歐洲視網膜醫師的觀點

在最近一期英國眼科醫學雜誌（British Journal Ophthalmology) ，有關於脈絡膜新生血管（choroidal neovascularization）造成老年性黃斑部病變 （age related macular degeneration) ，目前最好治療方法的整理。

Evolving European guidance on the medical management of neovascular age related macular degeneration

PDT-V （光動力療法：靜脈注射 Verteporfin 藥物後，再使用689 nm 紅光雷射）適用於：

1. Subfoveal lesions with predominantly classic CNV
2. Occult with no classic CNV with evidence of recent disease progression and a lesion size ≤ 4 Macular Photocoagulation Study (MPS) disc areas (DA)
3. Juxtafoveal classic CNV so close to the fovea

Anti-angiogenic agents（抑制血管內皮細胞生長因子等藥物）適用於：

1. Subfoveal lesions with any proportion of classic CNV
2. Occult with no classic CNV
3. Juxtafoveal classic CNV so close to the fovea

Pegaptanib: 0.3 mg, 6 weeks, 9 times per year, at least 2 years. 六週眼內注射一次，一年注射九次

* All CNV subtypes
* FA: weeks 30 and 54. 30 及 54周時，再作螢光眼底攝影
* Concomitant use of PDT-V with predominantly classic CNV
* Granted by FDA and EMEA


Ranibzumab: 0.3 or 0.5 mg, monthly, 12 months. 一個月眼內注射一次，一年注射十二次

* Minimally classic or occult CNV
* Predominantly classic CNV
* Ranibzumab combined with PDT-V

可能併發症：（少見）

1. Ocular adverse event: uveitis, endophthalmitis （葡萄膜炎，眼內炎）
2. Non-ocular adverse event: CVA, AMI （中風，心肌梗塞）


Laser photocoagulation 氬氣雷射

1. Well demarcated juxtafoveal CNV
2. Extrafoveal classic CNV
3. 50 % persistent or recurrent CNV within 3 years of therapy
4. Significant and immediate vision loss


治療時需參考一星期內的螢光眼底攝影。

追蹤期間，至少要再作螢光眼底攝影，及檢查最佳矯正視力
。若視力惡化提早回診。

是否常規追蹤 OCT, ICG: 評估中


Choice of therapy 治療的選擇

Extrafoveal classic CNV

* Laser photocoagulation 氬氣雷射

Juxtafoveal classic CNV

* Laser photocoagulation 氬氣雷射
* PDT-V or Pegaptanib or Ranibzumab: So close to fovea; predominantly or minimally classic with occult CNV

Subfoveal lesions

* Predominantly classic CNV

o PDT-V or Pegaptanib or Ranibzumab: Monotherapy for predominantly classic CNV, with or without occult CNV

* Minimally classic CNV

o Pegaptanib: Minimally classic subfoveal CNV of any size
o PDT-V: Small (≤ 4 Macular Photocoagulation Study (MPS) disc areas (DA)
o Ranibzumab

* Occult with no classic CNV

o Pegaptanib
o PDT-V: with evidence of recent disease progression and a lesion size ≤ 4 Macular Photocoagulation Study (MPS) disc areas (DA)
o Ranibzumab


CNV and RPED （網膜色素上皮層剝離）

* No treatment recommended. 尚無有效治療


Failure to respond to therapy 何謂治療無效

* Failure to respond to laser photocoagulation
o Angiographic evidence of persistent or recurrent CNV

* Failure to respond to PDT-V
o 3 sessions: morphologically worsening and a decrease in VA 連續作三次仍無作用

* Failure to respond to Pegaptanib
o 3 intravitreal injections. 連續眼內注射三次仍無作用


Combination of therapies 合併治療

* Under investigation 仍在研究中


Discontinuation of therapy 何時停止治療

* Laser photocoagulation
o No leakage

* PDT-V: every 3, 6, 12 months. 每三，六，十二個月評估

o Minimal fluorescein leakage from CNV (<50%>
o Scar-like (fibrosis)
o Minimal or no subretinal fluid on OCT


Ranibzumab 目前台灣已可專案申請使用，Pegaptanib 且等明年。