Sivaprasad Sobha, Acharya Nachiketa, Hykin Phil
Moorfields Eye Hospital, London, UK.
Clin Ophthalmol. 2008 Jun;2(2):347-54. doi: 10.2147/opth.s2601.
The pathogenesis of age-related macular degeneration (AMD) is unclear, but it can take either a neovascular/exudative/wet form, characterized by choroidal neovascularization (CNV), or a dry form. No treatments are available for the dry form, but there are a number of pharmacological interventions that inhibit vascular endothelial growth factor (VEGF), which is central to the pathogenesis of CNV and neovascular AMD. Available anti-VEGF agents either target all active VEGF isoforms (eg, ranibizumab), or take a more selective approach and inhibit only VEGF(165) (eg, pegaptantib sodium). Current guidance on their use is equivocal and restrictive at best, resulting in associated difficulties in securing adequate, timely funding for treatment. The Moorfields Eye Hospital undertook an audit of 70 patients receiving intravitreal (ITV) pegaptanib sodium on a pro re nata (prn) dosing schedule. Despite initial funding delays, the audit recorded superior treatment outcomes compared with those reported in the VISION trials at 12 weeks: 88% of audit patients maintained stable vision, 29% gained vision and 6% experienced severe vision loss compared with 70%, >/=6% and </=10% of patients in VISION at 54 weeks, respectively. The audit indicates a positive correlation between patients with better baseline visual acuity (VA) and improved therapeutic benefits, including a greater likelihood of both vision gain and vision preservation. Experience at Moorfields also suggests that pegaptanib sodium is more useful in occult lesions than minimally classic lesions, and clinical experience suggests that combination therapies may offer the best approach with anti-VEGF therapies. Further randomized clinical trials will help better determine the optimal treatment strategies with pegaptanib sodium in neovascular AMD.
年龄相关性黄斑变性（AMD）的发病机制尚不清楚，但它可以呈现新生血管/渗出性/湿性形式，其特征为脉络膜新生血管（CNV），或者干性形式。干性AMD尚无治疗方法，但有多种抑制血管内皮生长因子（VEGF）的药物干预措施，VEGF是CNV和新生血管性AMD发病机制的核心。现有的抗VEGF药物要么靶向所有活性VEGF异构体（如雷珠单抗），要么采取更具选择性的方法，仅抑制VEGF(165)（如培加他尼钠）。目前关于其使用的指导意见充其量是模棱两可且具有限制性的，导致在确保获得足够、及时的治疗资金方面存在相关困难。摩尔菲尔兹眼科医院对70例接受按需（prn）给药方案玻璃体内注射培加他尼钠的患者进行了一项审计。尽管最初资金延迟，但审计记录显示，与VISION试验在12周时报告的结果相比，治疗效果更佳：审计患者中有88%视力保持稳定，29%视力提高，6%经历严重视力丧失，而VISION试验在54周时的患者分别为70%、≥6%和≤10%。审计表明，基线视力（VA）较好的患者与改善的治疗效果之间存在正相关，包括视力提高和视力保留的可能性更大。摩尔菲尔兹的经验还表明，培加他尼钠在隐匿性病变中比最小经典病变更有用，临床经验表明联合治疗可能是抗VEGF治疗的最佳方法。进一步的随机临床试验将有助于更好地确定培加他尼钠在新生血管性AMD中的最佳治疗策略。
