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Meta-Analysis
. 2015 Oct 23;2015(10):CD006537.
doi: 10.1002/14651858.CD006537.pub3.

Laser treatment of drusen to prevent progression to advanced age-related macular degeneration

Gianni Virgili  1 , Manuele Michelessi, Maurizio B Parodi, Daniela Bacherini, Jennifer R Evans
Affiliations
Meta-Analysis

Laser treatment of drusen to prevent progression to advanced age-related macular degeneration

Gianni Virgili et al. Cochrane Database Syst Rev. .

Abstract

Background: Drusen are amorphous yellowish deposits beneath the sensory retina. People with drusen, particularly large drusen, are at higher risk of developing age-related macular degeneration (AMD). The most common complication in AMD is choroidal neovascularisation (CNV), the growth of new blood vessels in the centre of the macula. The risk of CNV is higher among people who are already affected by CNV in one eye.It has been observed clinically that laser photocoagulation of drusen leads to their disappearance and may prevent the occurrence of advanced disease (CNV or geographic atrophy) associated with visual loss.

Objectives: To examine the effectiveness and adverse effects of laser photocoagulation of drusen in AMD.

Search methods: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015, Issue 7), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to August 2015), EMBASE (January 1980 to August 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to August 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 3 August 2015.

Selection criteria: Randomised controlled trials (RCTs) of laser treatment of drusen in AMD in which laser treatment had been compared with no intervention or sham treatment. Two types of trials were included. Some trials studied one eye of each participant (unilateral studies); other studies recruited participants with bilateral drusen and randomised one eye to photocoagulation or control and the fellow eye to the other group.

Data collection and analysis: Two review authors independently selected studies and extracted data. We pooled data from unilateral and bilateral studies using a random-effects model. For the bilateral studies, we estimated the within-person correlation coefficient from one study and assumed it was valid for the others.

Main results: The update of this review found two additional studies, totaling 11 studies that randomised 2159 participants (3580 eyes) and followed them up to two years, of which six studies (1454 participants) included people with one eye randomised to treatment and one to control. Studies were conducted in Australia, Europe and North America.Overall, the risk of bias in the included studies was low, particularly for the larger studies and for the primary outcome development of CNV. Photocoagulation did not reduce the development of CNV at two years' follow-up (odds ratio (OR) 1.07, 95% confidence interval (CI) 0.79 to 1.46, 11 studies, 2159 participants (3580 eyes), high quality evidence). This estimate means that, given an overall occurrence of CNV of 8.3% in the control group, we estimated an absolute risk reduction by no more than 1.4% in the laser group, according to the lower CI limit. Only two studies investigated the effect on the development of geographic atrophy and could not show a difference, but estimates were imprecise (OR 1.30, 95% CI 0.38 to 4.51, two studies, 148 participants (148 eyes), low quality evidence).Among secondary outcomes, photocoagulation led to drusen reduction (OR 9.16, 95% CI 6.28 to 13.4, three studies, 570 participants (944 eyes), high quality evidence) but was not shown to limit loss of 3 or more lines of visual acuity (OR 0.99, 95% CI 0.81 to 1.22, nine studies, 2002 participants (2386 eyes), moderate quality evidence).In a subgroup analysis, no difference could be shown for conventional visible (eight studies) versus subthreshold invisible (four studies) photocoagulation for the primary outcomes (P value = 0.29). The effect in the subthreshold group did not suggest a relevant benefit (OR 1.27, 95% CI 0.82 to 1.98). No study used micropulse subthreshold photocoagulation.No other adverse effects (apart from development of CNV, geographic atrophy or visual loss) were reported.

Authors' conclusions: The trials included in this review confirm the clinical observation that laser photocoagulation of drusen leads to their disappearance. However, treatment does not result in a reduction in the risk of developing CNV, and was not shown to limit the occurrence of geographic atrophy or visual acuity loss.Ongoing studies are being conducted to assess whether the use of extremely short laser pulses (i.e. nanosecond laser treatment) cannot only lead to drusen regression but also prevent neovascular AMD.

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Conflict of interest statement

None known.

Figures

1
1
Potential impact of a new study on the meta‐analysis using the command 'extfunnel' in Stata (see Data synthesis and Langan 2012). sig: significant.
2
2
Study flow diagram.
3
3
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
4
4
Photocoagulation versus control, outcome: Development of CNV at two years (see Figure 5; CNVPT; Laser to Drusen Study 1995; Olk 1999; PTAMD unilateral 2002). Graphical assessment of the risk of bias due to incomplete outcome data in unilateral studies with missing data reported (see Appendix 8). The minimum and maximum odds ratio change, compared to complete or available cases, is assessed graphically and subjectively taking into account its 95% CI. CI: confidence interval; max: maximum; min: minimum.
5
5
Forest plot of comparison: 1 Photocoagulation versus control, outcome: 1.1 Development of choroidal neovascularisation (two studies provided data on both unilateral and bilateral participants).
6
6
Contour enhanced funnel‐plot investigating small study bias for the primary outcome 'development of choroidal neovascularisation or geographic atrophy'. Shaded areas are areas of statistical significance as explained in the legend.
1.1
1.1. Analysis
Comparison 1 Photocoagulation versus control, Outcome 1 Development of choroidal neovascularisation (CNV).
1.2
1.2. Analysis
Comparison 1 Photocoagulation versus control, Outcome 2 Development of CNV: sensitivity analysis assuming moderate correlation (0.5) for bilateral studies.
1.3
1.3. Analysis
Comparison 1 Photocoagulation versus control, Outcome 3 Development of geographic atrophy.
1.4
1.4. Analysis
Comparison 1 Photocoagulation versus control, Outcome 4 Visual loss of 2 to 3+ lines.
1.5
1.5. Analysis
Comparison 1 Photocoagulation versus control, Outcome 5 Loss of ≥ 0.3 log units of contrast sensitivity at 2 years.
1.6
1.6. Analysis
Comparison 1 Photocoagulation versus control, Outcome 6 Reading speed (words/minute).
1.7
1.7. Analysis
Comparison 1 Photocoagulation versus control, Outcome 7 Drusen reduction.
1.8
1.8. Analysis
Comparison 1 Photocoagulation versus control, Outcome 8 Subgroup analysis: development of CNV by type of laser.
1.9
1.9. Analysis
Comparison 1 Photocoagulation versus control, Outcome 9 Subgroup analysis: development of CNV in subthreshold vs. visible/standard photocoagulation.
See this image and copyright information in PMC

Update of

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References to other published versions of this review

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