Возрастная макулодистрофия сетчатки («влажная» форма)

[buskopan]

Пациенту (женщина - 58 лет) проделано 5 внутриглазных инъекций Авастина. Желаемый результат не достигнут.
В течении года сделано несколько раз КТ глаза. Положительные изменения после Авастина длятся не долго.
Прошу узких специалистов отписаться в теме касательно ФТП визудином. В Баку как я понимаю этим не занимаются.

Спасибо

[Terapevt]

[quote name='buskopan' post='4406596' date='Mar 5 2009, 18:55 '][/quote]
Заур, в Баку этим занимается Лейла- она делает инъекции Авастина не то аналога. Подборка литературы у меня есть- результаты исследований расплывчаты. Смотрел родственницу с этой патологией немец, операцию не посоветовал, про инъекции сказал что дорогие и пока новые.

[buskopan]

[quote name='Terapevt' post='4407082' date='Mar 5 2009, 22:11 ']Заур, в Баку этим занимается Лейла- она делает инъекции Авастина не то аналога. Подборка литературы у меня есть- результаты исследований расплывчаты. Смотрел родственницу с этой патологией немец, операцию не посоветовал, про инъекции сказал что дорогие и пока новые.[/quote]Спасибо Шахла ханум.
Лейлу не могу найти. Кажется она уехала из Баку. Как раз она и делала инъекции Авастина. Но как я отметил положительный рисунок КТ от силы держался несколько недель. А ФТП она не занимается. У нас не практикуют "визудином" . К сожалению дальнейшее использование Авастина пациенту противопоказано и нужен альтернативный метод лечения. На втором глазу, была проведена имплантация ИОЛ после удаления катаракты, поэтому как понимаете надежда на второй глаз тоже не большая и цена за сохранность зрения не имеет значения.

С Уважением

[Terapevt]

[quote name='buskopan' post='4407912' date='Mar 6 2009, 07:32 ']С Уважением[/quote]
пару месяцев назад врач из Целамига сказала что Лейла едет в США. Позвони от моего имени и имени Ляман-х из кафедры Саида-х 390 0037 она тебе скажет когда приедет Лейла.

[buskopan]

[quote name='Terapevt' post='4408479' date='Mar 6 2009, 10:57 ']пару месяцев назад врач из Целамига сказала что Лейла едет в США. Позвони от моего имени и имени Ляман-х из кафедры Саида-х 390 0037 она тебе скажет когда приедет Лейла.[/quote]Спасибо большое Шахла ханум.
Я поговорил. Она будет только в июне.

[LADY'N]

[quote name='buskopan' post='4406596' date='Mar 5 2009, 18:55 ']Пациенту (женщина - 58 лет) проделано 5 внутриглазных инъекций Авастина. Желаемый результат не достигнут.
В течении года сделано несколько раз КТ глаза. Положительные изменения после Авастина длятся не долго.
Прошу узких специалистов отписаться в теме касательно ФТП визудином. В Баку как я понимаю этим не занимаются.

Спасибо[/quote]
в Баку в клинику Целамиг на днах приезжает доктор из Турции Мехмет Бахадур,который занимается проблемами глазного дна.я слышала что очень хороший специалист с мировым именем.если не ошибаюсь на этой неделе.можете обратиться к нему

[buskopan]

[quote name='LADY' post='4423618' date='Mar 10 2009, 16:00 ']в Баку в клинику Целамиг на днах приезжает доктор из Турции Мехмет Бахадур,который занимается проблемами глазного дна.я слышала что очень хороший специалист с мировым именем.если не ошибаюсь на этой неделе.можете обратиться к нему[/quote]Спасибо большое за ответ.
Дело в том, что другого метода лечения МДС в мире еще не придумали. Авастин мы уже, как я отметил, делали. Остался относительно новый метод фототерапии визудином, но в Баку его не делают даже доктора из Турции (я уже интересовался) так как большой риск. Думаю в следующем месяце отправить пациентку в Москву. Просто хотелось узнать мнение офтальмологов касательно нового метода. Ведь проблема довльно распространенная на сегодняшний день.
В любом случае спасибо Вам за совет.

[Terapevt]

[quote name='buskopan' post='4426525' date='Mar 11 2009, 09:15 '][/quote]
Заур, близкого мне человека 2 года назад смотрели 2 немца-офтальмолога. Они не были специалистами по макулодистрофии, но они сказали, что в инъекциях авастина и аналогов важно попасть в нужную точку. Мы навели справки о Мехмете, о нем хорошие отзывы со стороны офтатальмологов. Покажите своего больного лучше специалисту- предоставьте им выбор лечения.

[buskopan]

[quote name='Terapevt' post='4438933' date='Mar 13 2009, 13:16 ']Заур, близкого мне человека 2 года назад смотрели 2 немца-офтальмолога. Они не были специалистами по макулодистрофии, но они сказали, что в инъекциях авастина и аналогов важно попасть в нужную точку. Мы навели справки о Мехмете, о нем хорошие отзывы со стороны офтатальмологов. Покажите своего больного лучше специалисту- предоставьте им выбор лечения.[/quote]Шахла ханум,
Все интраокулярные инъекции, кроме первой, пациентке делала Уважаемая Лейла ханум. Мое огромное почтение этому, действительно знающему свое дело, специалисту с большой буквы.
У меня нет ни грамма сомнений, что она их делала правильно т.к. после инъекций некоторое время наблюдалось значительное улучшение со стороны центрального зрения. Первую же инъекцию, за не маленькую сумму, делал турецкий офтальмолог, после которой наблюдался ряд осложнений, в том числе занос инфекции. Дело конечно не в деньгах. Пациентка - моя мама. А для мам как понимаете, мы ищем все только лучшее. По словам специалистов - Авастин относительно новый препарат патогенез, которого до конца не изучен. Это подтверждают и российские офтальмологи, и Лейла ханум. Поэтому до ее приезда хотелось бы узнать об альтернативном методе лечения.
В любом случае большое Вам человеческое Спасибо за коментарии по теме.
С Уважением

[LADY'N]

[quote name='buskopan' post='4426525' date='Mar 11 2009, 09:15 ']Спасибо большое за ответ.
Дело в том, что другого метода лечения МДС в мире еще не придумали. Авастин мы уже, как я отметил, делали. Остался относительно новый метод фототерапии визудином, но в Баку его не делают даже доктора из Турции (я уже интересовался) так как большой риск. Думаю в следующем месяце отправить пациентку в Москву. Просто хотелось узнать мнение офтальмологов касательно нового метода. Ведь проблема довльно распространенная на сегодняшний день.
В любом случае спасибо Вам за совет.[/quote]
вчера в одном из офтальмологических журналов я прочитала что в Москве в институте Гельмгольца проводили комбинированное лечение кеналог(интраветриально)+через 2 недели терапия визудином.результаты:повышение зрения на 20-30%.эффект держится до 6 месяцев-года,затем можно повторно.

[buskopan]

[quote name='LADY' post='4466381' date='Mar 19 2009, 19:08 ']вчера в одном из офтальмологических журналов я прочитала что в Москве в институте Гельмгольца проводили комбинированное лечение кеналог(интраветриально)+через 2 недели терапия визудином.результаты:повышение зрения на 20-30%.эффект держится до 6 месяцев-года,затем можно повторно.[/quote]Кеналогом видимо страхуются во избежание побочных реакций визудина.
От того, что процедура дорогая ВИЗУДИН пока только исследуют. Но 20-30% конечно уже хороший результат, отличный от Авастина.
Подождем пока доисследуют.

Да и ...Спасибо больше

[Terapevt]

[quote name='buskopan' date='Mar 20 2009, 11:40 ' post='4468
[/quote]
Заур, может найдете что-то полезное

[url="http://www.medscape.com/resource/amd?src=0_nl_mp_mad"]http://www.medscape.com/resource/amd?src=0_nl_mp_mad[/url]
[url="http://www.medscape.com/viewarticle/506716_4"]http://www.medscape.com/viewarticle/506716_4[/url]
[url="http://www.medscape.com/viewarticle/532219_5"]http://www.medscape.com/viewarticle/532219_5[/url]
[url="http://www.medscape.com/viewarticle/563985?src=mp"]http://www.medscape.com/viewarticle/563985?src=mp[/url]
[url="http://www.medscape.com/viewarticle/543338?src=mp"]http://www.medscape.com/viewarticle/543338?src=mp[/url]
[url="http://www.medscape.com/viewarticle/562643?src=mp"]http://www.medscape.com/viewarticle/562643?src=mp[/url]

[url="http://www.medscape.com/viewarticle/545207_4"]http://www.medscape.com/viewarticle/545207_4[/url]
http
//www.medscape.com/viewarticle/578979?src=mp&spon=25&uac=70483EJ
[url="http://www.medscape.com/viewarticle/520823?src=mp"]http://www.medscape.com/viewarticle/520823?src=mp[/url]
[url="http://www.medscape.com/viewarticle/523869"]http://www.medscape.com/viewarticle/523869[/url]

[buskopan]

[quote name='Terapevt' post='4468085' date='Mar 20 2009, 12:09 ']Заур, может найдете что-то полезное[/quote]
Спасибо Шахла ханум.
Я уже копался на медскейпе касательно амд. Американцы как всегда акцентируют внимание на антиоксидантной терапии, в чем конечно есть смысл. Лечат в основном Авастином. Вся остальная альтернатива на уровне human trials.
Кое что интересное нашел правда. Касательно профилактического [b][url="http://www.medscape.com/viewarticle/543338?src=mp"]применения лютеина[/url][/b] ...правда эти тесты тоже проведены на женщинах до 40 лет.
Вот описание [url="http://amt.allergist.ru/lutein_b.html"][b]аналога[/b][/url]

С Уважением

[Nelllie***]

[color="red"]Реклама запрещена[/color]

[konidja]

[quote name='Nelllie***' post='4471264' date='Mar 21 2009, 16:54 ']Попробуйте вот это
[b]Флавигран - очанка[/b][/quote]
В лечении возрастной макулодистрофии роли не играет.

[Terapevt]

[quote name='konidja' post='4483260' date='Mar 25 2009, 12:44 ']В лечении возрастной макулодистрофии роли не играет.[/quote]
+100

[Nelllie***]

[quote name='konidja' post='4483260' date='Mar 25 2009, 12:44 ']В лечении возрастной макулодистрофии роли не играет.[/quote]
А вы пробовали? Это отличное средство от любых проблем со зрением.Знаю пожилую женщину,которой оно помогло.

[buskopan]

[quote name='Nelllie***' post='4493628' date='Mar 28 2009, 01:16 ']А вы пробовали? Это отличное средство от [b]любых проблем со зрением[/b].Знаю пожилую женщину,которой оно помогло.[/quote]значить это открытие.
Какой диагноз был у пожилой женщины? Дайте контакты человека с макулодистрофией, которому помогла очанка.

[Terapevt]

[quote name='buskopan' post='4494228' date='Mar 28 2009, 08:40 ']значить это открытие.
Какой диагноз был у пожилой женщины? Дайте контакты человека с макулодистрофией, которому помогла очанка.[/quote]
Заур, не стоит тратить много сил на эту дискуссию. Но и допускать такое на медифоруме тоже нельзя.

[Nelllie***]

У нее было ухудшение зрения именно старческое.Я вас не заставляю мне верить.

[buskopan]

[quote name='Nelllie***' post='4495179' date='Mar 28 2009, 13:27 ']У нее было ухудшение зрения именно старческое.Я вас не заставляю мне верить.[/quote]Все понятно. Спасибо.

[Кельтская Богиня]

[quote name='Nelllie***' post='4493628' date='Mar 28 2009, 01:16 ']А вы пробовали? Это отличное средство [b]от любых проблем со зрением[/b].Знаю пожилую женщину,которой оно помогло.[/quote]

да уж. медицина шагнула далеко....

[buskopan]

[quote name='Кельтская Богиня' post='4497013' date='Mar 28 2009, 20:16 ']да уж. медицина шагнула далеко....[/quote]
медициной там и не пахнет. Просто пиар добавок пошел.

просьба модераторам либо закрыть тему, либо убрать посты не по теме.

Спасибо.

[Кельтская Богиня]

[quote name='buskopan' post='4497148' date='Mar 28 2009, 21:55 '][b]медициной там и не пахнет. Просто пиар добавок пошел.[/b]

просьба модераторам либо закрыть тему, либо убрать посты не по теме.

Спасибо.[/quote]

ну так и я о том же. простите, что не в тему. просто не могла пройти мимо.

[Nelllie***]

Этот препарат одобрен РАМН,наверно,вы знаете что это...

[buskopan]

[quote name='Nelllie***' post='4502215' date='Mar 29 2009, 21:54 ']Этот препарат одобрен РАМН,наверно,вы знаете что это...[/quote]
читайте название темы
Возрастная макулодистрофия сетчатки («влажная» форма), [b]Фотодинамическая терапия "визудином"[/b]

[Terapevt]

[quote name='buskopan' post='4503775' date='Mar 30 2009, 08:57 '][/quote]
Заур, привожу из up-to-date, мне некогда читать, если будет что-то новое, скажете.





Age-related macular degeneration: Treatment

Author
Jorge G Arroyo, MD, MPH Section Editor
Jonathan Trobe, MD
Kenneth E Schmader, MD Deputy Editors
H Nancy Sokol, MD



Last literature review version 16.1: January 2008 | This Topic Last Updated: February 15, 2008 (More)


TREATMENT WET TYPE ARMD — Effective therapies for exudative or wet type ARMD are intravitreous injection of a VEGF inhibitor, thermal laser photocoagulation, photodynamic therapy, and probably macular translocation surgery.

VEGF inhibitors — Vascular endothelial growth factor (VEGF) is a potent mitogen and vascular permeability factor that plays a pivotal role in neovascularization. A number of anti-VEGF molecules have been developed, that may help limit the destructive effects of choroidal neovascular membranes in patients with ARMD. Longterm cardiovascular effects of these medications in the treatment of ARMD are unknown [18] . (See "Overview of angiogenesis inhibitors", section on Vascular endothelial growth factor (VEGF)).

Ranibizumab — Ranibizumab is a recombinant humanized monoclonal antibody with specificity for VEGF [19] . It has been studied in randomized trials: The MARINA study, a randomized trial in 716 patients with minimally classic or occult wet ARMD, compared 24 monthly injections with ranibizumab 0.3 mg, ranibizumab 0.5 mg, or sham injection [20] . After one year, more patients treated with 0.3 mg or 0.5 mg ranibizumab lost fewer than 15 letters from baseline visual acuity (95 and 95 percent versus 62 percent with sham injection). Additionally, more patients treated with ranibizumab improved by at least 15 letters (25 and 34 percent versus 5 percent). In addition to measured improvement in visual acuity, there was significant improvement in visual function, as assessed by questionnaire, in ranibizumab-treated patients, compared to a decline in visual function in sham-treated patients at 12 month assessment [21] . Benefits were maintained at two years, and confirmed with findings of decreased leakage with fluorescein angiography and decreased fibrosis on optical coherence tomography [22] . Side effects in patients treated with ranibizumab included endophthalmitis in five patients (1.0 percent) and serious uveitis in six patients (1.3 percent). The ANCHOR study, a randomized trial in 423 patients with predominantly classic wet ARMD. compared ranibizumab 0.3 mg and ranibizumab 0.5 mg with sham injection plus photodynamic therapy with verteporfin [23] . After one year, more patients treated with 0.3 or 0.5 mg ranibizumab lost fewer than 15 letters of visual acuity (94 and 96 percent versus 64 percent with verteporfin). In addition, more patients treated with ranibizumab improved by at least 15 letters (36 and 40 percent versus 6 percent). Side effects in the 140 patients treated with ranibizumab 0.5 mg included endophthalmitis in two patients and serious uveitis in one patient. Predictors of response to ranibizumab were better baseline visual acuity, smaller choroidal neovascularization lesion size, and younger patient age [24] .

Ranibizumab was approved by the Food and Drug Administration in the United States in 2006 for the treatment of wet ARMD at a dose of 0.5 mg by intravitreal injection every month [25] . Subsequent to approval, the manufacturer issued a letter to providers describing interim findings from the SAILOR study of intravitreal ranibizumab injections for wet ARMD [26] . At an average follow-up of 230 days, there was an increased risk of stroke for patients treated with 0.5 mg compared to 0.3 mg of ranibizumab (1.2 versus 0.3 percent respectively). However, the stroke rate in both groups was lower than anticipated, and the clinical significance of the dose-related difference is uncertain, pending trial conclusion. The SAILOR trial is ongoing, with completion anticipated by the end of 2007.

Bevacizumab — Although not studied in randomized trials, clinicians have used intravitreal injections of the anti-VEGF drug bevacizumab as a treatment for ARMD [27-29] . Bevacizumab and ranibizumab are closely related antibodies; ranibizumab is essentially an antibody fragment (Fab fragment) of bevacizumab with some modifications to the amino acid sequence that increase its binding of VEGF [30] . (See "Structure of immunoglobulins").

Bevacizumab is approved in the United States as an intravenous infusion for the systemic therapy of colorectal cancer. A prospective case series in 17 patients with wet ARMD treated with intravitreal bevacizumab (2.5 mg in 0.1 mL every four weeks for a total of three injections) found improvement in vision in the majority of patients, as well as marked retinal anatomic improvements [31] .

Treatment with intravitreal bevacizumab is far less expensive than treatment with intravitreal ranibizumab ($50 compared to $1950 per injection) [27,29,32] . A federally-funded multicenter head-to-head randomized trial, comparing bevacizumab and ranibizumab in 1200 patients with ARMD, is underway in the US [29] .

Systemic administration of anti-VEGF medications such as bevacizumab is also being studied in the treatment of ARMD [33] .

Pegaptanib — Pegaptanib is a VEGF inhibitor that was studied in two randomized trials with a total of 1186 patients ages 50 and older with subfoveal choroidal neovascularization secondary to ARMD [34] . Pegaptanib (at three different doses) was administered by intravitreous injection every six weeks for 48 weeks. Compared with placebo, fewer patients treated with pegaptanib lost three or more lines of visual acuity (31 versus 45 percent). Side effects included endophthalmitis, which was seen in 1.3 percent of patients. Ongoing benefits were seen in patients who were randomly assigned to continue pegaptanib for a second year [35] . Intravitreal pegaptanib has been reported to cause systemic allergic reactions, including urticaria and angioedema [36] .

The benefit associated with pegaptanib in these trials was similar to that generally seen with photodynamic therapy [37] . However, the clinical role of pegaptanib is uncertain given the apparently greater benefits seen with other intravitreal anti-VEGF medications.

Treatment schedules for VEGF inhibitors — Although both the MARINA and ANCHOR trials evaluated monthly injections, the optimal frequency for injections of VEGF inhibitors is not known, and monthly injections may be poorly accepted by patients. One paper suggests regular patient monitoring with a combination of clinical examination for evidence of new hemorrhage, and optical coherence tomography (OCT) for evidence of new leakage to determine need for retreatment [38] .

Thermal laser photocoagulation — Thermal laser photocoagulation uses a relatively high intensity of thermal laser energy to cause coagulation of the abnormal choroidal neovascular membrane. A consequence of this treatment, however, is focal damage to the overlying retina with the resultant formation of a permanent blind spot. This treatment has, therefore, been limited to lesions outside of the central macula. It is an outpatient procedure that requires only topical anesthetic drops. Furthermore, thermal laser photocoagulation is restricted to use in patients with well-defined neovascularization which is only present in approximately 15 percent of patients with exudative ARMD.

Several large randomized, controlled trials have found that thermal laser photocoagulation decreases the rate of severe visual loss and preserves contrast sensitivity in patients with extrafoveal choroidal neovascular membranes associated with well-defined neovascular complexes due to exudative ARMD [39-45] . Benefits have been reported to persist beyond three years, although choroidal neovascularization recurs within two years in approximately one-half of patients treated.

Laser photocoagulation does not restore lost vision. Furthermore, although the central fovea is spared by the laser and relativity full vision is often retained, patients frequently note a peripheral scotoma in the area of the laser treatment. Finally, some studies have reported an acute loss of vision with laser therapy, which limits its acceptability [40,45] .

A systematic review has concluded that laser photocoagulation for choroidal neovascularization is no longer recommended, with the availability of newer pharmacologic therapies and the risk of scotomata and vision loss with photocoagulation [46] . We feel that it may still be of use in selected patients with small extrafoveal choroidal involvement.

Photodynamic therapy — Photodynamic therapy involves intravenous injection of the photosensitizing dye verteporfin just prior to treatment with a cool photo-activating laser. Animal studies demonstrate that treatment activates the verteporfin within the choroidal neovascular membrane. The activated dye forms reactive free radicals that damage the vascular endothelium and result in thrombosis of the damaged vessels. Neovascular tissue retains dye more than normal vessels so that only diseased vessels are affected. However, with time some of these vessels may reopen [47,48] ; 33 percent of 108 eyes in one study, for example, showed evidence of recurrent choroidal neovascularization at 18 months following a course of photodynamic therapy [49] . Retreatment with photodynamic therapy is safe [50,51] .

Photodynamic therapy is primarily indicated in patients who have a subfoveal neovascular membrane, in whom treatment with a conventional laser is contraindicated because it would extend through the fovea. An analysis of two randomized trials including 609 patients, and a subsequent systematic review of three trials (1022 patients) found that photodynamic therapy was associated with a significantly lower rate of vision loss at one year follow-up compared with placebo [47,52] . Vision outcomes remained relatively stable over three year follow-up [50] . One small randomized trial (n=62) compared photodynamic therapy and intravitreal bevacizumab and found that visual acuity showed greater improvement at six months in patients treated with bevacizumab [53] . This finding needs to be confirmed with additional and longer term studies.

Though early studies showed that photodynamic therapy was not as effective for patients with occult neovascularization compared to patients with classic neovascular lesions [47] , subsequent randomized trials have also demonstrated benefit for treatment in some patients with small lesions of occult choroidal neovascularization [51,54,55] . A small preliminary randomized study found that the combination of photodynamic therapy with bevacizumab resulted in greater visual improvement at one month than either therapy alone [56] . No advantage was found for using a periocular glucocorticoid injection as adjuvant to photodynamic therapy [57] .

Surgery — Two main classes of surgical procedures have been tried for ARMD, submacular surgery and macular translocation surgery:

Submacular surgery — Submacular surgery involves the removal of abnormal subretinal neovascularization and, if present, large submacular hemorrhages.

Submacular surgery was evaluated in the NIH-sponsored multicenter randomized Submacular Surgery Trials (SSTs) [58] . Two of these trials evaluated submacular surgery in patients with ARMD who had subfoveal choroidal neovascularization that was either less than 50 percent hemorrhagic [59] or at least 50 percent hemorrhagic [60] . Patients with less than 50 percent hemorrhage who were treated with surgery had no better visual outcomes than those who were observed and not treated [59] . Patients with at least 50 percent hemorrhage who were treated with surgery also did no better on the primary outcome (stable or improved visual acuity); however, there did appear to be a lower rate of severe loss of visual acuity after 24 months in patients treated with surgery compared with observation (21 versus 36 percent) [60] . Patients with at least 50 percent hemorrhage who were treated surgically had a higher rate of rhegmatogenous retinal detachment (16 versus 2 percent).

Given the lack of benefit in most patients, the high rates of retinal detachment, and the fact that surgery was not compared with an active therapy such as photodynamic therapy, submacular surgery should not generally be performed for choroidal neovascularization in ARMD, but it may be considered in patients with large submacular hemorrhages.

Macular translocation surgery — Macular translocation surgery involves surgically detaching the macula and moving it from a more diseased area of retinal pigment epithelium to a less diseased area. It is a surgical technique that has been used to treat subfoveal choroidal neovascularization.

Macular translocation surgery is experimental and is undergoing evaluation. A theoretical advantage of macular translocation over current treatments is the potential preservation of foveal photoreceptor function. The original surgical technique (macular translocation with 360-degree retinotomy) used is technically challenging and initially had a high rate of complications, although complication rates appear to decrease with experience [61,62] . More recent modifications in the procedure and improvements in equipment have made the surgery more feasible.

Results from case series with macular translocation surgery are encouraging [63-66] . The majority of patients appear to achieve stabilization or improvement in central visual function, and approximately two-thirds of patients are able to read after surgery.

Most of the patients treated with macular translocation surgery have no other proven treatment options available, as the sizes and characteristics of their lesions would not be appropriate for photodynamic therapy or laser photocoagulation. However, given the substantial risks involved (retinal detachment, proliferative vitreoretinopathy, diplopia), further investigation is needed to better understand the precise risks and benefits of this procedure. Additionally, at least one case series suggests that early benefits with surgery are not sustained [67] .

Radiation therapy — External beam radiation therapy has been studied in patients with ARMD. A meta-analysis of randomized, controlled trials concluded that there was no consistent evidence of benefit [68] . The long-term safety of radiation therapy is unknown.

Zinc and antioxidants — As noted above, AREDS found a statistically significant benefit of antioxidants (vitamins C and E and beta carotene) plus zinc supplementation on progression of early ARMD in one eye in patients with advanced ARMD or vision loss due to ARMD in the other eye [9] . It is reasonable to recommend treatment with these supplements in nonsmokers in the doses used in the study (see "Antioxidants and zinc" above), although patients should be aware that beta carotene supplementation has been linked to an increased risk of lung cancer and possibly to an increased risk of coronary heart disease. (See "Cigarette smoking and other risk factors for lung cancer", section on Dietary factors and see "Nutritional antioxidants in coronary heart disease"). We prefer treatment with zinc supplements alone in smokers.

Glucocorticoids — An uncontrolled trial of intravitreal injections with triamcinolone acetonide (25 mg) found short term improvements in vision in two-thirds of treated eyes [69] . These results require confirmation in randomized trials. Intravitreal injection of triamcinolone is associated with glaucoma, cataract, and endophthalmitis. Triamcinolone has also been injected into the posterior sub-Tenon's space (using the Nozick technique) for ARMD and other conditions [70,71] . The risks associated with this technique appear to be minimal. The pharmacokinetics of posterior sub-Tenon's triamcinolone injection are currently under investigation.

Anecortave acetate is an antiangiogenic cortisone that has shown evidence of benefit in preliminary trials when administered via a posterior juxtascleral route every six months [72,73] . A randomized trial that compared anecortave acetate to photodynamic therapy in 530 patients with predominantly classic subfoveal choroidal neovascularization found similar percentages who maintained vision at one year with both treatments (45 versus 49 percent) [74] . However, the trial failed to prove that anecortave acetate therapy was not inferior to photodynamic therapy according to the preplanned noninferiority criteria of the trial.

Ginkgo biloba — One small randomized study of 20 patients has investigated the use of ginkgo biloba in patients with ARMD [75] . Although improvements in visual acuity were reported, assessment of outcome was not masked, and the results must therefore be considered equivocal [76]

Wet ARMD summary — Effective therapies for exudative or wet type ARMD are intravitreous injection of a VEGF inhibitor, thermal laser photocoagulation, photodynamic therapy, and probably macular translocation surgery.

Thermal laser photocoagulation is recommended for patients with well-defined wet type extrafoveal (at least 200 microns away from the foveal center) ARMD. Photodynamic therapy is primarily indicated in patients who have a subfoveal neovascular membrane and is approved for patients with predominantly classic choroidal neovascular lesions. Photodynamic therapy also appears to be useful in a subset of patients with minimally-classic or occult lesions that are small in size and have evidence of progression (recent decrease in vision, increase in size of lesion, or development of subretinal hemorrhage).

Anti-VEGF treatment with ranibizumab, and perhaps bevacizumab, have shown promising results. These are particularly useful in patients with early, wet ARMD lesions, and may become first line treatment options in other settings as well. These are the first pharmacologic agents for wet ARMD that have shown an improvement in average vision, rather than simply stabilizing vision.

While it is still undergoing evaluation, macular translocation surgery appears to be of benefit and is reasonable to consider in patients who have failed or are not candidates for the above therapies. Submacular surgery for wet type ARMD does not appear to be of benefit in most patients. Radiation therapy has not been found beneficial. Growth factors continue to be studied.

It is reasonable to recommend treatment with the antioxidant vitamins A, C, and beta carotene, plus zinc, for patients with wet type ARMD. However, patients should be aware that beta carotene supplementation has been linked to an increased risk of lung cancer and possibly to an increased risk of coronary heart disease. Thus, treatment is not recommended in smokers. The doses used in the study that noted benefit were 500 mg vitamin C, 400 IU vitamin E, 15 mg beta carotene, and 80 mg zinc as zinc oxide and 2 mg cupric oxide (copper). Treatment benefits were noted only in patients who took all of these supplements.

It is important to emphasize to patients that none of the treatments for wet type ARMD address the fundamental pathological process. Instead, an attempt is made to limit the destructive effects of choroidal membranes on the retina and vision. These treatments are only able to slow down the relentless progress of ARMD. As additional modalities are developed and found to be effective, a treatment regimen consisting of multiple modalities such as surgery, laser, intravitreal steroids, and pharmacologic antiangiogenic treatment may prove to be the most effective.

Whenever possible, patients should be encouraged to enroll in clinical trials of treatments for ARMD. In the US, information on clinical trials is available at www.clinicaltrials.gov.


Wet AMRD treatment

In patients with wet ARMD in one eye, treatment with supplements may decrease progression to advanced ARMD in the fellow eye: We suggest that nonsmokers with wet ARMD be treated with daily oral supplements containing vitamin C 500 mg, vitamin E 400 IU, beta carotene 15 mg, zinc 80 mg (as zinc oxide), and copper 2 mg (as cupric oxide) (Grade 2B). (See "Zinc and antioxidants" above). We suggest that smokers with wet ARMD be treated with daily zinc 80 mg (as zinc oxide) (Grade 2B). (See "Zinc and antioxidants" above).

Effective specific therapies for exudative or wet type ARMD are intravitreous injection of a VEGF inhibitor, thermal laser photocoagulation (in selected patients), photodynamic therapy, and probably macular translocation surgery. The decision about specific therapies must take into account the likelihood of visual recovery, which is greater with smaller, more recent lesions, as well as the risks of the various therapies.

The following recommendations apply to active disease (leaking fluid, hemorrhage, or recent loss of vision): In patients who have acute lesions involving the fovea, as well as in patients with later lesions involving the fovea who do not have preserved vision in their second eye, we recommend intravitreal ranibizumab or bevacizumab (Grade 1B). We frequently also treat these patients with sub-Tenon's triamcinolone and with photodynamic therapy. (See "VEGF inhibitors" above and see "Glucocorticoids" above and see "Photodynamic therapy" above). In patients with lesions that do not appear to be acute who have preserved vision in a second eye and who do not seem likely to achieve reading vision in the affected eye, we suggest photodynamic therapy rather than intravitreal ranibizumab or bevacizumab (Grade 2B). We frequently also treat these patients with sub-Tenon's triamcinolone. (See "Photodynamic therapy" above). In patients with acute, small, well-defined extrafoveal lesions, we suggest treatment with thermal laser photocoagulation (Grade 2B). We frequently also treat these patients with sub-Tenon's triamcinolone. (See "Thermal laser photocoagulation" above). In patients with acute, large extrafoveal lesions or poorly defined extrafoveal lesions, we recommend treatment with intravitreal ranibizumab or bevacizumab (Grade 1B). We frequently also treat these patients with sub-Tenon's triamcinolone. (See "VEGF inhibitors" above and see "Glucocorticoids" above).

Macular translocation surgery is complex and is an option for patients who are not candidates for any other therapy. (See "Surgery" above).

Whenever possible, patients should be encouraged to enroll in clinical trials of treatments for ARMD. (See "Wet ARMD summary" above).

[buskopan]

[quote name='Terapevt' post='4503848' date='Mar 30 2009, 10:14 ']Заур, привожу из up-to-date, мне некогда читать, если будет что-то новое, скажете.
Age-related macular degeneration: Treatment[/quote]
Спасибо Шахла ханум. Это видимо с медскейпа ?
Суть.
хорошие новости, что макулотрансплантацию уже где-то делают. Но найти донора....Второй метод оперативного вмешательства субмакулярная хирургия более обнадеживает но...опять таки только начали делать.
все остальное обычная статистика. Есть хорошие результаты от фотодинамической терапии и положительные результаты от комплексной терапии витаминами и антиоксидантами.
Согласно статистике обнаружили риск инсультов при применении Авастина в определенных дозах. Так выходит что при ИБС он противопоказан.
АМД, по моим наблюдениям, больше склонна появляться у гипертоников. Ваш пациент тоже гипертоник на сколько мне известно.

Маму в апреле везу в Москву.
Будут новости дам знать.

[Terapevt]

[quote name='buskopan' post='4504151' date='Mar 30 2009, 10:03 '][/quote]
Это из самой-самой [b]up-to-date[/b], 2008.
Спасибо, четко, конкретно.
Наша общая знакомая умница! Она отложила инъекции Авастина.

[buskopan]

прошело больше года, стоит медицина в этом направлении...ведь ни на миллиметр не сдвинулась.

Есть офтальмологи? Огромное желание....с кем нибудь поспорить и поругаться и доказать, что ничего не делается.

[aspirin]

Деньги выбиваются и тратятся только на производство вакцин и тотальные вакцинации от "звериных" гриппов...