Ophthalmol. Sep 1993;111(9):1189-99. [Medline].

  100. Freund KB, Yannuzzi LA, Sorenson JA. Age-related macular degeneration and choroidal neovascularization. Am J Ophthalmol. Jun 15 1993;115(6):786-91. [Medline].

  101. Moisseiev J, Alhalel A, Masuri R, Treister G. The impact of the macular photocoagulation study results on the treatment of exudative age-related macular degeneration. Arch Ophthalmol. Feb 1995;113(2):185-9. [Medline].

  102. Nishijima K, Takahashi M, Akita J, Katsuta H, Tanemura M, Aikawa H, et al. Laser photocoagulation of indocyanine green angiographically identified feeder vessels to idiopathic polypoidal choroidal vasculopathy. Am J Ophthalmol. Apr 2004;137(4):770-3. [Medline].

  103. Shiraga F, Ojima Y, Matsuo T, Takasu I, Matsuo N. Feeder vessel photocoagulation of subfoveal choroidal neovascularization secondary to age-related macular degeneration. Ophthalmology. Apr 1998;105(4):662-9. [Medline].

  104. Reichel E, Musch DC, Blodi BA. Results from the TTT4CNV clinical trial. Invest Ophthalmol Vis Sci. 2005;46:E-abstract 2311.

  105. Aveline B, Hasan T, Redmond RW. Photophysical and photosensitizing properties of benzoporphyrin derivative monoacid ring A (BPD-MA). Photochem Photobiol. Mar 1994;59(3):328-35. [Medline].

  106. Allison BA, Waterfield E, Richter AM, Levy JG. The effects of plasma lipoproteins on in vitro tumor cell killing and in vivo tumor photosensitization with benzoporphyrin derivative. Photochem Photobiol. Nov 1991;54(5):709-15. [Medline].

  107. Hunt DW, Jiang H, Granville DJ, Chan AH, Leong S, Levy JG. Consequences of the photodynamic treatment of resting and activated peripheral T lymphocytes. Immunopharmacology. Jan 1999;41(1):31-44. [Medline].

  108. Novartis Ophthalmics. Visudyne launched in Japan for treatment of age-related macular degeneration [Novartis Web site]. May 10, 2004. Available at: http://www.us.novartisophthalmics.com/hcp/press-release/Visodyne_E_10.05.pdf. Accessed October 15, 2004.:[Full Text].

  109. Blumenkranz MS, Bressler NM, Bressler SB, Donati G, Fish GE, Haynes LA, et al. Verteporfin therapy for subfoveal choroidal neovascularization in age-related macular degeneration: three-year results of an open-label extension of 2 randomized clinical trials--TAP Report no. 5. Arch Ophthalmol. Oct 2002;120(10):1307-14. [Medline].

  110. Bergers G, Song S, Meyer-Morse N, Bergsland E, Hanahan D. Benefits of targeting both pericytes and endothelial cells in the tumor vasculature with kinase inhibitors. J Clin Invest. May 2003;111(9):1287-95. [Medline]. [Full Text].

  111. Bradley J, Ju M, Robinson GS. Combination therapy for the treatment of ocular neovascularization. Angiogenesis. 2007;10(2):141-8. [Medline].

  112. Jo N, Mailhos C, Ju M, Cheung E, Bradley J, Nishijima K, et al. Inhibition of platelet-derived growth factor B signaling enhances the efficacy of anti-vascular endothelial growth factor therapy in multiple models of ocular neovascularization. Am J Pathol. Jun 2006;168(6):2036-53. [Medline]. [Full Text].

  113. Dhalla MS, Shah GK, Blinder KJ, Ryan EH Jr, Mittra RA, Tewari A. Combined photodynamic therapy with verteporfin and intravitreal bevacizumab for choroidal neovascularization in age-related macular degeneration. Retina. Nov-Dec 2006;26(9):988-93. [Medline].

  114. Augustin AJ, Puls S, Offermann I. Triple therapy for choroidal neovascularization due to age-related macular degeneration: verteporfin PDT, bevacizumab, and dexamethasone. Retina. Feb 2007;27(2):133-40. [Medline].

  115. Schmidt-Erfurth U, Schlötzer-Schrehard U, Cursiefen C, Michels S, Beckendorf A, Naumann GO. Influence of photodynamic therapy on expression of vascular endothelial growth factor (VEGF), VEGF receptor 3, and pigment epithelium-derived factor. Invest Ophthalmol Vis Sci. Oct 2003;44(10):4473-80. [Medline].

  116. Costagliola C, Romano MR, Rinaldi M, dell'Omo R, Chiosi F, Menzione M, et al. Low fluence rate photodynamic therapy combined with intravitreal bevacizumab for neovascular age-related macular degeneration. Br J Ophthalmol. Feb 2010;94(2):180-4. [Medline].

  117. Potter MJ, Claudio CC, Szabo SM. A randomised trial of bevacizumab and reduced light dose photodynamic therapy in age-related macular degeneration: the VIA study. Br J Ophthalmol. Feb 2010;94(2):174-9. [Medline].

  118. Lim JY, Lee SY, Kim JG, Lee JY, Chung H, Yoon YH. Intravitreal bevacizumab alone versus in combination with photodynamic therapy for the treatment of neovascular maculopathy in patients aged 50 years or older: 1-year results of a prospective clinical study. Acta Ophthalmol. Mar 16 2010;[Medline].

  119. Bressler NM, Bressler SB, Childs AL, Haller JA, Hawkins BS, Lewis H, et al. Surgery for hemorrhagic choroidal neovascular lesions of age-related macular degeneration: ophthalmic findings: SST report no. 13. Ophthalmology. Nov 2004;111(11):1993-2006. [Medline].

  120. Hawkins BS, Bressler NM, Miskala PH, Bressler SB, Holekamp NM, Marsh MJ, et al. Surgery for subfoveal choroidal neovascularization in age-related macular degeneration: ophthalmic findings: SST report no. 11. Ophthalmology. Nov 2004;111(11):1967-80. [Medline].

  121. Abraham P, Yue H, Wilson L. Randomized, double-masked, sham-controlled trial of ranibizumab for neovascular age-related macular degeneration: PIER study year 2. Am J Ophthalmol. Sep 2010;150(3):315-324.e1. [Medline].

  122. Bressler NM. Photodynamic therapy of subfoveal choroidal neovascularization in age-related macular degeneration with verteporfin: two-year results of 2 randomized clinical trials-tap report 2. Arch Ophthalmol. Feb 2001;119(2):198-207. [Medline].

  123. Drexler W, Sattmann H, Hermann B, Ko TH, Stur M, Unterhuber A, et al. Enhanced visualization of macular pathology with the use of ultrahigh-resolution optical coherence tomography. Arch Ophthalmol. May 2003;121(5):695-706. [Medline].

  124. Hageman GS, Luthert PJ, Victor Chong NH, Johnson LV, Anderson DH, et al. An integrated hypothesis that considers drusen as biomarkers of immune-mediated processes at the RPE-Bruch's membrane interface in aging and age-related macular degeneration. Progress in Retinal and Eye Research. November 2001;20:705-32.

  125. Johnson TM, Glaser BM. Focal laser ablation of retinal angiomatous proliferation. Retina. Sep 2006;26(7):765-72. [Medline].

  126. Klein RJ, Zeiss C, Chew EY, Tsai JY, Sackler RS, Haynes C, et al. Complement factor H polymorphism in age-related macular degeneration. Science. Apr 15 2005;308(5720):385-9. [Medline].

  127. Matsuyama K, Ogata N, Matsuoka M, Wada M, Takahashi K, Nishimura T. Plasma levels of vascular endothelial growth factor and pigment epithelium-derived factor before and after intravitreal injection of bevacizumab. Br J Ophthalmol. Sep 2010;94(9):1215-8. [Medline].

  128. MPS Group. Macular Photocoagulation Study Group. Laser photocoagulation of subfoveal neovascular lesions of age-related macular degeneration. Updated findings from two clinical trials. Arch Ophthalmol. Sep 1993;111(9):1200-9. [Medline].

  129. MPS Group. Macular Photocoagulation Study Group. Recurrent choroidal neovascularization after argon laser photocoagulation for neovascular maculopathy. Arch Ophthalmol. Apr 1986;104(4):503-12. [Medline].

  130. MPS Group. Macular Photocoagulation Study Group. Subfoveal neovascular lesions in age-related macular degeneration. Guidelines for evaluation and treatment in the macular photocoagulation study. Arch Ophthalmol. Sep 1991;109(9):1242-57. [Medline].

  131. National Eye Institute. Comparison of Age-Related Macular Degeneration Treatment Trial (CATT). ClinicalTrials.gov. Available at http://clinicaltrials.gov/ct2/show/NCT00593450. Accessed 2/21/2008.

  132. [Best Evidence] Rosenfeld PJ, Brown DM, Heier JS, Boyer DS, Kaiser PK, Chung CY, et al. Ranibizumab for neovascular age-related macular degeneration. N Engl J Med. Oct 5 2006;355(14):1419-31. [Medline].

 
Previous
Next
 
Age-related macular degeneration (AMD), exudative.
Age-related macular degeneration (AMD), exudative.
Color photograph of the fundus shows nonexudative age-related macular degeneration (AMD) with geographic atrophy of the retinal pigment epithelium (RPE) and drusen. Absolute atrophy of the RPE occupies the foveal region in this case of nonexudative AMD. The central atrophic region causes a corresponding central scotoma. Note the large choroidal vessels, which are visible through the RPE defect. Drusen surround the region of geographic atrophy. Photo by Tim Steffens.
Late-frame fluorescein angiogram shows nonexudative age-related macular degeneration (AMD) with geographic atrophy of the retinal pigment epithelium (RPE) and drusen from the case of geographic atrophy illustrated in the image above. Geographic atrophy stains intensely with distinct borders, but no leakage is present to suggest a choroidal neovascular membrane (CNVM). Stain highlights the large choroidal vessels in the region of atrophy well. Photo by Tim Steffens.
Color photograph of the fundus shows classic choroidal neovascular membrane (CNVM) causing subretinal hemorrhage. Subretinal hemorrhage, which resulted from a classic CNVM, occupies the foveal region, causing a dense central scotoma. The subretinal hemorrhage can be large, mimicking a choroidal melanoma. On occasion, the subretinal hemorrhage can break through the retina, causing a vitreous hemorrhage. Patients who present with vitreous hemorrhage and evidence of age-related macular degeneration (AMD) in the other eye should be thought to have a CNVM, especially if they have no history of diabetes or other causes of vitreous hemorrhage. Photo by Tim Steffens.
Midframe from the fluorescein angiogram of the case in the image above reveals the discrete region of hyperfluorescence, which is characteristic of a classic choroidal neovascular membrane (CNVM). Late frames of the angiogram (not shown) revealed intense leakage from the CNVM. Subretinal hemorrhage is more commonly due to classic CNVM than occult CNVM and typically occurs along the peripheral aspect of the CNVM. Photo by Tim Steffens.
Midframe fluorescein angiogram shows classic plus occult choroidal neovascular membrane (CNVM). Temporal to the foveal region, image reveals a discrete region of hyperfluorescence that is suggestive of a classic CNVM. Photo by Tim Steffens.
Late-frame fluorescein angiogram shows classic plus occult choroidal neovascular membrane (CNVM). Late frames of the angiogram from the case in the image above show leakage from the discrete focus (seen in early frames). This finding is characteristic of the classic component. The surrounding late-stippled leakage is characteristic of the occult component. Photo by Tim Steffens.
Color photograph of the fundus shows a retinal pigment epithelium (RPE) tear. The RPE has torn from the nasal portion of the macula and assumed a scrolled, redundant configuration in the temporal portion of the macula. Associated sub-RPE and subretinal hemorrhage is present, as are hard exudates and subretinal fluid. Courtesy of Albert R. Frederick, Jr, MD.
Early-frame fluorescein angiogram shows a retinal pigment epithelium (RPE) tear. Fluorescein angiogram from the case illustrated in the image above temporally shows blockage of the choroidal flush by the redundant, scrolled RPE. Stained areas represent where the RPE was torn. Later frames of the angiogram (not shown) also showed leakage due to the associated choroidal neovascular membrane (CNVM). Courtesy of Albert R. Frederick, Jr, MD.
Late-frame fluorescein angiogram. Classic choroidal neovascular membrane (CNVM) before laser photocoagulation shows classic CNVM, which manifests as a discrete, early focus of hyperfluorescence with late leakage. Associated subretinal hemorrhage at the peripheral edge of the CNVM blocks the underlying choroidal flush. Photo by Tim Steffens.
Early-frame fluorescein angiogram shows classic choroidal neovascular membrane (CNVM) after laser photocoagulation. Classic CNVM illustrated in the image above was photocoagulated. The patient underwent repeat fluorescein angiography (image shown here) 2 weeks later to rule out persistence. Note nonperfusion of the choriocapillaris and CNVM in the laser scar. Photo by Tim Steffens.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.