The Trouble With Photodynamic Therapy

To examine the role of photodynamic therapy (PDT) in the treatment of retinal disease and the obstacles to use in the United States for evidence-based indications.

Perspective essay.

This article includes a historical summary, example case report, and relevant literature review.

PDT has been approved by the US Food and Drug Administration for use in neovascular age-related macular degeneration (AMD), but has been superseded by anti-vascular endothelial growth factor drugs and is rarely used for this indication. It is regularly used in polypoidal choroidal vasculopathy (PCV) without reimbursement difficulty because PCV is acknowledged to be a form of AMD. It is effective for serous retinal detachment associated with choroidal hemangioma. Because this is a rare indication, insurers generally authorize its use. It is the most effective treatment for chronic central serous retinopathy (CSR), a relatively common indication; however, authorization from insurers is difficult to obtain, leading to avoidable loss of vision because patients often will not or cannot pay chargemaster prices. Many retina specialists eschew PDT because the expense in time and the laser does not balance the difficulties with reimbursement and the comparative advantage of allocating their time in other ways.

In the United States, finding a retina specialist who performs PDT is challenging for patients with diseases for which it is indicated. Obtaining coverage for CSR is difficult for retina specialists treating patients with CSR in the United States, but not internationally. As a result, delayed or no treatment for cases indicated leads to avoidable loss of vision. A suggested solution is that insurers agree to cover PDT for chronic CSR at a rate equal to 1.3 times Medicare reimbursement for neovascular AMD.