Incidence of Macular Atrophy after Untreated Neovascular Age-Related Macular Degeneration: Age-Related Eye Disease Study Report 40.

PURPOSE: To report the natural history of untreated neovascular age-related macular degeneration (nAMD) regarding subsequent macular atrophy. DESIGN: Prospective cohort within a randomized, controlled trial of oral micronutrient supplements. PARTICIPANTS: Age-Related Eye Disease Study (AREDS) participants (55-80 years) who demonstrated nAMD during follow-up (1992-2005), prior to anti-vascular endothelial growth factor (VEGF) therapy. METHODS: Color fundus photographs were collected at annual study visits and graded centrally for late age-related macular degeneration (AMD). Incident macular atrophy after nAMD was examined by Kaplan-Meier analysis and proportional hazards regression. MAIN OUTCOME MEASURES: Incident macular atrophy after nAMD. RESULTS: Of the 4757 AREDS participants, 708 eyes (627 participants) demonstrated nAMD during follow-up and were eligible. The cumulative risks of incident macular atrophy after untreated nAMD were 9.6% (standard error, 1.2%), 31.4% (standard error, 2.2%), 43.1% (standard error, 2.6%), and 61.5% (standard error, 4.3%) at 2, 5, 7, and 10 years, respectively. This corresponded to a linear risk of 6.5% per year. The cumulative risk of central involvement was 30.4% (standard error, 3.2%), 43.4% (standard error, 3.8%), and 57.0% (standard error, 4.8%) at first appearance of atrophy, 2 years, and 5 years, respectively. Geographic atrophy (GA) in the fellow eye was associated with increased risk of macular atrophy (hazard ratio [HR], 1.70; 95% confidence interval [CI], 1.17-2.49; P = 0.006). However, higher 52-single nucleotide polymorphism AMD genetic risk score was not associated with increased risk of macular atrophy (HR, 1.03; 95% CI, 0.90-1.17; P = 0.67). Similarly, no significant differences were observed according to SNPs at CFH, ARMS2, or C3. CONCLUSIONS: The rate of incident macular atrophy after untreated nAMD is relatively high, increasing linearly over time and affecting half of eyes by 8 years. Hence, factors other than anti-VEGF therapy are involved in atrophy development, including natural progression to GA. Comparison with studies of treated nAMD suggests it may not be necessary to invoke a large effect of anti-VEGF therapy on inciting macular atrophy, although a contribution remains possible. Central involvement is present in one third of eyes at the outset (similar to pure GA) and increases linearly to half at 3 years.

AMD--the retinal disease with an unprecised etiopathogenesis: in search of effective therapeutics.

AMD (age-related macular degeneration) is a progressive vision-threatening ocular disease, affecting central region of the retina--the macula--and manifesting in the elderly. AMD is a degenerative disease, and the degeneration affects primarily the retinal pigment epithelial (RPE) cells and secondarily the photoreceptors, leading consequently to disturbances or partial loss of central vision and legal blindness. Clinically, the disease is classified as: atrophic--dry AMD (in majority of cases), and neovascular--wet AMD (with choroidal neovascularization--CNV: 10-15% of all AMD cases). Pathogenesis of AMD is complex, multifactorial and only poorly recognized. Main risk factors include: advanced age, genetic predispositions, environmental determinants, history of exposure to intensive light and smoking. At least four molecular processes contribute to the development of AMD pathology: lipofuscinogenesis, drusogenesis, inflammation and choroidal neovascularization (in wet AMD). Since vascular endothelial growth factor (VEGF) is a predominant proangiogenic factor in CNV. the wet AMD can be treated with intravitreous application of "anti-VEGF" agents (Avastin, Lucentis, Eylea). Till now, there is no approved therapy for dry AMD, although several agents/treatments are currently in clinical trials. This paper briefly describes major molecular and cellular events leading to AMD, and presents currently used and new experimental therapeutic strategies against AMD.

A prospective study on different methods for the treatment of choroidal neovascularization. The efficacy of verteporfin photodynamic therapy, intravitreal bevacizumab and transpupillary thermotherapy in patients with neovascular age-related macular degeneration.

BACKGROUND: The aim of this study was to compare the efficacy of verteporfin photodynamic therapy (PDT), intravitreal injections of bevacizumab (IVB) and transpupillary thermotherapy (TTT) in patients with neovascular age-related macular degeneration (AMD). MATERIAL/METHODS: The study design was a prospective, interventional, comparative case series. Between December 2006 and March 2009, 426 eyes of 426 consecutive patients presenting with neovascular AMD were included into the study. Patients presented with subfoveal CNV predominantly classic, minimally classic, and occult with no classic component; lesion size less than 5000 µm in the greatest linear dimension, and the area of hemorrhages ≤1/3 were randomized to receive either PDT (group I) or IVB (group II) in a 1:1 ratio. Other patients with CNV were included into the group III and received TTT. RESULTS: One hundred eyes were treated with PDT. Mean baseline logMAR BCVA was 0.62 and final visual acuity decreased to 0.74 (p<0.05, Wilcoxon test); 104 eyes were treated with IVB. Mean baseline BCVA was 0.82 and final visual acuity increased to 0.79 (p>0.05, Wilcoxon test); 222 patients were treated with TTT. Mean baseline BCVA was 1.10 and final visual acuity decreased to 1.15 (p>0.05, Wilcoxon test). Among all eyes the average number of treatment sessions was 2.34 (SD 1.17). CONCLUSIONS: Our study shows that IVB injections had the best efficacy in the improvement of final BCVA. However, both IVB and TTT demonstrated good stabilization of vision. Although after PDT final BCVA was significantly worse from baseline, it may also be beneficial for some patients with neovascular age-related macular degeneration.

[Efficacy of intravitreal injections of ranibizumab compared to visudyne phototherapy in myopic choroidal neovascularization associated with high myopia]. / Comparaison du traitement par injections intravitréennes de ranibizumab à la photothérapie dynamique dans la néovascularisation choroïdienne compliquant la myopie forte.

INTRODUCTION: Myopic choroidal neovascularization (CNV) is the first cause of CNV in young patients. The aim of this study was to compare the efficacy of intravitreal injections (IVT) of ranibizumab with photodynamic therapy (PDT) in this indication. PATIENTS AND METHODS: Retrospective comparative study analyzing the visual acuity (VA) outcomes of CNV myopic patients treated with either IVT or PDT. RESULTS: Twenty-seven eyes of 25 patients were treated with PDT (group 1) and 18 eyes of 17 patients were treated with IVT of ranibizumab (group 2). Demographic data were similar in the two groups. The median initial VA was 20/80 for group 1 and 20/160 for group 2 (P=0.37). At 1 year, the median VA was 20/80 for group 1 (P=0.32) and 20/63 for group 2 (P=0.04). A significant improvement in VA was observed in 23.1% and in 27.3% of cases in groups 1 and 2, respectively (P=0.53). A significant VA worsening was observed in 34.6% of cases in group 1 and in 9.1% of cases in group 2 (P=0.21). CONCLUSION: IVT of ranibizumab compared to PDT treatment showed greater efficacy in this study.

[Dynamic phototherapy with silicone oil in treating choroidal subfoveal neovascularization in high myopia]. / Photothérapie dynamique sous huile de silicone pour traiter des néovaisseaux choroïdiens du myope fort.

UNLABELLED: We report a case of a high myopic patient, treated with photodynamic therapy for macular neovascularization in the presence of silicon oil. Four months later, the patient's vision was again at 4/40, with no active neovascularization. INTRODUCTION: Retinal detachment and macular neovascularization are common complications in high myopia patients. Sometimes these two conditions occur simultaneously and their treatment can become more problematic. OBSERVATION: We report the case of a high myopia patient treated with photodynamic therapy for subfoveal neovascularization through a vitreous cavity filled with silicone oil. The treatment was successfully completed with no problems. CONCLUSION: Photodynamic therapy can be achieved successfully through a vitreous cavity filled with silicone oil.

[Triple therapy for the treatment of choroidal neovascularization with pigment epithelium detachment in age-related macular degeneration]. / Traitement des décollements de l'épithélium pigmentaire par photothérapie dynamique, IVT de ranibizumab, sous-ténonienne de triamcinolone.

PURPOSE: To investigate the effect of a triple therapy associating subtenon triamcinolone acetonide, intravitreous ranibizumab and photodynamic therapy for treatment of retinal pigment epithelium detachment (RPED) complicating occult choroidal neovascularization in age-related macular degeneration. PATIENTS-METHOD: A prospective clinical trial including 27 patients showing retinal pigment epithelium detachment. We treated these patients with intravitreous ranibizumab injections and subtenon triamcinolone injections as well as a single session of photodynamic therapy at 48 h. At least two more intravitreous ranibizumab injections were added at 1-month intervals. RESULTS: Initial visual acuity was 1.3/10 at 9 months, which was minimal follow-up. Twenty-three patients had total resumption of retinal pigment epithelium detachment on optical coherence tomography imaging after 1 month. One patient had ocular hypertension and needed trabeculectomy, one had a pigment epithelium break but with good functional results. Seven patients needed six intravitreous injections of ranibizumab with partial or total resumption in six cases. DISCUSSION: RPED is a severe complication of choroidal neovascularization in age-related macular degeneration. Untreated, it means a rapid loss of macular function. Often damage is bilateral. Simple intravitreous injection of ranibizumab is not satisfying. An association of photodynamic therapy and intravitreous triamcinolone injections shows good results. We propose a triple treatment for the best possible synergy. Our preliminary results are encouraging. Since we did not want to inject a large volume of Triamcinolone into the vitreous, we chose subtenon injections. CONCLUSION: Treatment of retinal pigment epithelium detachment is difficult. Associating intravitreous injection of ranibizumab, dynamic phototherapy, and subtenon triamcinolone provides good results.

Association of systemic steroids and mycophenolate mofetil as rescue therapy for uveitic choroidal neovascularization unresponsive to the traditional immunosuppressants: interventional case series.

To study the efficacy of systemic steroids (SS) associated with mycophenolate mofetil (MMF) for the control of juxta/sub-foveal uveitic choroidal neovascularization (CNV) unresponsive to the traditional immunosuppressive agents. Patients with juxta/sub-foveal uveitic CNV unresponsive to the traditional immunosuppressive drugs were treated with SS and MMF. The study was designed as a prospective, consecutive, open-label, interventional case series. Visual gain and loss were defined as improving or worsening of two or more lines of best-corrected visual acuity (BCVA), respectively. CNV size outcome was dichotomized as "increased" or "stable/reduced", if increased >200 µm(2), or reduced ≥ 200 µm(2) or not modified by 200 µm(2), respectively. Nine cases (12 eyes) have been considered; ages ranged from 27 to 56 years. The mean follow-up time was 18.2 ± 2.9 months (min: 14 months, max: 23 months). At base-line, the mean BCVA was 0.3 ± 0.17, improving up to 0.57 ± 0.25 and to 0.63 ± 0.22 (P < 0.001, paired t-test) at the 6 and 12-month follow-ups, respectively. At the last follow-up, all the patients had stable/improved BCVA (P < 0.0001, Fisher's exact test) and stable/reduced lesion size (P < 0.0001, Fisher's exact test). None of the patients complained of any severe adverse event during the treatment. The combination of SS and MMF seems to be a promising strategy in order to control uveitic CNVs unresponsive to the traditional immunosuppressive agents. Further studies are needed to validate the data of this case series.

A prospective randomised study on low-dose transpupillary thermotherapy versus photodynamic therapy for neovascular age-related macular degeneration.

AIM: To compare the efficacy of low-dose transpupillary thermotherapy (TTT) and verteporfin photodynamic therapy (PDT) in patients with occult neovascular age-related macular degeneration (AMD). METHODS: Patients were randomised to receive either low-dose TTT (136 mW/mm) (and sham PDT) (n = 52) or PDT (and sham TTT) (n = 46) with retreatment if leakage was documented by fluorescein angiography. At baseline and at every follow-up, best corrected visual acuity (BCVA) was measured with the Early Treatment Diabetic Retinopathy Study (ETDRS) chart, lesion size on fluorescein angiography and foveal thickness with optical coherence tomography. The primary outcome measure was the proportion of patients who lost <15 letters at 12 months' follow-up. Secondary outcome measures included the proportion of patients who gained >/=0 letters, the change in mean lesion size and the change in foveal thickness at 12 months' follow-up. RESULTS: The percent of patients losing fewer than 15 letters at 12 months was 75.0% in the TTT group and 73.9% in the PDT group (p>0.05). The percent of patients with preserved or improved BCVA was 36.5% in the TTT group versus 23.9% in the PDT group (p>0.05). The mean decrease in foveal thickness was 15% for TTT and 24% (p>0.05) for PDT-treated patients, and the mean increase in total lesion area was -0.7% and -1.1% (p>0.05), respectively. CONCLUSION: In this prospective, randomised trial low-dose TTT and PDT appeared to be equally efficient at stabilising visual acuity in patients with occult neovascular AMD. Low-dose TTT may be considered as an alternative to PDT in this set of patients and also as an adjuvant to pharmacotherapy.

Resolution of macular oedema in occult choroidal neovascularization under oral Sorafenib treatment.

PURPOSE: To report on the effect of oral nexavar (Sorafenib) treatment in one patient with neovascular age-related macular degeneration (AMD) and advanced renal cell cancer (RCC). METHODS: After two intravitreal injections of bevacizumab (1.25 mg) for occult choroidal neovascularization (CNV) in AMD, the patient was started on oral Sorafenib (400 mg twice daily) treatment for RCC. RESULTS: Visual acuity (VA) was 20/80 in the left eye and optical coherence tomography (OCT) demonstrated persistent central thickening to 251 microm after bevacizumab. After 6 weeks of oral Sorafenib treatment, VA had increased to 20/70 and a significant decrease in retinal thickness to 208 microm was observed on OCT. The patient remained stable during a further 3 months of follow-up. CONCLUSIONS: Resolution of macular oedema and stabilization of VA under oral treatment with the multikinase inhibitor Sorafenib was observed. This observation warrants further investigation.

Ranibizumab for the treatment of neovascular age-related macular degeneration: a review.

BACKGROUND: Choroidal neovascular (wet) age-related macular degeneration (ARMD) is becoming more prevalent worldwide as life expectancy continues to increase. Ranibizumab for intravitreal injection is an inhibitor of human vascular endothelial growth factor A approved by the US Food and Drug Administration for the treatment of ARMD in June 2006. The actions of ranibizumab result in reduced cell proliferation, reduced formation of new blood vessels, and minimization of vascular leakage. OBJECTIVE: This paper reviews the pharmacologic and pharmacokinetic properties, clinical efficacy, and safety profile of ranibizumab, and pharmacoeconomic considerations associated with its use. METHODS: MEDLINE (1966-December 2006) and International Pharmaceutical Abstracts (1970-December 2007) were searched for original research studies (Phase I, II, III, and IIIb), abstracts, and review articles concerning ranibizumab. The search terms were choroidal neovascularization, macular degeneration, Lucentis, ranibizumab, retinal degeneration, and vascular endothelial growth factor. Preference was given to Phase IlfllI studies. Selected information from the manufacturer of ranibizumab was also included. RESULTS: The efficacy of ranibizumab has been studied in 3 large clinical trials having the same primary efficacy end point, the proportion of patients losing <15 letters from baseline at 12 months (Early Treatment of Diabetic Retinopathy Study chart). A multicenter, Phase III, randomized, double-blind, sham-controlled, 24-month clinical trial evaluated ranibizumab 0.3 and 0.5 mg in 716 patients with minimally classic or occult choroidal neovascularization (CNV) associated with ARMD. The results for the primary efficacy end point were 94.5% and 94.6% in the ranibizumab 0.3- and 0.5-mg groups, respectively, compared with 62.2% in the sham-injection group (P < 0.001, both ranibizumab groups vs sham injection); at 24 months, the corresponding proportions were 92.0%, 90.0%, and 52.9% (P < 0.001, both ranibizumab groups vs sham injection). A 2-year, Phase I/II, single-masked (masked patient and visual acuity examiner, unmasked investigator), multicenter trial evaluated the tolerability and efficacy of the combination of ranibizumab 0.5 mg and verteporfin photodynamic therapy (PDT) compared with verteporfin PDT alone in 162 patients with predominantly classic CNV. For the primary efficacy end point, the results were 90.5% for ranibizumab + PDT and 67.9% for PDT alone (P < 0.001). Receipt of ranibizumab + PDT was also associated with improved visual acuity, with 23.8% of patients gaining >15 letters from baseline, compared with 5.4% of those who received PDT alone (P = 0.003). Finally, an international Phase III, double-blind, active-controlled study compared ranibizumab 0.3 and 0.5 mg with verteporfin PDT in 423 patients with predominantly classic lesions associated with CNV secondary to ARMD. For the primary efficacy end point, the results were 35.7% for ranibizumab 0.3 mg, 40.3% for ranibizumab 0.5 mg, and 5.6% for verteporfin PDT (P < 0.001). Serious adverse ocular events, which occurred in association with < 0.1% of intravitreal injections in these trials, included retinal detachment and endophthalmitis. Less serious adverse ocular reactions occurring in < 2% of patients included intraocular inflammation and increased intraocular pressure. CONCLUSION: The findings of these 3 large clinical trials suggest that ranibizumab was effective and well tolerated in patient.

Long term results after transpupillary thermotherapy in eyes with occult choroidal neovascularisation associated with age related macular degeneration: a prospective trial.

AIM: To evaluate long term results after transpupillary thermotherapy (TTT) in eyes with exudative age related macular degeneration. METHODS: In a prospective clinical study eyes with occult or predominantly occult choroidal neovascularisation and no pretreatment were scheduled to have a TTT with a power of 630 mW. Visual acuity for far and near distances as well as contrast sensitivity were evaluated 6, 12, and 24 months postoperatively and statistically analysed. RESULTS: 47 eyes fulfilled the inclusion criteria. Overall, 70% of the patients showed an improved (14%) or had unchanged (56%) ETDRS vision after 24 months. Reading vision was stabilised (51%) or better (5%) in 56% of the eyes at this time. However, the increasing number of eyes with severe deterioration resulted in a significant decrease of both parameters over time (p = 0.0002 and p = 0.0003, respectively). Contrast sensitivity could be maintained (70%) or improved (9%) in 79%. Statistical analyses indicated a trend but no significant decrease over time (p = 0.056). CONCLUSION: Although in the majority of patients far and near distance acuity could be stabilised on average a significant decrease over time after TTT was observed. Statistical comparison of months 12 and 24 showed no further deterioration.

[Transpupillary thermotherapy in exsudative age-related macular degeneration. Two-years results and findings on the other eye]. / Transpupilární termoterapie u exsudativní vekem podmínené makulární degenerace. Výsledky po 2 letech a nálezy na druhém oku.

UNLABELLED: The purpose of the prospective randomized study was to analyze long-term results of transpupillary thermotherapy (TTT) in exsudative age-related macular degeneration (ARMD) after 24 months of follow-up and to compare them with findings on the other, not treated eye. MATERIAL AND METHODS: Seventy-two patients aged 50-93 years (average age 70.6 years) with one eye treated by means of TTT and the other considered as control were in the study. Occult choroidal neovascularization (CNV) was treated in 33 eyes (45.8%), serous ablation of the pigment epithelium (SAPE) in 21 eyes (29.2%), and classical CNV in 18 eyes (25.0%). In all patients, the central visual acuity (VA) on EDTRS chart was specified, the macular findings were observed by means of indirect binocular ophthalmoscope and bio-microscopically with the contact lens on the slit lamp, and fluorescence angiography and optical coherence tomography (OCT) examinations were performed before and 3, 6, 12, 18, and 24 months after the TTT treatment. RESULTS: The final VA improved or remained unchanged in 27 eyes (37.5%), and worsened in 45 eyes (62.5%), by 5 or more lines the VA worsened in 19 eyes (26.4%). The average VA decreased from initial 0.24 to final 0.13, but the decrease in different forms of ARMD varied. In SAPE the highest initial as well as final average VA was found, in occult and classical CNV the initial and final average VA was almost identical. Exsudative changes observed by means of biomicroscopical, fluoroangiographical, and OCT examinations totally disappeared in 59.7%, 63.9%, and 59.7% respectively. At the end of the follow-up period we observed chorioretinal atrophy of different stage in the macula in all eyes (100%) and subretinal fibrosis in 44 eyes (61.7%). Both these findings represented final stages of natural course of exsudative ARMD. On the contrary, differently pronounced areas of chorioretinal atrophy corresponding with applied laser burns represented scars after the coagulation. It developed in 31 eyes (43.0 %) and pointed to the possible destructive consequence of the TTT. In 33 patients (45.8%), late stages of exsudative ARMD, mostly disciform scars with chorioretinal atrophy were found on the other not treated eye. In these eyes the final average VA was 0.05, e.g. more than one half worse than final average VA in treated eyes. CONCLUSIONS: Results of TTT treatment after 24 month of follow-up demonstrated full regression of exsudative changes in the macula in 60% of eyes and improved or stable VA in 37.5 % of eyes. Results in SAPE and classical CNV confirmed the efficacy of TTT treatment in those forms of ARMD. The TTT did not prevent the appearance and progress of the chorioretinal atrophy and subretinal fibrosis, causing the main obstacle of better functional results. Extremely unfavorable course of exsudative ARMD in the other (not treated) eye could indirectly confirm the positive influence of the TTT in theARMD treatment. Despite all positives are the possibilities of the TTT limited and determined by the basis and natural course of exsudative ARMD.

[Transpupillary thermotherapy for subfoveal choroidal neovascularization. A 9-month follow-up]. / Transpupillare Thermotherapie bei subfovealer choroidaler Neovaskularisation. Ein 9-Monats-Follow-up.

PURPOSE: The purpose of this study was to evaluate the efficiency, stability, and safety of transpupillary thermotherapy as a treatment of subfoveal occult choroidal neovascularizations (CNV) in age-related macular degeneration. METHODS: Transpupillary thermotherapy (TTT) was performed in 40 patients with uni- or bilateral predominantly occult CNV. Laser light derived from an infrared diode laser at 810 nm was used to apply spots for a duration of 60 s. A complete ophthalmic examination was performed prior to and 9 months after the treatment. RESULTS: After 9 months, visual acuity remained stable in 65% (+/-2 lines). In 35% of the patients TTT could not prevent further visual loss. Retinal leakage, assessed by fluorescein angiography, stabilized in 67.5% of the treated patients. CONCLUSIONS: The present data show stabilization of visual acuity in 65% after TTT. Compared to the natural course of occult and mixed subfoveal CNV, these data give some evidence for patient benefit after TTT.

A review of treatments for macular degeneration: a synopsis of currently approved treatments and ongoing clinical trials.

PURPOSE OF REVIEW: The purpose of this report is to review recent literature and ongoing clinical trials of the treatment of neovascular age-related macular degeneration. RECENT FINDINGS: Advances in the understanding of the pathogenesis of age-related macular degeneration and choroidal neovascularization have resulted in the emergence of pharmacotherapies targeting various aspects of angiogenesis. Preliminary results with the new agents have been encouraging. Moreover, longer follow-up and subgroup analyses of the Treatment of Age-Related Macular Degeneration with Photodynamic Therapy and Verteporfin in Photodynamic Therapy studies have suggested new potential indications for photodynamic therapy. SUMMARY: Currently a patient with wet macular degeneration may have multiple investigational options that were unavailable several years ago. Ongoing clinical trials are aimed at determining the long-term safety and efficacy of these new pharmacologic and combination therapy modalities.

Diode laser modifications for treatment of choroidal neovascularisation.

The aim of this paper is to describe various diode laser modifications and their use in treating choroidal neovascularisation in age-related macular degeneration. Diode lasers are used to treat selected choroidal neovascular membranes. Alterations in microprocessor connectivity, and parameters such as maximum spot size, light delivery time and coupled Joule meter, were made so that ophthalmic surgeons could specify treatment possibilities. A trimodal (photocoagulation, transpupillary thermotherapy and photodynamic therapy) application laser device coupled to a single light source has been developed. The new diode laser modifications were technically successful. Microprocessor connectivity was obtained, larger spot sizes were achieved, light delivery time could be extended and energy parameters were available at the display.

[Transpupillary thermotherapy in age-related macular degeneration. Preliminary results]. / Transpupilární termoterapie u vekem podmínené makulární degenerace. Predbezné výsledky.

OBJECTIVE: To evaluate anatomical and functional results of transpupillary thermotherapy (TTT) in age-related macular degeneration (ARMD) with a chorioid neovascular membrane (CNVM). MATERIAL AND METHODS: TTT was performed by means of a diode laser (Iris Medical Oculight Six) in 38 eyes of 35 patients aged 46-93 years, mean 70.6 years. Ocult CNVM was treated in 34 eyes, classical CNVM in 4 eyes. In TTT we applied 1 to 5 points (on average 1.9 spot) and used a laser beam with a diameter of 0.5-3 mm (mean width 1.61 mm). In 10 eyes with occult CNVM (29%) TTT was repeated after 1-6 months. The patients were followed up after TTT for 6-18 months on average for 9.5 months. RESULTS: The final visual acuity (VA) improved after TTT in two eyes (5.3%), remained unchanged in 22 eyes (57.9%) and deteriorated in 14 eyes (36.8%). The mean VA after TTT declined from 0.23 to 0.17. Biomicroscopic manifestations of exudation disappeared or receded in 29 eyes with occult CNVM (85.3%) and in 3 eyes with classical CNVM (75%). Fluoroangiographic examination revealed a reduced or absent extravasation of the dye in 24 eyes with occult CNVM (70.5%) and in 3 eyes with classical CNVM (75%). Optic coherent tomography confirmed regression of exudative changes and the development of a chorioretinal scar in 23 eyes with occult CNVM (67.6%) and 3 eyes with classical CNVM (75%). CONCLUSION: TTT is a new potential therapy of ACMD with CNVM. It is indicated in particular in occult CNVM. It can be however used also in classical CNVM. TTT is not economically pretentious and can be used also in other than large clinical departments. It is important to test the possibilities and limitations of TTT on a large number of patients and assess its position among other therapeutic procedures.