Get access

Submacular surgery for choroidal neovascularisation secondary to age-related macular degeneration

  • Review
  • Intervention

Authors


Abstract

Background

Vitreoretinal surgeons proposed submacular surgery to remove the fibrovascular tissue causing damage to the centre of the retina, in the attempt to limit central visual loss in people affected by neovascular age-related macular degeneration (AMD).

Objectives

This review aims at assessing the effectiveness of submacular surgery for preserving or improving vision in patients with AMD.

Search methods

We searched CENTRAL, MEDLINE, EMBASE and LILACS. There were no language or date restrictions in the search for trials. The electronic databases were last searched on 11 February 2009.

Selection criteria

We included randomised or quasi-randomised controlled trials comparing submacular surgery with any other treatment or observation.

Data collection and analysis

Two authors independently extracted the data. The risk ratio (RR) of visual loss and visual gain was estimated at one year.

Main results

Two multicentre studies with a similar design were conducted between 1997 and 2003 and compared submacular surgery with observation in people affected by subfoveal neovascular AMD with (n=336) or without (n=454) extensive blood in the macula. At one year there was high quality evidence of no benefit for preventing visual loss (RR: 0.96; 95% confidence interval (CI): 0.84 to 1.09). No difference could be demonstrated regarding the chance of visual gain (RR: 1.06; 95% CI: 0.75 to 1.51), although this evidence was of low quality because of imprecision. The risk difference was -2% (95% CI: -10% to 5%) and 1% (95% CI: -4% to 6%) for visual loss and visual gain, respectively, thus excluding a large benefit with surgery in terms of absolute risk in this sample. There was high quality evidence that cataract needing surgery (RR: 8.69; 95% CI: 4.06 to 18.61) and retinal detachment (RR: 6.13; 95% CI: 2.81 to 13.38) were more common among operated patients, and detachment occurred in 5% of patients with no extensive blood and in 18% of those with extensive blood beneath the macula.

A pilot study compared submacular surgery with laser photocoagulation in 70 patients. No difference between the two treatments could be demonstrated for any outcome measure, but estimates were very imprecise because of small sample size.

Authors' conclusions

There is no benefit with submacular surgery in most people with subfoveal choroidal neovascularisation due to AMD in terms of prevention of visual loss. Furthermore, the risk of developing cataract and retinal detachment increases after surgery.

摘要

背景

視網膜(黃斑)下手術治療年齡相關性黃斑部病變所引發之脈絡膜新生血管

視網膜科醫師藉由視網膜(黃斑)下手術,移除傷害視網膜中央的纖維血管組織,以遏止新生血管型年齡相關性黃斑部病變所造成的中央視力喪失。

目標

本篇旨在評估視網膜(黃斑)下手術對於保存或增進年齡相關性黃斑部病變患者視力的療效。

搜尋策略

我們搜尋了CENTRAL, MEDLINE, EMBASE and LILACS 等資料庫的相關文獻。在臨床試驗部份,搜尋不拘任何語言或時間。電子資料庫的搜尋更新至2009/2/11。

選擇標準

我們納入了比較視網膜(黃斑)下手術與任何其他治療或保守觀察的隨機分派或准隨機分派臨床試驗。

資料收集與分析

由兩位作者個別獨立分析資料。以一年為期限來評估視力喪失或視力回復的風險比例。

主要結論

1997年至2003年有兩個設計類似的跨院研究,對於年齡相關性黃斑部病變合併大量黃斑部出血(n = 336)或無黃斑部出血(n = 454)的病患,比較視網膜(黃斑)下手術或保守觀察倆者的差異。在一年期的研究,可信度極高的證據顯示手術對於預防視力惡化並無幫助(風險比例 0.96;95%,信賴區間:0.84∼ 1.09)。關於促進視力的機會,雖然證據可性度不高,但手術與觀察兩者之間並無差異(風險比例 1.06;95%,信賴區間:0.75∼ 1.51)。關於視力喪失兩者的風險差異是−2%(95%信賴區間:−10%∼ 5%);關於視力回復兩者的風險差異則是1% (95%信賴區間:−4%∼ 6%);手術在這個樣本中反而是個危險因子而非助益。可信度極高的證據顯示接受手術的病患有較高的比例發生需手術的白內障(風險比例 8.69;95%信賴區間:4.06∼ 18.61)及視網膜剝離(風險比例 6.13;95%信賴區間:2.81∼ 13.38);此外視網膜剝離在無黃斑部出血的病患佔了5%,在合併大量黃斑部出血的患者則佔了18%。另外有一個包含了70位患者的前導性研究比較了視網膜下手術與雷射光凝治療。雖然樣本數較小,證據力不足,但結果顯示兩者對於任何視力結果並無差異。

作者結論

對於預防黃斑下新生血管性年齡相關性黃斑部病變患者的視力喪失,視網膜下手術並無任何助益,反而增加白內障與視網膜剝離的發生機率。

翻譯人

本摘要由高雄榮民總醫院畢勇賢翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

新生血管性年齡相關性(或濕性)黃斑部病變肇因於中央視網膜(黃斑部)下異常的新生血管層。此病會造成中央視野的盲點,是西方國家造成老人法定眼盲最常見的原因。原藉由視網膜下手術移除致病的新生血管組織,希望能夠遏止視力惡化,或甚至促進視力進步。然而,根據我們發現的兩個大型跨院研究結果,在790名年齡相關性黃斑部病變患者,不論有無合併黃斑部大量出血,手術皆無法預防視力喪失。此外,白內障或視網膜剝離等併發症可在術後伴隨發生。

Plain language summary

Surgical removal of choroidal neovascularisation in patients with neovascular age-related macular degeneration

Neovascular or wet age-related macular degeneration (AMD) is caused by blood vessels growing as a layer of tissue under the central retina (the macula). The disease leads to the development of a blind spot in the centre of the visual field and is the most common cause of legal blindness among the elderly in the western world. Surgery has been used to remove tissue lying beneath the macula, within which grow the small, new blood vessels which are the cause of wet AMD. It was hoped that removal of this tissue might limit the development of AMD, and perhaps even improve vision. 

We found two large multicentre studies conducted in 790 people affected by choroidal neovascularisation, with or without extensive blood beneath the macula. The results of these studies suggested that visual loss cannot be prevented using surgery. In addition, complications such as cataract and retinal detachment can arise during follow-up, in patients who have the procedure.