Combination therapy with triamcinolone acetonide and bevacizumab for the treatment of severe radiation maculopathy in patients with posterior uveal melanoma

Abstract

PurposeTo evaluate the role of intravitreal triamcinolone acetonide in patients who developed severe, visually compromising radiation maculopathy or progressed despite anti-angiogenic treatments.MethodsAn Institutional Review Board approved, consecutive, retrospective study from 2006 to 2009 of patients who developed severe, visually compromising radiation retinopathy manifesting as macular edema secondary to iodine-125 plaque brachytherapy for posterior uveal melanoma, were treated with a combination of intravitreal bevacizumab and intravitreal triamcinolone. Patients were evaluated with spectral domain optical coherence tomography (SD-OCT) at 2–4 month intervals following plaque removal. Treatment with intravitreal bevacizumab commenced at the first signs of visually compromising macular edema diagnosed with SD-OCT. Triamcinolone acetonide was administered to patients with severe maculopathy as consolidative therapy, or for patients that were refractory to repeated bevacizumab injections with persistent or worsening cystoid macular edema and lack of improvement or progressive worsening of best corrected visual acuity (BCVA).ResultsTwenty-five patients were evaluated after receiving a combination of intravitreal bevacizumab and triamcinolone. Initial treatment commenced at a mean of 14.5 (range of 2–42) months after plaque brachytherapy. Patients were given a mean of two injections (range 1–6) of triamcinolone acetonide, and a mean of 8.8 bevacizumab injections (range of 1–26) with a mean follow-up of 31.2 months. Radiation maculopathy upon first detection had a mean SD-OCT grade of 3.6 (median = 4), with an associated mean entry level BCVA of 20/70. Visual acuity at time of first intravitreal triamcinolone was 20/138. At last follow-up (mean of 45.5 months after plaque brachytherapy) mean BCVA was 20/136; however, 9 of 25 (36%) patients who presented with severe radiation maculopathy demonstrated 20/50 or better vision at last follow-up.ConclusionThis case series suggests a beneficial role for intravitreal triamcinolone as a consolidation treatment for patients who present with severe radiation maculopathy or as an adjuvant to bevacizumab for refractory or progressive maculopathy.

Intravitreal triamcinolone acetate for radiation maculopathy recalcitrant to high-dose intravitreal bevacizumab

“…Shah et al 17 presented 25 patients who had received ITA 4 mg in addition to 1.25 mg bevacizumab for either severe RM or RM refractory to IVB monotherapy. In that study, severity was based on macular oedema demonstrated on OCT and refractory was defined as minimal improvement in oedema after three injections.…”

“…This study also differs from Shah in that we only treated recalcitrant cases. 17 Therefore, there was an extended time interval between the onset of RM and the initiation of ITA. Further, cases that had only failed low dose anti-VEGF therapy may have improved with higher doses and were thus not necessarily recalcitrant.…”

“…In cases recalcitrant to anti-VEGF agents, reports have shown success in maintaining VA by using dexamethasone implant. 16 Shah et al 17 recently presented a case series of RM recalcitrant to low dose IVB (1.25 mg) successfully stabilised with ITA.…”

Options for management of intra ocular tumors

“…The combination of intravitreal triamcinolone and bevacizumab has been used for radiation-induced macular edema with some efficacy. [ 26 ] Secondary retinal detachment caused by necrosis of the tumor can also sometimes respond to intra vitreal steroids. [ 27 ] NVG can be treated with intra vitreal bevacizumab.…”

Fellow Eye Macular Edema Improvement after Intravitreal Bevacizumab for Radiation Retinopathy

“…Clinically, RR can be classified as proliferative or nonproliferative, and both stages can be related to macular edema, which is associated with worse visual outcomes [ 7 ]. Several treatment modalities, such as laser photocoagulation or intravitreal triamcinolone injections [ 8 – 10 ], have already been tested, but intravitreal antiangiogenic injections seem to be the most currently used therapeutic option [ 11 – 17 ].…”