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Rapid Responses: Rapid Responses published:
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Surgery for age related macular degeneration
- David G. Charteris, David Wong, Lyndon da Cruz (25 March 2003)
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Smoking and risk of Age Related Maculopathy.
- Simon P Kelly, Richard Edwards, Peter Elton, Paul Mitchell. (1 April 2003)
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Re: Surgery for age related macular degeneration
- Amresh Chopdar, Usha Chakravethy, Dinesh Verma (2 April 2003)
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Re: Smoking and risk of Age Related Maculopathy.
- Amresh Chopdar, Usha Chakraverthy, Dinesh Verma (2 April 2003)
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David G. Charteris, Consultant Ophthalmic Surgeon Moorfields Eye Hospital, City Road, London EC1V 2PD, David Wong, Lyndon da Cruz
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Dear Editor We read the clinical review on age related macular degeneration (AMD) with interest.(1) The authors are congratulated for giving a succinct and comprehensive review of the subject. They used Medline for literature search but appeared to have neglected over 75 publications on macular relocation surgery for age related and myopic macular degeneration. The authors concluded “…no current treatment will restore vision that has already been lost”. The excitement over macular relocation is precisely because it is capable of improving vision in some patients despite moderate and severe visual loss.(2,3) Lai et al reported that at 6 months, the reading vision was significant improved from 0.54 to 0.40 LogMAR units in a consecutive series of 15 patients[ p=0.02](4). In a consecutive series of 90 patients, the Cologne group found that 12 months after surgery, one third improved (by 3 or more lines of distance visual acuity), one third stabilised and one third deteriorated.(5) Pertile and Claes recently reported that in a consecutive series of 50 cases with a median follow-up of 21 months 66% improved (2 or more lines), 28% remained stable (± 1 line) and only 6% deteriorated (2 or more lines).(6) Macular relocation surgery is complex and prone to complications including proliferative vitreoretinopathy (PVR).(7) As experience of this surgery increases it appears however that the complication rate (and surgical time) is falling and that the success rate is rising.(8) Recent work showing that adjuvant treatments can be used to prevent PVR have also given rise to optimism.(9) Moreover, macular relocation surgery has the potential to treat geographic atrophy (dry AMD) and advanced disease (including subfoveal haemorrhage) which will not be amenable to any anti- angiogenic strategy. An international prospective randomised controlled trial (MARAN )(a) is underway for patients with occult subfoveal choroidal neovascular membrane funded by the Deutsche Forschungsgemeinschaft (the German medical research council). Other non-comparative pilots studies are being undertaken to identify which subgroups of patients who are most likely to benefit from macular relocation surgery and to assist in the planning of other prospective randomised trials. Whilst semiconductor chip technology and the “electronic eye” have captured the imagination of public, in truth the “bionic eye” is perhaps much further away from benefiting patients than macular relocation surgery. David Wong (b) , David Charteris (c) , Lyndon da Cruz (c) (a) Macular Relocation for Age Related Neovascular disease (b) St Paul's Eye Unit, Royal Liverpool University Hospital (c) Moorfields Eye Hospital References 1. Chopdar A, Chakravarthy U, Verma D. Age related macular degeneration. BMJ 2003;326(7387):485-8. 2. Cekic O, Ohji M, Hayashi A, Fujikado T, Tano Y. Foveal translocation surgery in age-related macular degeneration. Lancet 1999;354(9175):340. 3. Wong D, Harding S, Grierson I. Foveal translocation with secondary confluent laser for subfoveal CNV in AMD: 12 month follow up. Br J Ophthalmol 2000;84(6):670-1. 4. Lai JC, Lapolice DJ, Stinnett SS, Meyer CH, Arieu LM Keller MA, Toth CA Visual outcomes following macular translocation with 360-degree peripheral retinectomy. Arch Ophthalmol 2002; 120: 1317-24. 5. Aisenbrey S, Lafaut BA, Szurman P, Grisanti S, Luke C, Krott R, Thumann G, Fricke J, Neugebauer A, Hilgers RD, Esser P, Walter P, Bartz-Schmidt KU. Macular translocation with 360 degrees retinotomy for exudative age- related macular degeneration. Arch Ophthalmol 2002;120(4):451-9. 6. Pertile G, Claes C. Macular translocation with 360 degree retinotomy for management of age-related macular degeneration with subfoveal choroidal neovascularization. Am J Ophthalmol 2002;134(4):560. 7. Eckardt C, Eckardt U, Conrad HG. Macular rotation with and without counter-rotation of the globe in patients with age-related macular degeneration. Graefes Arch Clin Exp Ophthalmol 1999;237(4):313-25. 8. Toth CA, Freedman SF. Macular translocation with 360-degree peripheral retinectomy impact of technique and surgical experience on visual outcomes. Retina 2001;21(4):293-303. 9. Asaria RH, Kon CH, Bunce C, Charteris DG, Wong D, Khaw PT, GW Aylward Adjuvant 5-fluorouracil and heparin prevents proliferative vitreoretinopathy : Results from a randomized, double-blind, controlled clinical trial. Ophthalmology 2001;108(7):1179-83. Competing interests: None declared |
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Simon P Kelly, Consultant Ophthalmic Surgeon. Bolton Hospitals NHS Trust., Richard Edwards, Peter Elton, Paul Mitchell.
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Dear Editor. The review of age-related macular degeneration (AMD) by Chopdar and co-authors was timely(ref 1). However they did not draw attention to the association of current smoking with AMD. Three large, well executed, population based, cross sectional studies examined AMD risk factors in Australia, Europe and North America. The pooled results for 12,468 subjects studied therein strongly suggest an association between current smoking and AMD(ref2). For all types of AMD, an odds ratio of 3.12 (95% CI 2.10-4.64) was observed when current smokers were compared with subjects who had never smoked. In addition, subjects who had stopped smoking had a slightly increased risk of AMD compared with those who had never smoked: odds ratio 1.36 (95% CI 0.97-1.90). The association was maintained when atrophic AMD and neovascular AMD were evaluated separately, odds ratios of 2.54 (95% CI 1.25-5.17) and 4.55 (95% CI 2.74 -7.54), respectively, and when current smokers were compared with never smokers. Longer follow up further confirms the link between smoking and AMD (ref 3- 4). The Australian Blue Mountains Eye Study showed that smokers developed late AMD ten years earlier than non-smokers.(ref 4) Because of this smoking was estimated to cause or contribute to up to 20% of blindness in persons aged over 50. The author’s prevention and treatment section focused largely on high -technology therapeutic interventions. Despite the strong association between smoking and AMD, there was no mention of the important role of smoking cessation in prevention. It seems to us that those concerned with eye health are not giving enough weight to smoking cessation and those concerned with tobacco control and smoking cessation are not giving enough weight to eye health(ref 5). Many of the general population and many patients attending eye services recognise the systemic adverse effects of smoking. In our experience they are largely unaware of the link with eye disease. However, when warned of the increased risk, they are often keen to stop smoking and frequently do so. Older smokers and their doctors often struggle to find compelling reasons why they should give up smoking late in life – risk of sudden death from heart attack or stroke may be less persuasive than the loss of independence caused by blindness. Appropriate smoking cessation support should be offered. The ocular hazards of smoking should be highlighted further. In Australia, national co-ordinated efforts on network television to raise the public awareness of smoking as a cause of blindness have been encouraging. Simon P Kelly.
Richard Edwards.
Peter Elton.
Paul Mitchell.
REFERENCES. 1 Chopdar A, Chakravarthy U, Verma D. Age related macular degeneration. BMJ 2003; 326: 485-8 2 Smith W, Assink J, Klein R, Mitchell P, Klaver CCW, Klein BEK, et al. Risk factors for age-related macular degeneration. Pooled findings from three continents. Ophthalmology 2001; 108: 697-704. 3 Klein R, Klein BEK, Tomany SC, Moss SE. Ten-year incidence of age- related maculopathy and smoking and drinking. The Beaver Dam Eye Study. Am J Epidemiol 2002; 156: 589-98. 4 Mitchell P, Wang JJ, Smith W, Leeder SR. Smoking and the 5-year incidence of age-related maculopathy: the Blue Mountains Eye Study. Arch Ophthalmol 2002; 120: 1357-63. 5 Mitchell P, Chapman S, Smith W. "Smoking is a major cause of blindness": a new cigarette pack warning? (editorial) Med J Aust 1999; 171:173-4. Competing interests: None declared |
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Amresh Chopdar, Consultant Ophthalmologist East Surrey Hospital, Redhill, RH1 5RH, Usha Chakravethy, Dinesh Verma
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Dear sir We fully agree with the analyses of present status of Surgery for age related macular degeneration by Charteris et al. Our paper was primarily aimed at general physicians and we did not want to send confusing messages with lots of highly specialised evolving treatment those are not yet available widely. We have tried to send a positive message to a wider audience to draw their attention to a growing problem. A. Chopdar, U. Chakraverthy, D. Verma Competing interests: None declared |
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Amresh Chopdar, Consultant Ophtalmologist East Surrey Hospital, Redhill, RH1 5RH, Usha Chakraverthy, Dinesh Verma
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Dear Sir We recognise that smoking is a risk factor for agerelated macular degeneration. We clearly advocate cessation of smoking as outlined in page 487 of our article.[1] 1. Chopdar A, Chakraverthy U, Verma D; BMJ 2003;326:485-8 Competing interests: None declared |
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