eMedicine Specialties > Ophthalmology > Retina

Neovascular Membranes, Subretinal

Author: Steve Charles, MD, Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine
Contributor Information and Disclosures

Updated: Dec 6, 2006

Introduction

Background

Choroidal neovascular membranes (CNVMs) are associated with many diseases. The most common causes are age-related macular degeneration (AMD), presumed ocular histoplasmosis syndrome (POHS), myopic macular degeneration, trauma, and angioid streaks; however, many cases are idiopathic.

The natural history of patients with AMD should not be overlooked when pilot studies of new therapies are reported. In a randomized trial (of 481 patients) of interferon alpha-2, 62% of the placebo group stabilized at 1 year, losing less than 3 lines of vision. Randomized clinical trials are necessary in assessing treatment efficacy in cases of CNVMs secondary to AMD as well as other causes. Submacular surgery, photodynamic therapy, translocation, and transpupillary thermotherapy (TTT) have been advocated as a means of stabilizing vision, where stable is defined as vision that is unchanged as opposed to a modest reduction in the rate of vision loss. A therapy that purports to stabilize vision requires large numbers of patients in a randomized trial with long-term follow-up to prove stabilization.

Subfoveal CNVMs do not result in a loss of ambulatory vision if untreated. The natural history of subfoveal CNVMs never results in total blindness, while this outcome is all too frequent with macular translocation and occasionally with submacular surgery.

Pathophysiology

CNVMs may be thought of as the initial phase of a choroidal scar. Because these structures angiographically demonstrate a network of vessels, they are often referred to as "nets." The early phase of these lesions is termed exudative, while the later phase is termed cicatricial. Increased permeability of new vessels to fluorescein and indocyanine green (ICG) creates the familiar angiographic appearance referred to as leakage.

Vascular endothelial growth factor (VEGF) is present during the neovascularization phase. Because the scars are often circular in nature, they are called disciform scars when they enter the cicatricial phase. CNVMs, like all scarring disorders, seem to be a repair process with tissue loss or damage initiating the repair activity. The cause of tissue destruction in AMD is probably apoptosis, programmed cellular death. POHS, trauma, laser therapy, and angioid streaks all have in common a defect in the retinal pigment epithelium (RPE) and/or choriocapillaris. Localized hypoxia related to increasing hydrophobic properties of the Bruch membrane may play a significant role.

Frequency

United States

The overall prevalence of neovascular AMD in people older than 40 years is estimated to be 1.47%.

Mortality/Morbidity

CNVMs and most related diseases are not characterized by increased mortality rates. Smoking increases the progression rate of AMD by 350-500%, and, of course, smoking dramatically increases cancer and cardiovascular death rates. Morbidity is limited to the loss of central vision; the peripheral vision is always retained in cases of CNVMs unless complications of surgical therapy occur.

Race

The incidence rate of AMD is less in blacks than in whites (see Age).

  • Blue eyes are twice as likely as dark-colored eyes to develop AMD. AMD is the most frequent cause of CNVMs.
  • Other causes of CNVMs are not associated with differences in racial incidence, except for angioid streaks associated with sickle cell disease and ethnic differences in the incidence of myopia.

Sex

Ocular trauma is more common in men than in women and is a known cause of CNVMs. AMD is more common in women than in men. No known significant sexual predilection exists for other causes of CNVMs.

Age

The prevalence of AMD increases rapidly with age.

  • AMD is more common after age 60 years, with the frequency increasing for patients in their 70s and an even greater frequency for patients in their 80s. The frequency of AMD is 11.90% in white men older than 80 years and 16.39% in white women older than 80 years.
  • Histoplasmosis typically occurs in the 30s or 40s.
  • Angioid streaks occur in individuals aged 30-60 years.
  • Myopic macular degeneration typically occurs after age 25 years.

Clinical

History

  • Patient complaints
    • Decreased central vision
    • Central or paracentral, relative or absolute scotomas
    • Distortion (metamorphopsia)
    • Central light flashes or flickering
    • Impaired color vision
    • Prolonged recovery from light stress

Physical

Perform an examination using a slit lamp biomicroscopy and a fundus contact lens or 60-, 78-, or 90-diopter (D) lens. Fluorescein angiography (FA) is required in virtually all cases. ICG angiography is useful in approximately 5-10% of cases. Optical coherence tomography (OCT) has become an essential part in the assessment of these patients.

  • Clinical findings
    • Grey or ill-defined CNVMs can be subfoveal, juxtafoveal, extrafoveal, peripapillary, or even in the periphery. Experienced observers often visualize these lesions without angiography, although angiography is necessary in virtually all instances.
    • Subretinal hemorrhage is common and frequently outlines the CNVM. In some cases, very large choroidal hemorrhages occur that can be mistaken for malignant melanomas of the choroid.
    • Exudate, serous fluid, or both are often present with choroidal neovascularization (CNV). Angiographically well-defined membranes are referred to as classic. In many cases, the neovascular membrane is ill-defined and is termed occult. Large amounts of subretinal blood, fluid, or exudate may prevent clinical or angiographic visualization of the underlying CNVM.

Causes

AMD, POHS, myopia, trauma, angioid streaks, certain hereditary macular degenerations, and other causes of macular RPE damage have been associated with CNVM formation. Many cases are idiopathic.

More on Neovascular Membranes, Subretinal

Overview: Neovascular Membranes, Subretinal
Differential Diagnoses & Workup: Neovascular Membranes, Subretinal
Treatment & Medication: Neovascular Membranes, Subretinal
Follow-up: Neovascular Membranes, Subretinal
References
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Further Reading

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Keywords

choroidal neovascular membrane, CNVM, choroidal neovascularization, CNV, subretinal neovascular membrane, SRNVM, nets membranes, exudative macular degeneration, wet macular degeneration

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Contributor Information and Disclosures

Author

Steve Charles, MD, Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine
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

Medical Editor

Vytautas A Pakainis, MD, Chief of Ophthalmology, Dorn Veterans Administration Medical Center, Professor of Ophthalmology, Ophthalmology, University of South Carolina School of Medicine
Vytautas A Pakainis, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and South Carolina Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Steve Charles, MD, Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine
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

CME Editor

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.

 
 
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