Low-fluence PDT better than anti-vascular endothelial growth factor

Sir,

It was interesting to read the article “Low-fluence photodynamic therapy” for early onset choroidal neovascular membrane (CNVM) following LASIK by Dr. George J Manayath et al.[1] The authors have to be commended for an excellent work. But I have some reservations that I would like to state.

Were there any pathological myopia changes recorded by the refractive surgeon, prior to the refractive surgery? The time lapse between break in Bruch's membrane at the macula and appearance of CNVM is usually quite long. Often many weeks and not just 2 weeks. The break in Bruch's membrane can be induced by the stretch of the microkeratome, for a minute or so (the time the microkeratome suction ring exerts pressure) cannot be deduced from a single case study.

I disagree with the author's statement that low fluence PDT is an alternative to intravitreal anti vegf anti-vascular endothelial growth factor (VEGF) injections for the following reasons.

The anti vegf VEGF has been shown to be clearly superior to the PDT for the treatment of subfoveal CNVM in Myopia.[2] “The superior functional results of anti-VEGF drugs provide the reason for the first-line status of this treatment modality. Increasing safety data and consistent results of prospective pilot trials have proved photodynamic therapy to be inferior”.[3] Considering the cost of PDT and the ease of intraviteral injection, I would have expected the authors to try intravitreal injection of anti VEGF, rather than the inferior quality of treatment of low fluence PDT. Also statistics extracted from near by Retina Centre (Retina Institute of Karnataka, Bangalore) revealed that the PDT rate that used to be around 50 in 2004 has now come down to less than 6, in 2011, since the ubiquitous use of anti-VEGF. It is to the credit of the authors that they do mention in passing the anti-VEGF treatment for myopic choroidal neovscularization.