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PURPOSE: To evaluate the incidence of self-reported decrease in visual acuity within 7 days of photodynamic therapy (PDT) for choroidal neovascularization secondary to age-related macular degeneration (AMD) and to describe the anatomical and clinical course of patients with documented significant visual loss. METHODS: Consecutive records of all patients with exudative AMD treated with PDT over a 16-month period at a community-based retina referral practice were reviewed for instances of self-reported visual change within 7 days of treatment. The primary outcome measure was Snellen visual acuity. Secondary outcome measures were fluorescein angiography (FA) and anatomical findings. RESULTS: Among 1,894 PDT treatments performed for 821 patients, there were 32 instances (for 30 patients) of self-reported visual change within 7 days of PDT. A decrease in > or =2 lines of Snellen visual acuity was documented for 10 patients (1.2% of patients or 0.5% of treatments), and all occurred within 3 days of PDT (median, 1 day) in all patients. Median pre-PDT vision was 20/60 (range, 20/50 to 20/200). Vision within 3 days after PDT was 20/100 or worse in all 10 cases and counting fingers or worse in 3. Subretinal hemorrhage occurred in four cases. FA of eyes without hemorrhage showed a circular area of choroidal hypoperfusion (corresponding to the PDT spot) in all five eyes with persistence of the hypofluorescence up to 4 months later. Visual improvement after the initial acute decrease was seen in 3 patients (30%; 95% confidence interval, 7-65%) by 3 months after PDT. CONCLUSIONS: Acute visual decrease after PDT for AMD is uncommon. Visual recovery may occur in some patients, but a precise estimate is difficult to determine given the small sample size.