Single-session photodynamic therapy combined with intravitreal bevacizumab and triamcinolone for neovascular age-related macular degeneration

Abstract

BackgroundTo evaluate the efficacy of triple therapy consisting of single-session photodynamic therapy (PDT), intravitreal bevacizumab (IVB) and intravitreal triamcinolone (IVT) as initial pulse therapy followed by repeat intravitreal bevacizumab injections for maintenance treatment in neovascular age-related macular degeneration (AMD).MethodsIn a prospective interventional case series, patients with subfoveal choroidal neovascularization (CNV) secondary to AMD underwent pulse therapy with single-session PDT according to the standard protocol followed by 1.25 mg IVB and 2 mg IVT 48 hours later. Best corrected visual acuity (BCVA) was assessed and optical coherence tomography (OCT) and fluorescein angiography (FA) were performed prior to treatment. BCVA and OCT measurements were repeated at 6 week intervals and FA was obtained after 12 weeks and when necessary thereafter. Repeat injections of IVB were performed based on fluorescein angiographic evidence of CNV leakage.ResultsThis series included 17 eyes of 17 patients with mean age of 67.6 ± 7.2 years. Mean follow up duration was 50.4 ± 15.5 weeks. Mean BCVA prior to treatment was 0.74 ± 0.33 logMAR which improved to 0.52 ± 0.36 logMAR after 12 weeks (P = 0.012) and 0.41 ± 0.38 logMAR after 24 weeks (P = 0.001). Mean pretreatment central macular thickness (CMT) was 395 ± 181μ which was significantly reduced to 217 ± 69μ (P = 0.005), 231 ± 79μ (P = 0.028) and 221 ± 87μ (P = 0.05) six, twelve and twenty-four weeks after initial treatment respectively. Visual acuity improvement and CMT reduction was maintained during the follow-up period. IVB injections were repeated once, twice and three times in 10, 7 and 2 eyes at a mean interval of 20.2 ± 10.1, 19 ± 13.7 and 15 ± 1.4 weeks after initial therapy, respectively.ConclusionInitial pulse triple therapy consisting of single-session PDT combined with IVB and IVT improves vision and reduces CMT in neovascular AMD. Repeat IVB injections maintain the visual gain from the initial combination therapy.

Comparative Assessment of Photodynamic Therapy for Typical Age-Related Macular Degeneration and Polypoidal Choroidal Vasculopathy: A Multicenter Study in Hyogo Prefecture, Japan

“…Another report suggested that anti-VEGF therapy showed a limited effect in patients with PCV [28]. More recent reports propose that the combination of PDT and anti-VEGF therapy may yield better results than PDT alone in treating exudative AMD [29, 30], but they did not mention the differential effects of this combination therapy among the different AMD phenotypes. Using the data from the present study as the baseline outcome of PDT in each phenotype of AMD, further studies regarding the effects of modified or combined therapy should be conducted.…”

Comparative study of photodynamic therapy monotherapy versus triplemanagement in age-related macular degeneration

“…Glaucoma and cataract progression secondary to IVTA application were particularly reported in many series (6,20,24,25). Augustin et al (26) reported glaucoma in 46 patients (25%) after treatment with 25 mg IVTA combined with PDT and antiglaucomatous medication was started in these cases.…”

“…There is also disagreement about the timing of the therapy. While Chan et al (20) preferred to apply corticosteroids 5 min after PDT, Augustin et al (6) and Ahmedieh et al (25) applied dexamethasone and bevacizumab intravitreally 16 h and 48 h after PDT, respectively. Ranibizumab was intravitreally injected 1 week after PDT in the PIER study (16).…”

Intravitreal bevacizumab (Avastin) for age-related macular degeneration: a critical analysis of literature

“…51 One small Bevacizumab for age-related macular degeneration S Jyothi et al series assessed the effects of triple therapy (intravitreal triamcinolone, PDT and bevacizumab) and þ 17 letters gain was noted at 6 months. 17 A larger series by Augustin et al 23 studied 104 eyes treated with PDT, intravitreal dexamethasone and bevacizumab, and oral minocycline, and obtained a mean improvement of þ 8 letters at 10 months with a low number of retreatments. Nonetheless, this procedure required vitrectomy with retrobulbar anaesthesia.…”

“…The most common combination tried was with PDT. 17,18,22,23,32,35,49,50,54,61,66 Intravitreal bevacizumab was administered at the same session to up to 14 days post-PDT. The mean number of PDT sessions required at 6 months was 1.4 and the average intravitreal bevacizumab therapy was 2 (range 1-4) at 6 months.…”