When to intervene
In selected cases of wet AMD, or when macular disease is associated with mechanical complications (macular hole, pucker), laser or macular surgery may be used. These are specialist, selective procedures: they are needed in specific cases, but in those cases they can restore significant visual function.
- Laser in dry AMD
- No laser treatment has been shown to slow dry AMD.
- PDT indication
- Specific forms of wet AMD (PCV, recurrent MNV) — combined with anti-VEGF.
- Vitrectomy indication
- Macular hole, macular pucker with traction, macular oedema with vitreous traction.
- Follow-up
- Always necessary — macular disease is chronic, so regular check-ups and the Amsler grid test at home are required.
Laser treatments
Laser treatments for macular disease are outpatient procedures and are quick, but their role is now limited: in wet AMD the main treatment is anti-VEGF injections.
Photodynamic therapy (PDT) is reserved for particular forms of wet AMD (polypoidal choroidal vasculopathy, recurrent MNV) — often combined with anti-VEGF injections.
The procedure
The treatment is carried out by placing a contact lens on the eye that focuses the laser, after anaesthetic eye drops. PDT requires a preliminary intravenous injection of a light-sensitive medicine (verteporfin), which is then selectively activated by the laser on the neovascular areas.
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Nanosecond laser (2RT)
Not a standard treatmentIt uses pulses of light lasting nanoseconds on the retinal pigment epithelium. It was proposed to slow dry AMD in the intermediate stages.
In the largest controlled study (LEAD, 2019) it did not significantly slow the progression to the advanced form, and in patients with reticular pseudodrusen the disease progressed more quickly. For this reason it is not a recommended treatment: if it is suggested to you, ask your ophthalmologist what evidence there is for your case.
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Photodynamic therapy (PDT)
Specific forms of wet AMDIt combines a light-sensitive medicine injected into a vein (verteporfin) with a low-power laser that selectively activates it on the abnormal new blood vessels, causing them to close. A less invasive procedure than traditional laser photocoagulation.
Today it is reserved for particular forms of wet AMD — polypoidal choroidal vasculopathy (PCV) and recurrent neovascularisation that resists anti-VEGF treatment. It is often combined with anti-VEGF injections to maximise its effectiveness.
Achievable results
PDT combined with anti-VEGF gives good results in polypoidal choroidal vasculopathy (PCV) and in some atypical forms of wet AMD. In dry AMD, on the other hand, no laser has been shown to slow the disease. PDT is complementary to injections — they do not replace OCT monitoring and the Amsler grid test at home, which are essential for every patient.
Macular surgery
Some complications of macular disease or associated macular conditions (full-thickness macular hole, macular pucker with traction, vitreomacular traction) require incisional surgery: pars plana vitrectomy with peeling of the internal limiting membrane (ILM). It is precision microsurgery performed in the operating theatre.
Macular vitrectomy consists of removing the vitreous body through three small access points (25 or 27 gauge microsurgery) and, above all, performing the peeling of the ILM — the very thin membrane covering the macula. Special forceps gently lift the ILM, removing the traction forces that distort the macula.
Peeling is often preceded by removal of the epiretinal membrane in macular pucker. At the end, the eye is filled with saline or — in the case of a macular hole — with a gas tamponade (SF6 or C3F8) that keeps the hole closed while it heals.
The operation takes 1-2 hours, under local anaesthesia with sedation. Modern minimally invasive techniques allow faster recovery than in the past. After surgery for a macular hole, a face-down position, maintained for a few days, is essential to help the hole close.
When it is really needed
Macular surgery is not a first-line procedure for AMD. It is instead the treatment of choice for: full-thickness macular hole, macular pucker with marked metamorphopsia or loss of vision, vitreomacular traction syndrome. In these cases the anatomical success rate is high and often translates into significant recovery of central vision.
After surgery
Recovery after macular surgery requires discipline — above all, the required positioning if a gas bubble has been used. The success of the procedure depends largely on how closely the patient follows the instructions. What follows is only an example: always follow the instructions given by the centre that operated on you.
What to do
- Instil the eye drops (antibiotic, anti-inflammatory) strictly following the schedule in the discharge letter.
- If a gas tamponade is in place (macular hole), maintain the face-down position for the number of days set by the centre.
- Protect the operated eye with sunglasses during the day and, if prescribed, with a rigid eye shield at night, for the period advised by the centre.
- Gently clean the eyelids with sterile gauze and saline, without pressing on the eyeball.
- Attend all post-operative check-ups scheduled by the centre.
- Continue the Amsler grid test on the other eye: macular disease can also affect the fellow eye.
What to avoid
- DO NOT strain your eye: ask the centre when you can go back to reading, screens and other demanding visual activities.
- No physical exertion and no lifting heavy weights, including carrying children, for the period advised by the centre.
- Do NOT travel by air if there is gas in the eye (it can expand with cabin pressure): wait for complete reabsorption, confirmed by the ophthalmologist.
- No swimming pools, sea, saunas or whirlpool baths for the period advised by the centre.
- Avoid dusty, smoky or windy places in the first few weeks.
- Do NOT sleep on the side of the operated eye, for the period advised by the centre.
Important to remember
Both laser treatments and surgery do not replace long-term monitoring of macular disease: regular eye examinations, periodic OCT and the Amsler grid test at home remain essential. Contact your ophthalmologist straight away if you have sudden pain, rapid loss of vision, marked redness, flashes of light or an increase in floaters — these are early signs of complications (endophthalmitis, retinal detachment) that need urgent treatment.