Photodynamic therapy in the treatment of subfoveal choroidal neovascularisation

Subfoveal choroidal neovascularisation (CNV) is a major cause of visual disability, with age-related macular degeneration (AMD) the commonest cause. Confluent laser to CNV significantly reduces severe visual loss but the profound visual loss after treatment of subfoveal lesions and the high recurrence rate has meant its restriction to extrafoveal lesions. Developed initially as a treatment for cancers, photodynamic therapy (PDT) has been shown to successfully close CNV in the eye. Large international randomised placebo-controlled studies of the safety and efficacy of PDT with verteporfin are under way. The Treatment of Age-related Macular Degeneration with Photodynamic Therapy (TAP) study has demonstrated a reduction of visual loss in treated patients with any classic CNV. Subgroup analysis showed a greater benefit in predominantly classic lesions (p < 0.001, NNT: 3.6), increasing further for lesions with no occult component, roughly equivalent to pure classic (p < 0.01, NNT: 2.2) A significant benefit at 12 months has been shown in patients with CNV secondary to myopia in the Verteporfin in AMD (VIP) trial, but no benefit in pure occult lesions. Further research is required to establish cost-effectiveness and appropriate referral patterns in the UK and optimise treatment strategies. Further data are awaited from TAP/VIP. At present verteporfin PDT is indicated in eyes with subfoveal predominantly classic CNV secondary to AMD with visual acuity of 6/60 or better and lesions < 5,400 microm in diameter. Juxtafoveal lesions meeting the above criteria and CNV secondary to pathological myopia should also be considered for treatment. The efficacy of treatment of larger lesions, juxtapapillary CNV, occult/no classic with high-risk characteristics (HRC) and CNV from other causes remains unclear. The treatment of minimally classic lesions and those with occult/no classic without HRC is not indicated.