EXPERTS DEBATE RETINAL SURGERY

Two vitreoretinal surgeons debated the role of surgery in the treatment of age-related macular degeneration (AMD) during the Amsterdam Retina Debate at the 14th EURETINA Congress in London.

Dr Marco Mura MD, University of Amsterdam, The Netherlands, made the case for operating as a last resort in patients with severe visual loss due to AMD. Dr Frank Holz MD, University of Bonn, Germany, presented the case against surgery.

“I agree with you, Dr Holz, that surgery has a limited role in AMD. Surgery can be complex. The results are variable and centre-dependent. Further, it is a great burden for a large component of the target population,” said Dr Mura.

“But I believe it remains an option for a select group of patients,” he said, admitting that most trials show that surgery does not improve upon the natural history, and that anti-VEGF treatment has changed the landscape forever in favour of a pharmacological approach.

“Why bother to defend surgery?” asked Dr Mura. “What if anti-VEGF doesn’t work? What if this is an active and healthy patient’s only eye?” he asked.

“Clearly, there are obvious indications for surgery, such as submacular haemorrhages, RPE rips and non-response to medical treatment.

“In the case of a massive submacular haemorrhage, the natural history has a very poor prognosis,” said Dr Mura.

“Surgery is really the only option, and it works quite well. Submacular rTPA improves the prognosis in 68 per cent of patients as compared to no treatment.”

Referring to published studies on surgery for AMD, as well as a retrospective analysis of different surgical techniques he and his team recently submitted to the BJO, Dr Mura outlined his standard protocol for the treatment of submacular haemorrhages, which included subretinal rTPA injection; subretinal blood removal with the placement of an RPE-choroid patch; and subretinal blood removal followed by macular translocation.

Dr Mura then showed several compelling videos of his procedures, restoring useful vision to otherwise hopeless patients, primarily in those who had long since lost vision in one eye and had recently suffered a dramatic decrease in visual acuity in the other.

“I have patients who are desperate for an operation, having grown tired of monthly anti-VEGF with no visual improvement. These are the patients
that we should focus on,” concluded
Dr Mura.

Dr Holz began his argument by stating that the rare patient might experience some improvement in visual acuity, but he added that this is science, not storytelling. “We need numbers, we need proof and we need studies to support the case for surgery,” said Dr Holz.

He referred to a Cochrane meta-analysis, which indicated insufficient evidence for macular translocation surgery.

“Complications permanently impairing functional outcome occur with relatively high frequency after complex surgical interventions such as RPE-choroid patch translocations. These include patch fibrosis and PVR-induced retinal detachment. Stable VA maintenance is possible in some cases, but the majority lose vision over four-seven years.

“We have learned so much about the biology of the disease, and have thus developed effective, pathway-targeted interventions,” concluded Dr Holz.

“The best approach to improve care for our patients is to follow the biology,” he said, quoting a review article by Dr Joan W Miller.

Dr Holz proceeded to outline the highly complex nature of the disease, including choroidal neovascularizations, highlighting genetics, complement pathways, and multiple cytokines involved including VEGF and PDGF.

He admitted that there were unmet needs in AMD, such as dry AMD, RPE tears, subretinal haemorrhages and long-term treatment with anti-VEGF.

He described what he envisioned as being the future role of so-called “minor” surgery in innovative AMD treatments. These included delivery of long-acting drugs; stem cell therapy; and subretinal gene therapy.

“But the focus remains squarely on pharmacotherapy for the disease. In a recent 20-chapter book on AMD, only one was devoted to surgical therapy,” he noted.

Frank Holz: Frank.Holz@ukb.uni-bonn.de

Marco Mura: drmmura@yahoo.com