This was a randomised intervention study in wet AMD patients to investigate benefits of free RPE-choroid graft transplantation surgery versus (continuation of) anti-VEGF treatment. Twenty patients who met the inclusion criteria were subdivided into three subgroups, i.e. RPE tears involving the macula, submacular haemorrhages, or nonresponders to anti-VEGF. Patients were randomised to group 1: submacular haemorrhage, graft (n=6); group 2: RPE tear, graft (n=3); group 3: nonresponder, graft (n=1); group 4: submacular haemorrhage, anti-VEGF (n=5); group 5: RPE tear, anti-VEGF treatment (n=3), and group 6: nonresponder, anti-VEGF treatment (n=2). The results showed change in the mean number of Early Treatment of Diabetic Retinopathy Study (ETDRS) letters in the graft group one year postoperatively was –15 (range –54 to +26), whilst two patients experienced a gain of >10 letters. Gain results: two; loss: four; stable: three; LFO: one. The median preoperative visual acuity (VA) was 0.75 logMAR (range 0.46–2.8), and the mean postoperative VA was 1.48 logMAR (range 0.14–2.8). The change in the mean number of ETDRS letters in the anti-VEGF group was –8 (range –26 to +6); no patients experienced a >10 letter gain. Gain results: zero; loss: three; stable: six; LFO: one. The median preoperative VA was 1.36 logMAR (range 0.58–1.6), and the median postoperative VA was 1.42 logMAR (range 0.44–1.66). The study indicates that the RPE-choroid graft surgery may be considered as an alternative in the treatment of cases in which no other treatment option is available, e.g in patients with still relatively preserved retinal layers in the macular region with a relatively fresh RPE-choroid tear, or a submacular haemorrhage which is too old to be treated with recombinant tissue plasminogen activator and / or too thick to be treated with anti-VEGF therapy. In these patients no therapy or removal of the haemorrhage alone had a poor result. As regards the complications incurred in this study cohort: in the RPE-choroid graft group, recurrent retinal detachment due to proliferative vitreoretinopathy (PVR) developed in three out of 10 patients, severe hypotony in two (one without PVR) and recurrent submacular hemorrhage in three patients (two without PVR). cerebrovascular accident occurred in one patient. In the anti-VEGF group, a recurrent retinal detachment due to PVR developed in one out of 10 patients, a transient ischaemic attack in two, and a minor stroke occurred in one patient. Patients in the RPE-choroid graft group suffered more complications. VA gain and loss was obtained by both treatment methods. The authors suggest that greater VA gain might be possible for patients who undergo an RPE-choroid graft transplantation surgery than those who continue with anti-VEGF treatment alone. However, this may come at the risk of some severe complications. Limitations of this study were the small cohort, single centered and short follow up period. 

Comparing retinal pigment epithelium-choroid graft surgery and anti-VEGF therapy in patients with exudative age-related macular degeneration.
van Zeeburg EJT, Cereda MG, Amarakoon S, van Meurs JC.
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Sofia Rokerya

MBBS MRCOphth FRCSI, King's College University Hospital, UK.

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