MyVisionTest Newsletter Archive
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The big news this month in the low vision community has been an unfortunate ruling by the United States Court of Appeals for the District of Columbia that finds paper money discriminates against the blind. It charges the US Treasury with coming up with a redesigned paper currency that enables those with vision loss to be able to distinguish between various denominations by touch.
The ruling has been denounced by the National Federation of the Blind, the nation's largest blind advocacy group, as diminishing the capabilities of most blind people. They fear that the ruling may unintentionally do real harm to blind Americans by creating a misconception that the blind are unable to function unless they can identify items by touch.
It is quite telling that the legal action was not originated by a blind person, or even a blind advocacy group. According to an NPR report, it was the brain child of Jeffrey Lovitky, who is a lawyer that makes his living by suing the government. His girlfriend suffered vision loss as a complication of a medical illness. He noticed while dating her that she was unable to differentiate between bills of various denominations by touch, but it was not until after she died tragically in a house fire that he decided to make it into a legal issue.
"I was determined to do something. I knew I wanted to do a case in her honor," he told NPR.
Lovitky sought out the American Council of the Blind and they hired him to bring the legal action as a tribute to his deceased girlfriend. The rest, as they say, is history.
New research involving mice and rabbits has found that VEGF-triggered fluid leakage can be prevented by a drug applied topically in eye drop form.
Investigators working with mice and rabbits found that a class of drugs called Src kinase antagonists may be applied topically in eye drop form and strongly inhibit VEGF-mediated vascular leakage. Such topically applied drugs may prove valuable in the clinical management of diseases in which retinal edema due to VEGF-mediated fluid leakage leads to loss of vision, such as macular degeneration and diabetic retinopathy.
While Src kinase activity appears critical for VEGF-induced fluid leakage, it appears not to affect other physiologically important effects of VEGF. Thus, inhibiting Src kinase may be potentially safer than other anti-VEGF therapies.
The availability of a topically applied inhibitor of vascular permeability would represent a major therapeutic advance in the treatment of retinal vascular disease. These findings offer hope of a potentially safe and painless topically applied therapeutic option for treating vision loss due to macular edema.
WHAT IT MEANS TO YOU: Yet another study that shows progress in developing an eye drop treatment for retinal vascular disease. The days of having to endure frequent injections of anti-VEGF drugs may be numbered!
A new European health survey examining the relationship between low vision and quality of life provides evidence that persons with low vision have more trouble concentrating during reading and entertainment; loss of interest and enjoyment in their activities; feeling fatigued, irritable, sad, and tearful; having less hope for the future; and wishing for death. Another study published this past month finds that a comprehensive low vision program within the Veterans Administration can significantly improve vision function in patients with macular disease.
Because of the growing life expectancy in developed countries and the exponential increase in vision loss with increasing age, a growing number of elderly persons will eventually suffer from visual impairment and blindness. Indeed, a tripling of vision loss can be expected with each additional decade of life after the age of 50.
"Low vision, chronic visual impairment that limits everyday function, is one of the 10 most prevalent causes of disability in America," the authors of the VA study write. In addition to affecting daily function, low vision increases the risk of depression, injury and an overall decline in health.
The European health survey shows clearly the negative impact of low vision on quality of life. With growing visual impairment respondents not only feel sad and depressed more often, they also lose enjoyment and hope and have more frequent suicidal feelings. This relationship between low vision and overall well-being, together with its frequency and economic impact, makes visual impairment an important public health issue.
The VA low-vision rehabilitation program, which includes a home visit, counseling, assistive devices such as magnifiers and practice using them, significantly improved vision function in veterans with vision loss secondary to macular disease. Although the study found a trend toward improved quality-of-life scores on standardized questionnaires, the improvement did not reach statistical significance.
WHAT IT MEANS TO YOU: The European survey clearly documents the public health significance of low vision. Few people that are familiar with the VA's high-quality, comprehensive low vision rehabilitation program will question it's value, but the current study documents it's effectiveness in improving visual function. It is surprising and disappointing that no significant quality-of-life benefit was found. It is possible that a larger (it enrolled only 126 participants) or longer (participants were followed for only 4 months) study might uncover a quality-of-life benefit. With the growing prevalence of low vision, it is vitally important that Medicare be expanded to cover low vision care for all Americans.
According to a new study published in the May 2008 issue of the Journal of Neuroscience, the brains of blind people who have regained their vision are able to regain at least some of their original ability to process visual information, even after years of blindness. The researchers state that the research has practical application given recent progress in retinal implants and gene therapies that can restore vision to blind people.
It is known that when a person becomes blind the portion of the brain assigned to vision is reassigned to other duties, such as the senses of touch, speech, and sound. "Previous studies had shown that a variety of new sensory functions move into the visual cortex when a person loses their vision, especially when vision is lost as a young child," the researchers stated. Thus, the researchers wanted to know how the brains of blind people responded when vision was recovered after years of blindness.
The researchers worked with two people whose sight was partially restored by surgery in middle age after becoming blind as children.
The researchers found, through the use of functional MRI scans, that the subjects processed both sounds and visual stimuli within the visual cortex. In normally sighted people, the visual cortex processes only visual stimuli. The investigators state, "Our data show for the first time what happens to the new sensory input if a blind person has the chance to see again. The sound responses didn't go away. They persisted together with the restored visual responses, even after many years with regained sight."
The researchers conclude that the brain maintains its original ability to process visual input, even many years after being blind. Their findings offer hope that blind persons in the future who receive retinal implants or gene therapy to restore vision have the potential to regain full use of their eyesight.
WHAT IT MEANS TO YOU: Restoring vision to the blind is no longer the stuff of science fiction. It is good to learn that our brains retain the ability to process visual information many years after blindness has occurred. Someday in the not too distant future we may have the technology to routinely restore vision to the blind.
A new research study published in the May 2008 edition of the British Journal of Ophthalmology finds that lifetime exposure to sunlight is an important factor in the progression of late AMD. They report that an individual's sensitivity to sunlight exposure may have a role in AMD progression in addition to total lifetime exposure to sunlight.
The etiology of AMD remains unclear, but is suspected to involve both internal and external factors. It has been reported that abnormal skin sensitivity to sunlight or a propensity to tan is associated with AMD. However, there are several reports that sunlight exposure is not a risk factor for AMD.
In this case-control study of 215 Japanese men aged 50 years and older, facial wrinkle length and area of hyperpigmentation, which are considered to be associated with exposure to the sun, were measured using imaging and computer-based image analysis. Skin tone was also measured on the upper inner arm, which is not exposed to direct sunlight. Early and late AMD association with skin measurements was evaluated.
The researchers found significantly more facial wrinkling and less facial hyperpigmentation was present in late AMD cases. The relationship between skin tone and AMD risk was not statistically significant.
Melanin can act biochemically as an antioxidant in retinal pigment epithelial cells, lessening the harmful effects of UV-induced oxygen free radicals. Ocular melanin is thought to be able to physically protect the retina against light-induced cell toxicity through UV absorption. The protection against UV damage afforded by melanin, presumably through a biochemical mechanism, may explain why AMD is more common in lighter-skinned populations.
The investigators conclude that lifetime exposure to sunlight is an important factor in the progression of late AMD. An individual's reaction to sunlight exposure, as reflected through the development of focal hyperpigmentation on sun-exposed skin, may have a role in AMD progression in addition to total lifetime exposure to sunlight.
WHAT IT MEANS TO YOU: There is good evidence that sunlight exposure plays some role in the development of cataract and macular degeneration. The precise nature of this role remains to be defined, but it makes sense to take appropriate precautions to safeguard your eyes when spending time outdoors. These precautions include a broad brimmed hat and 100% UV filtering sunglasses. For additional protection, consider blue-blocker sunglasses. Those individuals that are most sun-sensitive (ie. burn easily, less hyperpigmentation) appear to be most at risk for the damaging effects of sunlight.
The use of Foresee Preferential Hyperacuity Perimetry (PHP) can detect the conversion of the dry form of AMD to the more destructive wet form of the disease, according to results from a study presented at the ARVO 2008 meeting.
"In some cases, the patient hasn't even realized any [visual] changes yet," Yuhua Lai, research coordinator, said during a poster session at the ARVO meeting.
The PHP vision test helps practitioners identify elevations in a patient's retinal pigment epithelium and the bowing of the photoreceptor layer by having patients identify bends they see in line targets on a computer screen.
The analysis was conducted within the multicenter Cost of Age-Related Macular Degeneration (CARMA) clinical trial. Nine patients progressed to wet AMD and eight of those patients showed abnormalities during the Foresee PHP test, Ms. Lai said. Optical coherence tomography helped confirm the diagnosis.
A version of the PHP vision test that patients can use at home is currently in clinical trials, she said.
WHAT IT MEANS TO YOU: This study documents the ability of a vision test to detect conversion of AMD from dry to wet. Other studies have shown that by monitoring vision closely, it is possible to detect CNV earlier, while it is away from the center of the macula and visual acuity is still good. Together, these studies add weight to the recommendation that patients with AMD monitor their vision closely. Whether it is formally with a device such as the PHP or informally by using straight lines in your surroundings may be less important than getting into the habit of checking your vision daily.
According to a research paper that appears in the May 2008 edition of the Journal of Vision, patients with recent onset macular degeneration read best when they place their central scotoma to the left of the words they are trying to read.
To compensate for their central vision loss, patients with macular degeneration (MD) have to learn to move their eyes such that objects they are attempting to look at falls onto a healthy peripheral part of the retina instead of the damaged macula, a practice known as eccentric viewing. The peripheral retinal location a patient chooses for detailed vision is called the "preferred retinal location" (PRL). Persons with MD often develop this behavior without even realizing they are doing it.
Most MD patients develop a PRL to the left or below the central scotoma. However, it is controversial whether a PRL to the left or below the central scotoma is optimal for reading. Several research studies recommend developing a PRL below the central scotoma, that is, placing the central scotoma above any visual target. However, there is currently no consensus among practitioners about which is the ideal PRL for people with MD.
Investigators studied reading behavior of normal subjects using an experimental reading procedure. The researchers found that subjects read best when using a region to the right of fixation. These results are in contrast to several studies suggesting a preference for a performance advantage for a region below or to the left of a central scotoma. These differences may relate to the patient's stage of adaptation.
The authors write that their results may relate best to early stages of MD when patients are first learning to use the PRL. At that time patients might benefit from using a PRL that results in least conflict with normal reading behavior. This implies that patients with recent onset MD should benefit from training to placing the central scotoma to the left of a target.
WHAT IT MEANS TO YOU: When re-learning how to read following the onset of macular degeneration, it may be helpful to look to the left of the words that you are attempting to read.
A new study provides evidence that variation in the mitochondrial genome contributes to susceptibility to AMD. The magnitude of the association suggests that it may be an important new risk factor for the development of AMD.
Mitochondria are located within all cells and play a central role in cellular energy production, free radical production, and apoptosis (cell death). Each of these processes has been implicated in the pathogenesis of AMD. Mitochondria also contain their own DNA, known as the mitochondrial genome. Under normal conditions, electrons leak from mitochondria as energy is produced and result in free radicals. The production of free radicals, and hence susceptibility to AMD, may differ depending on genetic variation within an individual's mitochondrial genome.
The current study investigated whether a variation within the mitochondrial genome (known as 4917G), previously associated with neurodegenerative diseases such as parkinsonism, is associated with increased risk for AMD. A group of 560 Caucasian age-matched pairs (280 cases and 280 unaffected) were studied. This study population was genotyped for 4917G plus other known AMD-associated nuclear genome polymorphisms (CFH, LOC387715 and ApoE). Following adjustment for nuclear genome polymorphisms, 4917G independently doubles the risk for the development of AMD (OR = 2.16).
The researchers conclude that a specific mitochondrial DNA variation previously implicated in other neurodegenerative diseases (4917G) appears to convey risk for development of AMD independent of other known genetic variations.
WHAT IT MEANS TO YOU: Genetics appears to play a large role in determining who develops AMD, and the role of mitochondria appears to be significant. Interestingly, the mitochondrial genome is inherited entirely from the mother (the father does not contribute any mitochondrial DNA to his offspring). Therefore, if the role of mitochondria in AMD is as significant as this study would suggest, a maternal history of AMD would be expected to be more significant than a paternal AMD history.
Students became doctors during Monday's graduation at the University of California San Francisco Medical School. Nat Gleason, one of the graduates, is legally blind.
Dr Gleason states that he is able to care for his patients as well as any other doctor despite his vision loss, and often does not even find it necessary to inform them of his disability. He does use low vision aids to read, and that is often the only thing that makes others aware that he is legally blind. Because he also lacks color vision, he will occasionally need to ask for assistance in identifying the color of lesions.
He believes his vision loss may make him a better doctor because he is able to personally relate with patients that are suffering with illnesses that have the potential to leave them disabled.
Dr. Gleason is an inspiration, but not just because of his disability. Teachers and classmates voted him the recipient of the 2008 Gold Headed Cane, which is awarded to the person who best exemplifies the qualities of a true physician. His next step is residency and an eventual career in general medicine.
Resolvins are derived from the metabolism of omega-3 polyunsaturated fatty acids - including EPA and DHA, the major constituents of fish oil. Many of the beneficial anti-inflammatory effects of fish oil appear to be mediated by these compounds. It is now believed that the resolution of inflammation is an active process controlled, in part, by resolvin E1 (RvE1). The purpose of RvE1 is to turn down acute inflammatory processes before too much damage is done to normal tissue. Studies have found that aspirin triggers the production of RvE1, whereas COX-2 inhibitors (such as Vioxx and Celebrex) inhibits the synthesis of RvE1. This may help to explain some of the untoward side effects of COX-2 inhibitors.
Data presented at the ARVO 2008 meeting demonstrate that, upon topical dosing, resolvin compounds achieve therapeutic concentrations at the level of the retina, offering the potential for a topical drug, administered as eye drops, to treat retinal disease.
Studies in mice demonstrated that RvE1 is highly effective in preventing vascular leakage and neovascularization, the main contributors to AMD and other degenerative retinal diseases. In a second study, the resolvin compound was also shown to be efficacious in preventing vascular leakage and neovascularization. In a third study, RvE1 significantly reduced apoptosis (cell death) of retinal pigmented epithelial (RPE) cells. Loss of RPE cells is an important contributor to vision loss resulting from several retinal diseases, including both wet and dry AMD. These data suggest that resolvins have important cell survival effects that could offer a therapeutic benefit in a wide range of retinal diseases.
"These are promising new data which demonstrate that resolvins provide robust inhibition of inflammation and promote cell survival in models of a major ocular disease, AMD," said Dr Nicholas G. Bazan of Louisiana State University. "These data support continued development of resolvins for the treatment of AMD and other retinal diseases."
WHAT IT MEANS TO YOU: Research into the resolvins offer hope that the beneficial effects of fish oil can be isolated, synthesized, and placed into an eye drop.
New data published by the Complications of Age-related Macular Degeneration Prevention Trial (CAPT) has shed additional light on the risk factors for progression of AMD and the value of close monitoring in the early detection of choroidal neovascularization (CNV). They report that increasing age and the presence of retinal pigments clumps where significantly associated with both the development of CNV and with progression to geographic atrophy (GA). In a separate report they find that close monitoring of patients with drusen can lead to earlier detection of CNV, when vision is still good and treatment results are best.
Patients recruited for the CAPT study, a randomized clinical trial, had bilateral large drusen and good vision. One eye of each person was selected randomly for low-intensity laser treatment of the drusen and their other eye was observed. The patients have now been followed closely for 5 years.
It has already been determined that low intensity laser treatment does not provide a clinically significant benefit. However, data from CAPT is still being analyzed to study the natural history of AMD.
After 5 years of follow-up, CNV developed in 21% of the 1,052 patients in the study. At the time of detection, 54% of the neovascular membranes were subfoveal. Visual acuity was 20/40 or better in 69% of affected eyes at the time of detection. Statistically significant risk factors for CNV were older age (Relative Risk [RR], 2.81), cigarette smoking (RR, 1.98), and focal hyperpigmentation (RR, 1.84). Statistically significant risk factors for geographic atrophy were older age (RR, 6.39), greater retinal area covered by drusen (RR, 5.10), retinal pigment epithelium (RPE) depigmentation (RR, 2.64), and focal hyperpigmentation (RR, 10.4).
The researchers concluded that increased age and focal hyperpigmentation were risk factors for the development of both CNV and GA. Cigarette smoking was significantly associated with CNV but not GA. Furthermore, when AMD patients are monitored closely, many CNV lesions can be detected outside of the fovea while vision is still good and when the lesions are still relatively small. This can significantly improve the outcomes of therapy.
WHAT IT MEANS TO YOU: Once again, a study finds the only modifiable risk factor for AMD progression is smoking. The other risk factors identified in this study, such as age and pigment clumping, are not things that we have any control over. If your eye doctor informs you that you have focal hyerpigmentation (pigment clumps) or other risk factors for progression, then more aggressive pursuit of preventative measures (nutritional, sun protection, smoking cessation) and close monitoring your vision for symptoms of CNV may be warranted. This study adds weight to the recommendation that all patients at risk for neovascular AMD, even those with only drusen, check their vision on a daily basis. It may be sufficient to simply be aware of the quality of the vision of each eye. However, more formal testing, with an Amsler grid, MyVisionTest, or some other tool, is probably more effective. I encourage all patients at risk for CNV to carefully check the vision of each eye on a daily basis using the vision test of their choice.
Most people don't think twice about simple kitchen tasks like chopping an onion or setting an oven timer. If you can't see, however, such basic jobs can be nearly impossible to perform - if not downright dangerous.
But throw in a talking microwave, a Braille kitchen timer, a George Foreman grill and a safety spatula - along with some specialized instruction - and now you're cooking.
"It's much more of a challenge for the visually impaired to learn cooking skills," said Loretta Finegan-Nelson, lead transition teacher at the Colorado School for the Deaf and the Blind.
"As baby boomers are aging and having failing sight because of macular degeneration, they are driving the industry to develop special equipment," she said. "And with the advantage of new technology we are seeing improvements of equipment that has always been around - like better timers."
Other cooking equipment that has come in handy for the vision impaired include:
- A hook that can be used to pull out an oven rack. From there, the blind student can place the dish being cooked on the rack, rather than reaching into the hot oven.
- A finger peeler, which has been successful in helping blind students learn how to peel foods. "They can hold the apple and feel as they run a finger over it to peel away skin," she said. "And they won't accidentally hit their hand as they might with a regular peeler."
- Pressure cookers, slow cookers, Foreman grills and the Rocket Grill. "All these are easy for blind students to learn how to use," Finegan-Nelson said. "The grill is really great. But for a blind student who can't see if meat is done, they must rely on the cooking times provided."
- Measuring spoons with the bowl bent up. "When a blind student uses measuring spoons, they can't see if the ingredient is leveled off," she said. "The bent spoons make it easier for them to level ingredients."
- Talking timers.
- Pizza cutters instead of knives. "Jeremy has been working hard to learn how to cut his burger," she said. "It's easier for him to roll the cutter over his meat than trying to use a knife."
Much of the equipment is available at stores and through online vendors that specialize in serving people with vision problems and other disabilities.
A new study shows that the use of the statin class of cholesterol lowering medications is associated with the progression of AMD. The authors urge caution when interpreting their results because other causes may be the reason for their findings. The authors presented their research at the ARVO 2008 meeting.
"We are not saying that statins are a risk factor in the progression of AMD. There are a lot of confounding variables. But what this study shows is that they don't seem to have a beneficial effect," the investigators said.
Using data from the AREDS study, the researchers analyzed data from 1266 subjects over 11 years of follow-up. All subjects had AMD and were also documented statin users. Statin use was found to significantly increase the risk of developing neovascular AMD.
The researchers concluded that statin use was associated with patients developing neovascular AMD. Despite this association, the investigators caution that a causal relationship should not be drawn from this study. They note that previous studies have found an inconsistent association between AMD and cardiovascular risk factors, such as elevated cholesterol.
Commenting on this study, Dr Thompson on the University of Maryland stated that "The significance here is that there have been conflicting reports as to whether statins are protective, and this study says that they are not. There needs to be further studies to sort this out."
WHAT IT MEANS TO YOU: Statins have many positive health benefits, and are commonly prescribed for lowering cholesterol. There is no evidence that statins cause progression of AMD; however, it appears that those individuals than are prescribed statins are also at greater risk of AMD progression. There is compelling evidence that many of the same underlying health conditions (obesity, smoking, high glycemic content diet, etc) that place people at risk of cardiovascular disease also place them at risk for AMD. Unfortunately, statin use does not appear to mitigate that risk.
A new study in the April 2008 edition of Investigative Ophthalmology and Vision Science investigating the effects of dietary quercetin on the retina finds that it may be protective against macular degeneration. Quercetin is a flavonoid, a large group of compounds that provide much of the color and flavor of plant foods. It is a strong antioxidant and free-radical scavenger. Cultured human retinal pigmented epithelium cells were stressed by exposing them to hydrogen peroxide. Cells treated with hydrogen peroxide alone (the control group) suffered significantly more damage than cells treated with hydrogen peroxide and quercetin. Quercetin can be found in many fruits and vegetables -- particularly citrus fruits, apples, onions, parsley, tea, and red wine. The authors conclude that quercetin appears to be helpful in the prevention of AMD.
A systematic review of the literature on rheophoresis for AMD was published in the May 2008 edition of Ophthalmologe. Rheopheresis is a form of filtration of the blood to remove certain large molecules. It is suggested that this process may improve the flow of blood through small vessels in the body. Since impaired blood flow is thought to contribute to the development of macular degeneration, rheopheresis was introduced as a possible treatment for this condition. The literature search uncovered two randomised clinical trials (RCTs) that studied the effectiveness of the procedure on patients with AMD. The RCTs included a total of 238 patients. The larger of the two studies showed no effect of the procedure at all, and the other one showed a small effect of questionable clinical significance. The researchers concluded that evidence of the effectiveness of rheopheresis for AMD is not currently available. They suggest that rheopheresis should still be considered an experimental therapy for AMD.
In a prospective study of patients with advanced dry AMD, researchers found that worsening of vision in dim lighting was a strong predictor of future vision loss. A total of 131 patients with geographic atrophy were enrolled and followed for a median of 4 years. Visual acuity (VA) was measured under normal lighting conditions and then with dim light to determine the low luminance deficit (LLD) - the difference in measured visual acuity under normal and dim light. A large LLD indicates a greater worsening of vision in dim lighting. Among participants with VA of 20/50 or better, the risk of losing 3 lines of visual acuity was 3 times greater if the LLD was large. The LLD is a simple, rapid, inexpensive test, that appears to predict future visual acuity loss in eyes with geographic atrophy. "The worsening of vision in dim lighting was a strong predictor of subsequent visual acuity loss in dry AMD," the researchers concluded. Ophthalmology. 2008 May 15. [Epub ahead of print]
A well-documented risk with choroidal neovascularization (CNV) resulting from AMD is that in time, the CNV will spread to the fellow eye, eventually leaving the patient with impaired vision in both eyes. A major question has been how -- or whether -- the spread of the CNV to the fellow eye can be prevented or slowed. Investigators now report that there is no difference in the time to progression from unilateral to bilateral disease among patients who are treated with photodynamic therapy (PDT) or vascular endothelial growth factor (VEGF) inhibitors. The researchers presented these results in a poster presentation at the ARVO 2008 meeting.
A new study published in the May 2008 edition of the American Journal of Clinical Nutrition finds that there is no interaction between lutein and DHA (a key constituent of fish oil) supplementation on macular pigment optical density. Therefore, a person taking lutein and fish oil supplements concurrently can expect to obtain the same benefits from each as a person taking each of them alone. The investigators found that lutein supplementation increased macular pigment more peripherally within the macula whereas DHA resulted in increased macular pigment centrally. Lutein and DHA supplementation may aid in prevention of AMD.
Surgeons are often reluctant to perform cataract surgery on patients with macular degeneration because of concerns over low potential for good vision after surgery. To investigate how well patients with AMD do following cataract surgery researchers analyzed the visual acuity of 696 patients with AMD that had cataract surgery. One year after cataract surgery, 62.1% of eyes had visual acuity was at least two lines better than before surgery, and 26.7% of eye had at least four lines of improvement. The authors conclude that cataract surgery can markedly improve visual acuity in patients with AMD. The study is published in the May 2008 edition of the journal Ophthalmologe.
A study involving mice published in the May 2008 edition of Investigative Ophthalmology and Vision Science raises the question of whether it may be possible to vaccinate people against VEGF, the chemical messenger that is responsible for the development of choroidal neovascularization (CNV) in wet AMD. Scientists have developed a vaccination derived from human vascular endothelial growth factor receptor 2 (VEGFR2). Vaccinated mice produce white blood cells that attack blood vessel cells expressing VEGFR2, preventing them from producing neovascularization in response to the presence of VEFG. CNV in mice given the vaccine had 80% less leakage and were 18% smaller compared with the control group. The investigators concluded that this study provides a rationale for anti-VEGF vaccination in the treatment of CNV.
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