Virgili G, Bini A
University of Florence, Department of Ophthalmology, Via le Morgagni 85, Florence, Italy, 50134.
Cochrane Database Syst Rev. 2007 Jul 18(3):CD004763. doi: 10.1002/14651858.CD004763.pub2.
Laser photocoagulation was the first treatment introduced to try to halt the progression of neovascular age-related macular degeneration (AMD), in which newly formed vessels or choroidal neovascularisation (CNV) grow under the macula leading to the occurrence of a scotoma or blind spot in the central visual field.
The aim of this review was to examine the effects of laser photocoagulation for neovascular AMD.
We searched the CENTRAL, MEDLINE, EMBASE, LILACS, NRR and ZETOC in March 2007.
We included randomised trials of laser photocoagulation in people with CNV due to AMD.
Two authors independently extracted the data. The risk ratio (RR) of severe visual loss (loss of six or more lines of visual acuity) was estimated at three months and two years after treatment.
Fifteen trials were included in the review (2064 participants). Three types of photocoagulation were used in the trials: direct photocoagulation of the entire CNV (11 trials), perifoveal photocoagulation (one trial) and grid photocoagulation (three trials). In 12 trials the control group was observation only. One trial compared photocoagulation to submacular surgery and two trials compared different lasers. Data on the progression of visual loss could be extracted from five of the eight trials of direct photocoagulation of the CNV versus observation. The treatment effect was in the direction of harm in all studies at three months follow up (RR 1.41, 95% confidence intervals (CI) 1.08 to 1.82). After two years the treatment effect was in the direction of benefit (RR 0.67, 95% CI 0.53 to 0.83). These studies were clinically heterogeneous with participants having CNV lesions in different locations and different baseline visual acuities. There was little evidence of statistical heterogeneity at three months but substantial statistical heterogeneity at two years. However, all treatment effects in the individual trials were in the direction of benefit. One study comparing perifoveal photocoagulation or observation of subfoveal CNV found benefits that were statistically significant only at two years (RR 0.36, 95% CI 0.18 to 0.72). Other comparisons did not demonstrate differences.
AUTHORS' CONCLUSIONS: In the medium to long term laser photocoagulation of CNV slows the progression of visual loss in people with neovascular AMD. However, it is associated with an increased risk of visual loss immediately after treatment and this period may be longer in people with subfoveal AMD. With the advent of modern pharmacological therapies, and concern for the impact of iatrogenic scotoma in subfoveal CNV, laser photocoagulation of subfoveal CNV is not recommended. No studies have compared photocoagulation with modern pharmacological agents for AMD for non-subfoveal CNV.
激光光凝术是最早用于试图阻止新生血管性年龄相关性黄斑变性（AMD）进展的治疗方法。在这种疾病中，新形成的血管或脉络膜新生血管（CNV）在黄斑下生长，导致中心视野出现暗点或盲点。
本综述的目的是研究激光光凝术治疗新生血管性AMD的效果。
我们于2007年3月检索了Cochrane中心对照试验注册库（CENTRAL）、医学索引数据库（MEDLINE）、荷兰医学文摘数据库（EMBASE）、拉丁美洲和加勒比地区卫生科学数据库（LILACS）、挪威医学索引数据库（NRR）和英国图书馆文献数据库（ZETOC）。
我们纳入了因AMD导致CNV的患者接受激光光凝术的随机试验。
两位作者独立提取数据。估计治疗后三个月和两年时严重视力丧失（视力下降6行或更多）的风险比（RR）。
本综述纳入了15项试验（2064名参与者）。试验中使用了三种光凝术：对整个CNV进行直接光凝（11项试验）、黄斑周围光凝（1项试验）和格栅样光凝（3项试验）。在12项试验中，对照组仅为观察。1项试验将光凝术与黄斑下手术进行了比较，2项试验比较了不同的激光。在8项对CNV进行直接光凝与观察的试验中，有5项可以提取视力丧失进展的数据。在所有研究中，随访三个月时治疗效果显示有害（RR 1.41，95%置信区间（CI）1.08至1.82）。两年后治疗效果显示有益（RR 0.67，95%CI 0.53至0.83）。这些研究在临床上存在异质性，参与者的CNV病变位置和基线视力不同。三个月时几乎没有统计学异质性的证据，但两年时有显著的统计学异质性。然而，各个试验中的所有治疗效果均显示有益。1项比较黄斑周围光凝或观察黄斑下CNV的研究发现，仅在两年时有益效果具有统计学意义（RR 0.36，95%CI 0.18至0.72）。其他比较未显示差异。
从中长期来看，CNV的激光光凝术可减缓新生血管性AMD患者视力丧失的进展。然而，它与治疗后立即出现视力丧失风险增加相关，对于黄斑下AMD患者，这一时期可能更长。随着现代药物治疗的出现，以及对黄斑下CNV中医源性暗点影响的关注，不建议对黄斑下CNV进行激光光凝术。尚无研究比较光凝术与治疗非黄斑下CNV的AMD的现代药物。
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