Transpupillary Thermotherapy of Occult Subfoveal Choroidal Neovascularization in Patients with Age-related Macular Degeneration Elias Reichel, MD, Audina M. Berrocal, MD, Michael Ip, MD, Arnold J. Kroll, MD, Vinay Desai, MD, Jay S. Duker, MD, Carmen A. Puliafito, MD Objective: To evaluate the efficacy of transpupillary thermotherapy for the treatment of occult subfoveal choroidal neovascularization (CNV) in patients with age-related macular degeneration. Design: A retrospective, noncomparative case series. Participants: Sixteen eyes of 15 consecutive patients who presented with occult subfoveal choroidal neovascularization secondary to age-related macular degeneration. Intervention: After informed consent was obtained, 16 eyes of 15 patients were treated with transpupillary thermotherapy. All patients underwent pretreatment fluorescein angiography and were deemed untreatable by the Macular Photocoagulation Study standard. Transpupillary thermotherapy was delivered using a diode laser at 810 nm. A variable spot size of 1.2 mm, 2.0 mm, or 3.0 mm was used depending on the size of CNV. The diode laser was delivered through a contact lens, and treatment was initiated in one spot for 60 seconds’ duration at a power range between 360 and 1000 mW. The end point was an area of no visible color change to a light-gray appearance. Main Outcome Measures: In all eyes, outcome was assessed by Snellen chart visual acuity and clinical examination. In 10 of 16 eyes, preoperative and postoperative fluorescein angiography and optical coherence tomography were available. In the remaining 6 of 16 eyes, exudation was measured by postoperative clinical examination alone. Results: Three eyes (19%) showed a two-or-more-line improvement in visual acuity over a period of 6 to 25 months. Mean follow-up was 13 months. Visual acuity remained stable (no change or one-line improvement) in nine treated eyes (56%). The remaining four eyes (25%) showed a decline (equal to one-line worsening or greater) in visual acuity. Fifteen eyes (94%) demonstrated decreased exudation on fluorescein angiography, optical coherence tomography, and/or clinical examination. Conclusions: Transpupillary thermotherapy shows no deleterious side effects in treating occult subfoveal choroidal neovascularization. A randomized, prospective study is necessary to evaluate treatment efficacy. Ophthalmology 1999;106:1908 –1914 Age-related macular degeneration (ARMD) is the leading cause of central visual loss in patients older than 50 years of age in the United States. The majority of eyes suffer severe visual loss as a result of choroidal neovascularization (CNV), which is the formation of new blood vessels either between the retinal pigment epithelium and Bruch mem- brane or the subretinal space. The only proven effective treatment is laser photocoagulation. The Macular Photoco- agulation Study demonstrated that treatment of well-defined subfoveal CNV was beneficial, but most patients experi- enced an immediate decline in vision because of damage to the overlying neurosensory retina. 1 Freund et al 2 demon- strated that only 13% of patients with CNV from ARMD are eligible for treatment by the Macular Photocoagulation Study criteria as the majority of patients present with occult CNV. Occult CNV has been defined on an angiographic basis as either (1) fibrovascular retinal pigment epithelial detach- ment or (2) late-phase leakage of an undetermined source. Unlike a serous retinal pigment epithelial detachment, a fibrovascular retinal pigment epithelial detachment will show an area of irregular elevation of the retinal pigment epithelium, often with stippled hyperfluorescence present in the midphase, and leakage or staining of this area in the late phases of the fluorescein angiogram. Studies of the natural history of occult CNV confirm the poor prognosis of this disease. In a retrospective study, Bressler et al 3 demon- strated that 63% of patients with occult CNV suffered a loss Originally received: January 19, 1999. Revision accepted: June 28, 1999. Manuscript no. 99032. From The New England Eye Center, Tufts University, Boston, Massachu- setts. Reprint requests to Elias Reichel, MD, 750 Washington Street, Box 450, Boston, MA 02111. 1908