Surgical Ablation of Retinal Angiomatous Proliferation

Abstract

A ge-related macular degeneration (AMD) remains the leading cause of visual loss in adults older than 65 years. Retinal angiomatous proliferation (RAP) is a newly recognized manifestation of exudative AMD that has a poor natural history and demonstrated resistance to treatment with conventional laser photocoagulation. A novel surgical technique has been developed in this pilot series that shows promise in the treatment of this subtype of neovascular lesions. Through specific surgical lysis of the feeding arteriole and draining venule of an RAP lesion, improvement in visual acuity has been noted. This has been correlated with resolution of intraretinal edema and flattening of associated pigment epithelial detachment, which was confirmed by fluorescein angiography, optical coherence tomography, and high-speed indocyanine green angiography.Arch Ophthalmol. 2003;121:558-561 Retinal angiomatous proliferation (RAP) has recently been described in a subset of patients with exudative age-related macular degeneration (AMD). 1 In RAP, the neovascular process originates from the retinal vasculature as opposed to the underlying choriocapillaris, as is seen with typical choroidal neovascularization. On clinical examination, the presence of intraretinal or preretinal hemorrhages associated with retinal vessels that abruptly curve toward the choroid is consistent with RAP. Cystoid macular edema, lipid exudates, and pigment epithelial detachment (PED) may be present.A classification system has been reported to further subdivide these lesions. Briefly, RAP stage 1 involves the proliferation of abnormal vessels in the intraretinal space, akin to the intraretinal microvascular abnormalities seen in diabetes mellitus. This intraretinal neovascularization often demonstrates retinal-retinal anastomoses and may continue to proliferate and leak. Stage 2 is defined by the presence of intraretinal edema and may be associated with serous PED and/or sub-retinal neovascularization. In stage 3, retinochoroidal anastomoses are present; associated fibrovascular PED is a late finding and is also seen in RAP stage 3. On fluorescein angiography, RAP appears as purely occult or minimally classic choroidal neovascularization. Standard indocyanine green (ICG) angiography reveals a hot spot in late frames. High-speed ICG angiography allows an accurate identification of the RAP lesion, retinal feeding arterioles, draining venules, and associated retinalretinal or retinochoroidal anastomoses. 1 Unfortunately, patients with RAP have poor visual outcomes after treatment with conventional laser photocoagulation. [2][3][4] Affected individuals often demonstrate a subacute decrease in visual acuity over the course of several months. Because of the inefficacy of laser photocoagulation and the poor natural history of RAP, alternative treatment options warrant further investigation. Patients with RAP stage 1 may be asymptomatic and remain undetected. Patients with RAP stage 3 often already have a disciform scar with irreversible overlying photoreceptor dysfun...

Angiographic results of retinal-retinal anastomosis and retinal-choroidal anastomosis after treatments in eyes with retinal angiomatous proliferation

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Angiographic results of retinal-retinal anastomosis and retinal-choroidal anastomosis after treatments in eyes with retinal angiomatous proliferation

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Intravitreal ranibizumab treatment of retinal angiomatous proliferation

“…Retinal angiomatous proliferation has been identified to have a poor prognosis, and therapy appears to be most challenging, as most of the established treatments for exudative AMD have limited success for RAP (Slakter et al 2000;Borrillo et al 2003;Boscia et al 2004Boscia et al , 2005 In our study, we found that at the end of the upload phase all but one eye had stable visual acuity. In eight eyes, visual acuity improved by three or more lines compared to baseline.…”

Global research trends and hotspots in the pathophysiology, imaging and therapy of type 3 macular neovascularization (MNV3) in age-related macular degeneration (AMD)

“…Surgical treatment was one of the earliest approaches. For stage II MNV3, surgical ablation demonstrated short-term efficacy ( 72 ). However, subsequent investigations revealed a 100% recurrence rate within 2–13 months postoperatively ( 73 ).…”

Angiographic results of retinal-retinal anastomosis and retinal-choroidal anastomosis after treatments in eyes with retinal angiomatous proliferation

“……”

Intravitreal ranibizumab treatment of retinal angiomatous proliferation

“…Retinal angiomatous proliferation has been identified to have a poor prognosis, and therapy appears to be most challenging, as most of the established treatments for exudative AMD have limited success for RAP (Slakter et al 2000;Borrillo et al 2003;Boscia et al 2004Boscia et al , 2005 In our study, we found that at the end of the upload phase all but one eye had stable visual acuity. In eight eyes, visual acuity improved by three or more lines compared to baseline.…”

Global research trends and hotspots in the pathophysiology, imaging and therapy of type 3 macular neovascularization (MNV3) in age-related macular degeneration (AMD)

“…Surgical treatment was one of the earliest approaches. For stage II MNV3, surgical ablation demonstrated short-term efficacy ( 72 ). However, subsequent investigations revealed a 100% recurrence rate within 2–13 months postoperatively ( 73 ).…”

Angiographic results of retinal-retinal anastomosis and retinal-choroidal anastomosis after treatments in eyes with retinal angiomatous proliferation

“……”

Intravitreal ranibizumab treatment of retinal angiomatous proliferation

“…Retinal angiomatous proliferation has been identified to have a poor prognosis, and therapy appears to be most challenging, as most of the established treatments for exudative AMD have limited success for RAP (Slakter et al 2000;Borrillo et al 2003;Boscia et al 2004Boscia et al , 2005 In our study, we found that at the end of the upload phase all but one eye had stable visual acuity. In eight eyes, visual acuity improved by three or more lines compared to baseline.…”

Global research trends and hotspots in the pathophysiology, imaging and therapy of type 3 macular neovascularization (MNV3) in age-related macular degeneration (AMD)

“…Surgical treatment was one of the earliest approaches. For stage II MNV3, surgical ablation demonstrated short-term efficacy ( 72 ). However, subsequent investigations revealed a 100% recurrence rate within 2–13 months postoperatively ( 73 ).…”