Graefe's Arch Clin Exp Ophthalmol (1986)224:101-105 Graefe'sArchive for Clinical and Experimental Ophthalmology © Springer-Verlag1986 Krypton red laser photocoagulation of peripapillary subretinal neovascular membranes* W.H. Annesley, Jr., H.G. Shah, A.M. Mansour, and W.L. Decker Retina Service, Wills Eye Hospital, Philadelphia, Pennsylvania, USA Abstract. The visual outcome of 20 eyes of 20 patients with peripapillary subretinal neovascular membranes (SRNVM) treated with krypton red laser photocoagulation (KRLP) was studied. Complete obliteration of the SRNVM was achieved in all eyes in the study. In 318 of 20 patients, the visual acuity improved or remained the same during an average follow-up of 9.9 months. There were no treatment- related complications. The efficacy of KRLP in the manage- ment of patients with peripapillary SRNVM is discussed. Introduction The natural history of peripapillary subretinal neovascular membranes (SRNVM) in the aging eye has not been well- documented, primarily because these lesions are relatively less common than macular SRNVM and because most symptomatic patients are treated with photocoagulation early in the course of their disease. However, extrapolation from information on the natural history of peripapillary SRNVM associated with the presumed ocular histoplasmo- sis syndrome (Gutman 1979) suggests an unfavorable visual prognosis if such neovascular lesions are left untreated Hemorrhages or exudates associated with peripapillary SRNVM (Figs. 1, 2a and b) may lead to serous or hemor- rhagic macular detachment and visual impairment (Harris et al. 1981 ; Gass 1977). If left untreated, the SRNVM may enlarge to involve the macula, further compromising central vision (Gass 1977). Isolated case reports have described successful closure of peripapillary SRNVM using xenon arc (Gutman 1979; Wessing 1983; Cantrill and Burgess 1980) and argon laser photocoagulation (Jay et al. 1984; Jack 1978). Krypton red laser photocoagulation (KRLP) has been reported to be effective for obliteration of macular subretinal neovascular membranes (Yassur et al. 1982; Bird and Grey 1979; Yan- nuzzi 1982), but its effectiveness in treating juxtapapillary SRNVM has not been demonstrated. We present here our results with KRLP of peripapillary SRNVM in the aging eye. * Presented at Jules Gonin Club, Lucerne, Switzerland in Sep- tember 1984 Offprint requests to: William H. Annesley, Jr., M.D., Retina Ser- vice, Wills Eye Hospital, 9th and Walnut Streets, Philadelphia, PA 19107, USA Subjects and methods The patient population consisted of 20 patients who were found to have peripapillary SRNVM on clinical examina- tion and were either symptomatic or had SRNVM involving the papillomacular bundle (Fig. 3) or temporal disc margin. Their ages ranged from 64 to 87 years with a mean of 73.7 years (Table 2). Patients below age 60 years, those with any history of prior laser photocoagulation, and those with SRNVM associated with the presumed ocular histoplasmo- sis syndrome, angioid streaks, optic disc drusen, an optic pit, or ocular trauma were excluded from this study. All the patients had a complete eye examination. This included slit lamp biomicroscopy, direct and indirect oph- thalmoscopy, Amsler grid testing, color fundus photogra- phy and intravenous fluorescein angiography prior to treat- ment with KRLP. Patients with SRNVM that extended into the foveal avascular zone (FAZ) on pre-treatment fluo- rescein angiography were also excluded from this study. The approximate distance from the center of the fovea and the area of SRNVM were measured from the positive 5 x magnified image of a mid-phase fluorescein angiogram frame, using the horizontal disc diameter (approximately 1.5 ram) as a reference measiarement. All patients were treated under topical anesthesia with KRLP by the senior author using a Coherent radiation krytpon red laser unit and a Goldmann contact lens. The instrument settings included 0.2-1.0 s exposure, 200 gm spot size and 200-500 mW intensity sufficient to produce a confluent whitening of the SRNVM (Fig. 4). Color fun- dus photography and fluorescein angiography were re- peated 2 weeks following KRLP to assess the adequacy of the treatment. A persistent SRNVM evidenced on a repeat fluorescein angiogram was treated until complete ablation was achieved (Fig. 5). Patients were then followed at 4 weeks, 6 months, and 1 year intervals with a complete clinical examination and a repeat fluorescein study. Results Twenty eyes of the 20 patients underwent KRLP to the peripapillary SRNVM. In all 20 eyes, complete closure of the SRNVM was achieved after an average of two treat- ment sessions. The frequency distribution of the treatments is presented in Table 1. In 9 of the 20 eyes (45%), the SRNVM was ablated after a single treatment. Five of the 20 eyes (25%) required two treatments and 6 (30%) re-