Šaric B., Šikic J., Katušic D., Vukojevic N.

Department of Ophthalmology, Faculty of Medicine, Clinical Hospital Center, Kišpaticeva 12, HR 10000 Zagreb - Croatia

Introduction: Age-related macular degeneration (ARMD) presents the leading cause of blindness in the occidental world. This pathologic process is associated with the development of choroidal neovascular membrane (CNVM). Consequently, investigators have attempted to develop new modalities in treating CNVMs. Our experience with implant brachytherapy led us to expect that relatively low levels of ionizing radiation may prevent the proliferation of endothelial cells of newly formed subretinal capillaries and may induce obliteration of the aberrant new vessels.
Methods: Fifty-eight patients with subretinal CNVM were referred to brachytherapy because they were untreatable by Macular Photocoagulation Study criteria. Control group were made of 27 patients who refused laser or irradiation therapy. Inclusion criteria were that all macular lesions have some evidence of CNMV due to ARMD demonstrable on fluorescein angiography as "classic" or "occult" CNVM, involving the foveal avascular zone and a best-corrected visual acuity of 0,05 or better. We used ruthenium 106 ophthalmic applicator model CCB (Bebig/Berlin-Germany). Patients were treated with a maximum dose of 24- 26 Gy (mean, 25 Gy), to the overlying retina, in a period of 22-48 hours (mean, 36 hours).
Results: After follow up period of 12 months, we marked exudative macular lesions as improved, stable or progressive. Improved lesions were defined as having decreased or resolved components (hemorrhage, exudate, and fluid). Decreased blood flow was noted in classic neovascular membranes, while lower fluorescence was noted on fluorescein angiography in occult neovascular membrane. Stable lesions were found to be relatively unchanged or slightly enlarged with minimal regression of components. Progressive lesions were present in either increased size or with more components. Overall, (54,8%) lesions were noted to be stable or improved. Visual acuity data showed that 34 eyes (58,62%) were within or improved by 1 or more lines from their base line visual acuity.
Discussion: This study clearly demonstrates that brachytherapy can be used as optional treatment for CNVM in ARMD. This is a unilateral treatment, which allows a large dose to be delivered to the macula with less irradiation to normal ocular structures, compared to the external beam radiotherapy. Unlike laser photocoagulation, brachytherapy can be used for subfoveal, both occult and classic, CNVM, and patients do not suffer the sudden irreversible visual loss and scotoma onset.

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