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

Abstract

Aim: To evaluate the efficacy and safety of triple therapy consisting single-session photodynamic therapy (PDT), intravitreal bevacizumab (IVB) and intravitreal triamcinolone (IVTA) for treatment of neovascular age-related macular degeneration (AMD) Methods: Consecutive patients with subfoveal choroidal neovascularisation (CNV) secondary to AMD were treated with PDT using a standard protocol immediately followed by 1.25 mg of IVB and 4 mg of IVTA. 1.25 mg of IVB was given at 3 months for residual leakage. Best-corrected Snellen visual acuity (BCVA) and fluorescein angiography (FA) were performed prior to treatment. BCVA, intraocular pressure (IOP) and presence of vitritis were documented at 1 and 6 weeks, 3 and 6 months. FA was repeated at 3 and 6 months. Outcome measures included visual improvement measured by logMAR equivalent, angiographic evident of leakage and safety profile. Results: 36 eyes of 33 patients, aged 76.4 (SD 10.5) years with mean follow-up of 14.7 (6.9-19.2) months were analysed. Baseline logMAR acuity was 1.22 (0.71). The mean logMAR acuity was 1.14 (0.62) and 1.18 (0.63) at 3 and 6 months respectively. At 6 months, 61.1% (22/36) showed stable or gaining vision, and 27.8% (10/36) gained three or more lines. Twentyeight eyes (77.8%) achieved CNV resolution by single session of triple therapy. One eye lost more than six lines due to retinal pigment epithelium rip, three eyes showed a significant cataract requiring surgery, and two showed persistent raised IOP at 6 months. None resulted in endophthalmitis or reported thromboembolic event. Conclusions: Short-term results of single session triple therapy suggested that it might be a useful treatment option for neovascular AMD based on its low retreatment rates, sustainable CNV eradication result and visual gain achievement. However, the risk and benefits of using intravitreal triamcinolone in addition to combined PDT and IVB warrant further evaluation.Age-related macular degeneration (AMD) is one of the leading causes of blindness in the developed world. It can be classified into non-neovascular (dry) and neovascular (wet) form. The neovascular form of AMD is characterised by the development of choroidal neovascularisation (CNV). It contributed to a minority of cases, approximately 10% to 20% but associated with 80% to 90% of visual loss.

Causes of interruption of bevacizumab therapy in age-related macular degeneration

“…The occurrence of AMD increases with age, so it is expected to become more prevalent in developed countries as life expectancy continues to increase (1)(2)(3)(4)(5) . Although exudative (or neovascular) AMD is less common than dry AMD, occurring in approximately 10 to 20% of the patients, it is usually responsible for most severe cases of vision loss (1,(6)(7) . Choroidal neovascularization (CNV), the abnormal growth of new blood vessels from choriocapillaris into the subretinal space, is the hallmark of exudative AMD and its treatment has been challenging researchers and specialists during the last decades.…”

“…Despite the better visual results achieved with bevacizumab therapy for choroidal neovascularization, its benefits seem to be temporary. Thereby, repeated injections are needed to reach and maintain the best visual acuity (6,13) . Many patients give up antiangiogenic therapy at different times and have worse functional outcomes, regardless of the usual improvement observed after the beginning of the treatment.…”

“…It has also been frequently and successfully used as an off-label intravitreal treatment of neovascular AMD since 2006. Bevacizumab has a longer halflife than ranibizumab, the actual most efficient anti-VEGF approved by ANVISA for AMD treatment, and is supposed to require less frequent dosing (1)(2)(3)(4)(5)(6)(7)(10)(11)(12) . Despite the better visual results achieved with bevacizumab therapy for choroidal neovascularization, its benefits seem to be temporary.…”

“…It has also been combined with intravitreal triamcinolone to permit more favorable results. Generally, results of PDT for subfoveal neovascular membranes have been limited to stabilization of the process and the visual acuity (1)(2)(5)(6) . Vascular endothelial growth factor (VEGF) has been proved to be important in the development of abnormal vessels and on the increase of its permeability in many pathological conditions.…”

Triple Therapy for Anti-Vascular Endothelial Growth Factor Nonresponders in Neovascular Age-Related Macular Degeneration: Impact of Different Photodynamic Therapy Parameters

“…Steroids are considered to be beneficial in reducing the inflammatory component of AMD as well as the post-PDT-V inflammatory response, but they have been associated with increased intraocular pressure and cataract progression [7]. Combination therapy with anti-VEGF agents, steroids and PDT-V has been proposed to interfere with multiple stimuli to pathologic vascular proliferation while reducing treatment frequency [8,9,10,11]. In previously published triple-therapy studies, PDT-V light fluence ranged from 25 to 50 J/cm 2 [8,9,10,11,12,13,14].…”