Retinal angiomatous proliferation treated by intravitreal triamcinolone and photodynamic therapy with verteporfin

Retinal Angiomatous Proliferation Treated with a Combination of Intravitreal Triamcinolone Acetonide and Photodynamic Therapy with Verteporfin

Purpose

Retinal angiomatous proliferation (RAP) is a particularly aggressive form of exudative age-related macular degeneration. Response to laser photocoagulation or to photodynamic therapy (PDT) alone is often disappointing. The purpose of this study was to determine whether intravitreal triamcinolone acetonide (TA) injections followed by PDT in eyes with early stage RAP may be effective.

Methods

Prospective uncontrolled study, enrolling 11 patients (11 eyes) with stage 2 RAP, treated with intravitreal TA injection followed by PDT. Patients with large pigment epithelium detachment, RAP stage 3, or pre-existing glaucoma and known steroid responders were excluded. All patients underwent a complete ophthalmic examination including fluorescein and indocyanine green (ICG) angiography and optical coherence tomography (OCT-3) at baseline and at 1, 3, 6, and 12 months. Informed consent was obtained from all patients.

Results

Mean follow-up was 14.9 months (range 6–21 months). Mean age was 82 years. In four patients a small pigment epithelium detachment was found on tomography. Initial visual acuity (VA) ranged from 0.1 to 0.6 on the Snellen scale. After calculating the logarithmic values the authors found an initial mean VA of logMAR 0.61, which improved by 1.5, 0.9, and 0.9 log lines after 3, 6, and 12 months, respectively. Although the VA gain from baseline tended to decrease with time, only 2 patients (18%) had an actual loss of acuity (≥3 lines). Retreatment was required in 5 eyes.

Conclusions

In this prospective pilot study examining the use of intravitreal TA followed by PDT with verteporfin in eyes with stage 2 RAP, without a large pigment epithelium detachment, the authors found a potential benefit in terms of stabilization or even improvement of vision.

Retinal Angiomatous Proliferation Reactivation 6 Months after High-Dose Intravitreal Acetonide Triamcinolone and Photodynamic Therapy

Purpose

To describe the incidence of retinal angiomatous proliferation (RAP) reactivation after combined treatment with a high-dose intravitreal triamcinolone acetonide (IVTA) and photodynamic therapy (PDT) at 1-year follow-up.

Methods

All patients had undergone a full ophthalmic examination. High-dose IVTA (20 mg) was injected via pars plana. Four to 7 days later, PDT was delivered.

Results

Fourteen eyes of 13 patients were included. Eight lesions (57%) reopened and needed retreatment with combined therapy at 6 months follow-up. At 1-year follow up, the lesion was obliterated in nine cases (64.2%) and best-corrected visual acuity improved from 0.87 logMar (range, 0.7–1) to 0.79 logMar (range, 0.5–1).

Conclusions

Combined therapy using high-dose IVTA and PDT is beneficial in stabilizing RAP. However, a high incidence of RAP reactivation has been observed at 6 months, even with a high-dose IVTA injection.

Ranibizumab in monotherapy and combined with photodynamic therapy for retinal angiomatous proliferation

Purpose

To compare the effects of intravitreal ranibizumab in monotherapy (group A) and combined with photodynamic therapy (PDT) with verteporfin (group B) in retinal angiomatous proliferation (RAP) treatment.

Methods

This was a multicentric, prospective, randomized clinical study conducted with parallel groups. The study eye in both groups received ranibizumab on days 1, 30, and 60 (loading dose); group B received PDT additionally on day 1. Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity (VA) testing and optical coherence tomography were performed monthly, and fluorescein angiography and indocyanine green angiography were performed quarterly. Retreatment criteria were leakage in fluorescein angiography or indocyanine green angiography, mean foveal thickness increase ≥100 µm, or VA decrease ≥5 letters.

Results

Twenty patients were recruited (ten patients in each group). Six eyes had previous treatment (three eyes in group A and three eyes in group B), so only 14 eyes were naïve. At 12-month follow-up, mean VA improved +1.5 letters in group A and +5.6 letters in group B (analysis of variance test; P>0.05). Two patients (20%) in both groups gained ≥15 letters (chi-square test; P>0.05). Mean changes in greatest linear dimension and in foveal thickness were not statistically significant between groups of treatment (analysis of variance test; P>0.05). Mean retreatments per patient were 1.8 (group A) and 0.9 (group B) (Mann–Whitney U-test; P>0.05). One patient died due to underlying disease not related to study medication.

Conclusion

Intravitreal ranibizumab administered in monotherapy or combined with PDT was efficacious in terms of VA stabilization in patients with RAP.

Ranibizumab in Retinal Angiomatous Proliferation (RAP): Influence of RAP Stage on Visual Outcome

Purpose.

To evaluate the influence of retinal angiomatous proliferation (RAP) stage on visual and anatomic outcome after ranibizumab (Lucentis®).

Methods.

This was a prospective study on consecutively diagnosed RAP eyes at the Hospital Clínico San Carlos, Madrid. Best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) are performed monthly. Indocyanine green angiography (ICG) and fluorescein angiography (FA) are performed at baseline and every 3 months thereafter. A starting dose of a monthly ranibizumab injection in the first 3 months is followed by retreatment in case of intraretinal edema, subretinal fluid, or pigment epithelium detachment (PED) in OCT, increased leakage in FA, or a hot spot in ICG.

Results.

A total of 53 eyes from 49 patients were included. The mean change in BCVA at 12 months was +7.3, +0.83, and −2.1 letters in stages IIA (21 cases), Il B (18 cases), and III (14 cases), respectively. After adjusting the change in BCVA according to baseline BCVA, β coefficient was −6.012 letters (p=0.025) in stage IIB and −9.762 letters (p=0.003) in stage III vs stage IIA. Four cases had a retinal pigment epithelium tear after injection of ranibizumab.

Conclusions.

Patients in stage II without PED have a better visual and anatomic evolution than patients in stage II with PED and stage III.

Treatment of recurrent retinal angiomatous proliferation with intravitreal triamcinolone acetonide followed by photodynamic therapy with verteporfin: A retrospective case series

OBJECTIVE

The aim of this study was to report the effect on tolerability of combined treatment with intravitreal triamcinolone acetonide (IVT) and photodynamic therapy (PDT) with verteporfin in patients with stage II retinal angiomatous proliferation (RAP) who had been treated previously with PDT and presented with recurrent RAP (R-RAP).

METHODS

This was a retrospective case series of patients with R-RAP after PDT (1-5 treatments) treated once with IVT followed 1 month later by PDT. A visual acuity test, fluorescein and indocyanine green angiography, and optical coherence tomography were performed at baseline and at 1, 3, and 6 months.

RESULTS

Five patients (4 men, 1 woman; mean [SD] age, 76.8 [3.9] years) with 6 eyes diagnosed with stage II R-RAP who had previously been treated with PDT and who received an IVT injection and PDT within 1 month were included in the study. Best corrected visual acuity (BCVA) remained stable after IVT in 5 eyes (83%) and deteriorated in 1 eye (17%). After PDT, BCVA remained stable in 2 eyes (33%) and deteriorated in 4 eyes (67%). IVT treatment combined with PDT also reduced fluorescein leakage. Median lesion size increased 24% before PDT and 61% at 6 months after PDT. One eye had intraocular hypertension at 3 months, and 1 eye developed a pigment epithelial tear after PDT.

CONCLUSION

The results were limited by the number of eyes and relatively short follow-up, but in this study, PDT after IVT did not appear to be as effective or well tolerated in 5 patients who had already been treated with PDT and presented with R-RAP.

Intravitreal ranibizumab (Lucentis) in the treatment of retinal angiomatous proliferation (RAP)

BACKGROUND

Retinal angiomatous proliferation (RAP) is a distinct variant of neovascular age-related macular degeneration (AMD). The aim of this study is to evaluate the functional and anatomic outcome after intravitreal ranibizumab (Lucentis) treatment in patients with RAP.

METHODS

Prospective study of consecutive patients with newly diagnosed or recurrent RAP treated with intravitreal ranibizumab at the Jules Gonin Eye Hospital between March 2006 and December 2007. Baseline and monthly follow-up visits included best-corrected visual acuity (BCVA), fundus exam and optical coherence tomography. Fluorescein and indocyanine green angiography were performed at baseline and repeated at least every 3 months.

RESULTS

Thirty-one eyes of 31 patients were treated with 0.5 mg of intravitreal ranibizumab for RAP between March 2006 and December 2007. The mean age of the patients was 82.6 years (SD:4.9). The mean number of intravitreal injections administered for each patient was 5 (SD: 2.4, range 3 to 12). The mean follow up was 13.4 months (SD: 3, range 10 to 22). The baseline mean logMAR BCVA was 0.72 (SD: 0.45) (decimal equivalent of 0.2). The mean logMAR BCVA was improved significantly (P < 0.0001) at the last follow-up to 0.45, SD: 0.3 (decimal equivalent 0.35). The visual acuity (VA) improved by a mean of 2.7 lines (SD 2.5). Mean baseline central macular thickness (CMT) was 376 microm, and decreased significantly to a mean of 224 microm (P < 0.001) at the last follow-up. Mean reduction of CMT was 152 microm (SD: 58). An average of 81.5% of the total visual improvement and 85% of the total CMT reduction occurred during the first post-operative month after one intravitreal injection of ranibizumab. During follow-up, an RPE tear occurred in one eye (3.2%) of the study group. No injection complications or systemic drug-related side-effects were noted during the follow-up period.

CONCLUSIONS

Intravitreal ranibizumab injections appeared to be an effective and safe treatment for RAP, resulting in visual gain and reduction in macular thickness. Further long-term studies to evaluate the efficacy of intravitreal ranibizumab in RAP are warranted.

The temporal sequence of combined intravitreal triamcinolone acetonide and photodynamic therapy for exudative age-related macular degeneration

BACKGROUND AND OBJECTIVE

To compare visual acuity results in patients with exudative age-related macular degeneration treated with two different temporal sequences of combination intravitreal triamcinolone acetonide and photodynamic therapy with verteporfin.

PATIENTS AND METHODS

A retrospective, comparative, interventional case series was used. Thirty-one eyes received intravitreal triamcinolone acetonide 1 week prior to photodynamic therapy, and 30 eyes received intravitreal triamcinolone acetonide followed by photodynamic therapy the same day.

RESULTS

There was no significant difference in visual acuity between the groups at baseline (P = .084), 6 to 12 weeks of follow-up (P = .085), or 1 year of follow-up (P= .093). When visual acuity outcomes were adjusted for baseline visual acuity, spot size, lesion type, age, and gender, there was no significant difference in visual acuity at 6 to 12 weeks (P = .44) or 1 year (P= .28).

CONCLUSIONS

There appears to be no significant difference in visual outcomes in eyes with exudative age-related macular degeneration treated with intravitreal triamcinolone acetonide 1 week prior to photodynamic therapy or those treated with intravitreal triamcinolone acetonide on the same day as photodynamic therapy.

The prevalence of retinal angiomatous proliferation in age-related macular degeneration with occult choroidal neovascularization

BACKGROUND

The purpose of the study was to ascertain the prevalence of retinal angiomatous proliferation (RAP) by means of dynamic indocyanine green angiography (d-ICGA) in patients with newly diagnosed fibrovascular pigment epithelium detachment (type 1) or late leakage of undetermined source (type 2) occult choroidal neovascularization (CNV) on fluorescein angiography.

METHODS

We carried out a review of digital fluorescein and ICG angiograms obtained by confocal scanning laser ophthalmoscope (HRA; Heidelberg Engineering GmbH, Dossenheim, Germany) in 253 consecutive patients (270 eyes) with a clinical diagnosis of type 1 or type 2 occult CNV on fluorescein angiography (1998 through 2003).

RESULTS

Sixty eyes had type 1 and 210 eyes type 2 occult CNV on fluorescein angiography. Overall, 57 cases of RAP were identified in 54 eyes (20%) with d-ICGA. RAP was present in 6 out of 60 eyes with type 1 (10%) and in 51 out of 210 eyes with type 2 occult CNV (24%). Mean distance of the lesion from the fovea was 682 +/- 304 microm (mean +/- SD).

CONCLUSIONS

d-ICGA is invaluable for early diagnosis of RAP in exudative age-related macular degeneration (ARMD). In our series, up to one fourth of type 2 occult CNV were in fact RAP.

Bevacizumab (Avastin) treatment in patients with retinal angiomatous proliferation

AIM

To determine the anatomical and functional outcome after injection of bevacizumab (Avastin, Genentech) in eyes with retinal angiomatous proliferation (RAP).

DESIGN

Prospective interventional case series.

METHODS

Sixteen eyes of 16 consecutive patients with visual loss due to RAP underwent intravitreal injections of 1.25 mg (0.05 ml) bevacizumab. Best corrected visual acuity testing, fluorescein and ICG-angiography as well as OCT imaging were performed at baseline and at each follow-up visit within a 3-month period.

RESULTS

Mean visual acuity pre-injection was 0.68 +/- 0.36 logMAR (n = 16), mean reading ability 0.58 +/- 0.26 logRAD (n = 11). Far vision increased significantly by a mean of 1.7 +/- 2 lines 4 weeks after the injection (p = 0.004), as did reading (0.6 +/- 2.3 lines, p > 0.05). Both remained stable up to 3 months. Central retinal thickness decreased from 367 +/- 112 microm (mean+/-SD) to 272 +/- 123 microm 3 months after injection (p = 0.006). Leakage decreased angiographically in 12 eyes (75%) and remained stable in four eyes (25%). Re-injection of bevacizumab within the 3-month follow-up period was performed once in eight eyes, and twice in one eye. No adverse events were observed.

CONCLUSION

Intravitreal bevacizumab (Avastin) resulted in a reduction of leakage, intra- and subretinal fluid. An increase in visual acuity was seen already 4 weeks after first injection. However, a complete occlusion of feeder vessels could not be achieved within this 3-month period. Randomized clinical trials would be required to evaluate dose and frequency of injections and possible beneficial effects of combination therapies, as well as the long-term results.

Chorioretinal anastomosis and photodynamic therapy:a two-year follow-up study

BACKGROUND

To evaluate the two-year efficacy of photodynamic therapy with Visudyne (PDT) in neovascular age-related macular degeneration (AMD) eyes with chorioretinal anastomosis (CRA).

METHODS

A non-randomized, institutional, prospective study, of 28 consecutive eyes of 23 patients, with CRA, treated with PDT. Masked best corrected visual acuity (VA) and angiographic features at baseline and during the period of two years were evaluated.

RESULTS

Twenty eight eyes completed one year and 19 eyes completed two years of follow-up. The number of treatments was 3 in the first year, and 0.8 in the second year. A VA loss < 3 lines occurred in 53% of the eyes, at two years. Treated eyes lost 0.5 lines in the first year and 2.4 lines in the second (p < 0.01). Recurrence with additional significant VA loss occurred in four eyes (21%) during the second year. Fourteen eyes (74%) showed no fluorescein leakage at two years.

CONCLUSION

AMD eyes with chorioretinal anastomosis can benefit from PDT with Verteporfin at two years. However, during the second year significant additional VA loss occurs mainly due to recurrence. New modalities of treatment are necessary to achieve VA improvement in CRA eyes.