Submacular surgery for patients with age-related macular degeneration

Choroidal neovascularization can cause severe visual disturbances. Current management options include observation, laser photocoagulation, photodynamic therapy, and surgical excision. Current guidelines for laser therapy have been well established but exclude many patients. Photodynamic therapy may hold some promise but its value is limited by the need for repeated treatments. An alternative therapy for patients with subretinal membranes may be surgical removal. The Submacular Surgery Trials seek to clarify the role of vitreous surgery in the management of CNV and are currently enrolling patients in all three arms: SST-H (subfoveal CNV associated with POHS and/or idiopathic cause), SST-N (AMD-associated CNV with at least some classic component and no prior laser therapy), and SST-B (large hematomas). The trials will determine whether patients with AMD and large subfoveal membranes that do not fit MPS guidelines or subfoveal hemorrhage have better outcomes following surgical excision or observation. Additionally, they will compare surgical outcomes to observation for patients with CNV from the presumed ocular histoplasmosis syndrome and idiopathic causes. Excision of choroidal neovascular membranes is technically possible and safe. The best candidates are those with membranes between the RPE and retina (type 2 membranes). A small retinotomy, gentle dissection, and pressure tamponade are critical to the technique. The Submacular Surgery Trials will help determine which patients will benefit from surgery.