Purpose:To evaluate the efficacy and safety of triple therapy with verteporfin photodynamic therapy (PDT), dexamethasone, and bevacizumab in choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD).Methods: This prospective, noncomparative, interventional case series included 104 patients. Verteporfin PDT was administered with a reduced light dose (42 J/cm 2 , accomplished by light delivery time of 70 seconds). Approximately 16 hours after PDT, dexamethasone (800 g) and bevacizumab (1.5 mg) were injected intravitreally. Patients attended follow-up visits every 6 weeks, undergoing visual acuity and intraocular pressure measurement, slit-lamp and ophthalmoscopic examination, and optical coherence tomography (OCT). Fluorescein angiography was performed every 3 months or earlier if OCT showed significant edema.Results: All 104 patients received one triple therapy cycle (5 patients received a second triple treatment due to remaining CNV activity). The triple therapy was complemented in 18 patients (17.3%) by an additional intravitreal injection of bevacizumab. The mean follow-up period was 40 weeks (range, 22-60 weeks). Mean increase in visual acuity was 1.8 lines (P Ͻ 0.01). Mean decrease in retinal thickness was 182 m (P Ͻ 0.01). No serious adverse events have been observed. Conclusion:In most patients with CNV due to AMD, triple therapy results in significant and sustained visual acuity improvement after only one cycle of treatment. In addition, the therapy offers a good safety profile, potentially lower cost compared with therapies that must be administered more frequently, and convenience for patients.RETINA 27:133-140, 2007 A s new therapies have become available to treat patients with choroidal neovascularization (CNV) due to age-related macular degeneration (AMD), it is clear that no single therapy addresses the multifactorial pathogenesis of the disease. CNV progresses from age-related changes in the retina and supporting tissues. With age, the cells of the retinal pigment epithelium (RPE) are less able to detoxify, and cellular debris (drusen) accumulates between Bruch membrane and the RPE. 1,2 As Bruch membrane and the adjacent choriocapillaris age, they become brittle, reducing the size of the choroidal capillaries, and in turn affect metabolic activity and lead to hypoxia. [1][2][3] This choroidal vascular atrophy with the associated inflammatory response is thought to be the principal cause of dry AMD development. 2,3 Immunologic signals associated with acute vascular compromise may lead to

Choroidal neovascularisation (CNV) often leads to severe vision loss and is becoming increasingly prevalent as the aging population grows. Age-related macular degeneration (AMD) is the most common cause of CNV, but CNV also affects younger people with pathological myopia, ocular histoplasmosis syndrome, angioid streaks and idiopathic disorders. The monotherapies available worldwide to treat patients with CNV have primarily been studied in CNV due to AMD, and all have their drawbacks. Combination therapy takes advantage of the strengths of each therapy and their different mechanisms of action to achieve good treatment outcomes with few repeated treatments. For example, combination (triple) therapy with verteporfin photodynamic therapy, anti-vascular endothelial growth factor (VEGF) therapy and anti-inflammatory therapy addresses three main targets of CNV development: the CNV itself, VEGF expression (which promotes CNV growth) and inflammation (which exacerbates the disease process). Such triple therapy has been shown to result in sustained improved vision after only one treatment. Vision outcomes similar to those observed with ranibizumab, the most promising and rigorously proven anti-VEGF monotherapy, may be possible with combination therapy without the need for continued monthly intravitreal injections, which are required if sustained outcomes are to be achieved with ranibizumab. The goal of CNV therapy is improved vision outcomes after one course of treatment. Combination therapy may lead to this goal. Such treatment could also result in fewer safety issues (fewer treatments are required and the unknown effects of continued long-term treatment are avoided), lower cost to both the patient and the medical system and greater convenience for patients (fewer clinic visits). However, combination therapy is beset with several challenges: different therapies, doses, timing and treatment sequences are possible, and it is therefore difficult to conduct large, definitive clinical trials to determine which treatment regimen is safest and most effective. Large controlled studies are needed to more clearly define effective and safe combination regimens for CNV.

The use of both innovative vitrectomy systems offers the advantage of a faster and less invasive surgical procedure. However, there are disadvantages which limit the indications for 25-gauge vitrectomy. The 23-gauge vitrectomy may overcome these disadvantages and - due to its wider range of application - may be used instead of conventional 20-gauge vitrectomy in most cases. It may therefore become the new standard for vitrectomy.

For patients with macular diseases, use of the original Amsler grid (white lines on a black background) should be recommended. This is particularly important for patients with visual acuity of 0.5 or better.