Age related macular degeneration
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7387.485 (Published 01 March 2003) Cite this as: BMJ 2003;326:485All rapid responses
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Dear sir
We fully agree with the analyses of present status of Surgery for
age related macular degeneration by Charteris et al. Our paper was
primarily aimed at general physicians and we did not want to send
confusing messages with lots of highly specialised evolving treatment
those are not yet available widely. We have tried to send a positive
message to a wider audience to draw their attention to a growing problem.
A. Chopdar, U. Chakraverthy, D. Verma
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor.
The review of age-related macular degeneration (AMD) by Chopdar and
co-authors was timely(ref 1). However they did not draw attention to the
association of current smoking with AMD. Three large, well executed,
population based, cross sectional studies examined AMD risk factors in
Australia, Europe and North America. The pooled results for 12,468
subjects studied therein strongly suggest an association between current
smoking and AMD(ref2). For all types of AMD, an odds ratio of 3.12 (95% CI
2.10-4.64) was observed when current smokers were compared with subjects
who had never smoked. In addition, subjects who had stopped smoking had a
slightly increased risk of AMD compared with those who had never smoked:
odds ratio 1.36 (95% CI 0.97-1.90). The association was maintained when
atrophic AMD and neovascular AMD were evaluated separately, odds ratios of
2.54 (95% CI 1.25-5.17) and 4.55 (95% CI 2.74 -7.54), respectively, and
when current smokers were compared with never smokers.
Longer follow up further confirms the link between smoking and AMD (ref 3-
4). The Australian Blue Mountains Eye Study showed that smokers developed
late AMD ten years earlier than non-smokers.(ref 4) Because of this
smoking was estimated to cause or contribute to up to 20% of blindness in
persons aged over 50.
The author’s prevention and treatment section focused largely on high
-technology therapeutic interventions. Despite the strong association
between smoking and AMD, there was no mention of the important role of
smoking cessation in prevention. It seems to us that those concerned with
eye health are not giving enough weight to smoking cessation and those
concerned with tobacco control and smoking cessation are not giving enough
weight to eye health(ref 5).
Many of the general population and many patients attending eye
services recognise the systemic adverse effects of smoking. In our
experience they are largely unaware of the link with eye disease. However,
when warned of the increased risk, they are often keen to stop smoking and
frequently do so. Older smokers and their doctors often struggle to find
compelling reasons why they should give up smoking late in life – risk of
sudden death from heart attack or stroke may be less persuasive than the
loss of independence caused by blindness. Appropriate smoking cessation
support should be offered.
The ocular hazards of smoking should be highlighted further. In
Australia, national co-ordinated efforts on network television to raise
the public awareness of smoking as a cause of blindness have been
encouraging.
Simon P Kelly.
Consultant Ophthalmic Surgeon
Bolton Hospitals NHS Trust,
Bolton BL4 OJR. UK
Richard Edwards.
Senior Lecturer in Public Health Medicine,
Evidence for Population Health Unit,
School of Epidemiology and Health Sciences,
The Medical School,
University of Manchester,
Oxford Road,
Manchester M13 9PT. UK
Peter Elton.
Director of Public Health,
Bury Primary Care NHS Trust,
21 Silver Street, Bury, BL9 0EN. UK
Paul Mitchell.
Professor of Clinical Ophthalmology,
University of Sydney Department of Ophthalmology
Centre for Vision Research,
Westmead Hospital, Westmead, 2145
Australia
REFERENCES.
1 Chopdar A, Chakravarthy U, Verma D. Age related macular
degeneration. BMJ 2003; 326: 485-8
2 Smith W, Assink J, Klein R, Mitchell P, Klaver CCW, Klein BEK, et
al. Risk factors for age-related macular degeneration. Pooled findings
from three continents. Ophthalmology 2001; 108: 697-704.
3 Klein R, Klein BEK, Tomany SC, Moss SE. Ten-year incidence of age-
related maculopathy and smoking and drinking. The Beaver Dam Eye Study. Am
J Epidemiol 2002; 156: 589-98.
4 Mitchell P, Wang JJ, Smith W, Leeder SR. Smoking and the 5-year
incidence of age-related maculopathy: the Blue Mountains Eye Study. Arch
Ophthalmol 2002; 120: 1357-63.
5 Mitchell P, Chapman S, Smith W. "Smoking is a major cause of
blindness": a new cigarette pack warning? (editorial) Med J Aust 1999;
171:173-4.
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor
We read the clinical review on age related macular degeneration (AMD)
with interest.(1) The authors are congratulated for giving a succinct and
comprehensive review of the subject. They used Medline for literature
search but appeared to have neglected over 75 publications on macular
relocation surgery for age related and myopic macular degeneration. The
authors concluded “…no current treatment will restore vision that has
already been lost”. The excitement over macular relocation is precisely
because it is capable of improving vision in some patients despite
moderate and severe visual loss.(2,3) Lai et al reported that at 6
months, the reading vision was significant improved from 0.54 to 0.40
LogMAR units in a consecutive series of 15 patients[ p=0.02](4). In a
consecutive series of 90 patients, the Cologne group found that 12 months
after surgery, one third improved (by 3 or more lines of distance visual
acuity), one third stabilised and one third deteriorated.(5) Pertile and
Claes recently reported that in a consecutive series of 50 cases with a
median follow-up of 21 months 66% improved (2 or more lines), 28% remained
stable (± 1 line) and only 6% deteriorated (2 or more lines).(6)
Macular relocation surgery is complex and prone to complications
including proliferative vitreoretinopathy (PVR).(7) As experience of this
surgery increases it appears however that the complication rate (and
surgical time) is falling and that the success rate is rising.(8) Recent
work showing that adjuvant treatments can be used to prevent PVR have also
given rise to optimism.(9) Moreover, macular relocation surgery has the
potential to treat geographic atrophy (dry AMD) and advanced disease
(including subfoveal haemorrhage) which will not be amenable to any anti-
angiogenic strategy.
An international prospective randomised controlled trial (MARAN )(a)
is underway for patients with occult subfoveal choroidal neovascular
membrane funded by the Deutsche Forschungsgemeinschaft (the German medical
research council). Other non-comparative pilots studies are being
undertaken to identify which subgroups of patients who are most likely to
benefit from macular relocation surgery and to assist in the planning of
other prospective randomised trials.
Whilst semiconductor chip technology and the “electronic eye” have
captured the imagination of public, in truth the “bionic eye” is perhaps
much further away from benefiting patients than macular relocation
surgery.
David Wong (b) , David Charteris (c) , Lyndon da Cruz (c)
(a) Macular Relocation for Age Related Neovascular disease
(b) St Paul's Eye Unit, Royal Liverpool University Hospital
(c) Moorfields Eye Hospital
References
1. Chopdar A, Chakravarthy U, Verma D. Age related macular
degeneration.
BMJ 2003;326(7387):485-8.
2. Cekic O, Ohji M, Hayashi A, Fujikado T, Tano Y. Foveal translocation
surgery in age-related macular degeneration. Lancet 1999;354(9175):340.
3. Wong D, Harding S, Grierson I. Foveal translocation with secondary
confluent laser for subfoveal CNV in AMD: 12 month follow up. Br J
Ophthalmol 2000;84(6):670-1.
4. Lai JC, Lapolice DJ, Stinnett SS, Meyer CH, Arieu LM Keller MA, Toth
CA Visual outcomes following macular translocation with 360-degree
peripheral retinectomy. Arch Ophthalmol 2002; 120: 1317-24.
5. Aisenbrey S, Lafaut BA, Szurman P, Grisanti S, Luke C, Krott R, Thumann
G, Fricke J, Neugebauer A, Hilgers RD, Esser P, Walter P, Bartz-Schmidt
KU. Macular translocation with 360 degrees retinotomy for exudative age-
related macular degeneration. Arch Ophthalmol 2002;120(4):451-9.
6. Pertile G, Claes C. Macular translocation with 360 degree retinotomy
for management of age-related macular degeneration with subfoveal
choroidal neovascularization. Am J Ophthalmol 2002;134(4):560.
7. Eckardt C, Eckardt U, Conrad HG. Macular rotation with and without
counter-rotation of the globe in patients with age-related macular
degeneration. Graefes Arch Clin Exp Ophthalmol 1999;237(4):313-25.
8. Toth CA, Freedman SF. Macular translocation with 360-degree peripheral
retinectomy impact of technique and surgical experience on visual
outcomes. Retina 2001;21(4):293-303.
9. Asaria RH, Kon CH, Bunce C, Charteris DG, Wong D, Khaw PT, GW Aylward
Adjuvant 5-fluorouracil and heparin prevents proliferative
vitreoretinopathy : Results from a randomized, double-blind, controlled
clinical trial. Ophthalmology 2001;108(7):1179-83.
Competing interests:
None declared
Competing interests: No competing interests
Re: Smoking and risk of Age Related Maculopathy.
Dear Sir
We recognise that smoking is a risk factor for agerelated macular
degeneration. We clearly advocate cessation of smoking as outlined in
page 487 of our article.[1]
1. Chopdar A, Chakraverthy U, Verma D; BMJ 2003;326:485-8
Competing interests:
None declared
Competing interests: No competing interests