gms | German Medical Science

The introduction of injections of anti-VEGF agents has improved visual outcome in a large proportion of patients with exudative age related macular degeneration (AMD).

Several subgroups of patients, however, have not been included in the pivotal anti-VEGF trials nor appear to benefit as much as the majority of patients with exudative AMD.

These subgroups include: an RPE tear; a submacular fibrotic reaction; old and acute submacular hemorrhage.

For the first three categories submacular surgery is an option: either macular rotation for smaller lesions (with champions as Klaus Eckardt and GraciaPertile) or a free graft of autologous retinal pigment epithelium. These invasive surgeries offer potential benefit, with in some patients spectacular proof of principle results, at the cost, however, of much more severe complications when compared to injections only.

RPE-grafts are of special interest, because RPE suspensions and sheets, produced with stemcell techniques, will be available in the neat future. Nevertheless, these developments have their old and new challenges: an inflammatory respons to tissue damage and the need for immunosuppression.

For acute hemorrhages pneumatic displacement is a much more widely practiced and accepted surgical approach, without, however, clear-cut and evidence-based guidelines so far.