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Advancing surgical techniques have made the surgical excision of subfoveal CNV possible in all cases. However, serious surgical complications lead to a limited visual outcome in many cases. The major complications that cause poor visual outcome are related to poor case selection and include injury to the RPE, with secondary atrophy of the choriocapillaris and damage to the neurosensory retina, and a high rate of persistent or recurrent CNV. Patients with POHS have localized disease of the RPE-Bruch's membrane complex and typically have CNV growing between the RPE and neurosensory retina (type 2 CNV). These patients have the best visual prognosis postoperatively because of the potential for maintaining native RPE beneath the fovea. Patients with AMD typically have CNV growing beneath the RPE (type I CNV). These patients are poor surgical candidates because the surgical excision of type I CNV is almost always associated with débridement of native subfoveal RPE and a poor visual outcome. Presently, all surgical studies have been retrospective and are characterized by limited follow-up. Therefore, whether surgical excision of subfoveal CNV is beneficial as compared to mere observation is uncertain. A large, randomized, prospective study currently is being performed. These Submacular Surgery Trials will attempt to determine whether these surgical procedures are more efficacious than observation and whether the benefits outweight the risks of surgery in these patients.

Purpose: To determine whether drusen in patients with age-related maculopathy and macular degeneration (ARM/AMD) are associated with focal changes in retinal pigment epithelium (RPE) lipofuscin fluorescence., Method: A new autofluorescence imaging device was used to study lipofuscin distribution associated with individual drusen in 20 patients with ARM/AMD. Paired monochromatic and autofluorescence fundus images were used for detailed analysis of the topography of autofluorescence at specific sites containing drusen. In four eyes, image analysis was used to compare the spatial distribution of the autofluorescence with the location of drusen and to quantify the autofluorescence distribution over individual drusen (54 drusen). REsuLTs. A specific pattern of autofluorescence was frequently found to be spatially associated with hard drusen and soft drusen between 60 and 175 microm in size. The pattern is characterized by a central area of decreased autofluorescence surrounded, in most cases, by an annulus of increased autofluorescence. The location of this pattern was highly correlated with the position of individual distinct drusen. The central low autofluorescence focus was on average 16% below the surrounding background, and the annulus, when present, was on average 6% more fluorescent than the background. Soft drusen larger than 175 microm and confluent soft drusen show either multifocal areas of low autofluorescence or a more heterogeneous distribution. CONCLUSIoNs. Autofluorescence imaging permits measurement of RPE lipofuscin at specific sites. RPE overlying drusen have altered autofluorescence, suggesting changes in RPE health.