Verteporfin and intravitreal triamcinolone acetonide combination therapy for occult choroidal neovascularization in age-related macular degeneration

Photodynamic Therapy and Intravitreal Bevacizumab with Versus without Triamcinolone for Neovascular Age-related Macular Degeneration; a Randomized Clinical Trial

PURPOSE

To compare the outcomes of photodynamic therapy (PDT) combined with intravitreal bevacizumab (IVB) with versus without intravitreal triamcinolone (IVT) in neovascular age-related macular degeneration (AMD).

METHODS

Eighty-four eyes with active CNV secondary to AMD with no prior treatment were enrolled and followed for 1-year. Eligible eyes were randomly assigned to either PDT/IVB or PDT/IVB/IVT. The main outcome measure was change in best-corrected visual acuity (BCVA).

RESULTS

Mean patient age was 71 ± 9 years. BCVA changes from baseline were statistically significant in both study arms at all follow-up intervals, however no significant difference was observed between the two groups regarding BCVA changes at week 12 (95% CI:-0.11-0.12 LogMAR) and other time points (all P > 0.6). Mixed model analysis revealed a significant effect from age (P < 0.001), pigment epithelial detachment (P = 0.009) and baseline BCVA (P < 0.001) on visual improvement. Significant central macular thickness (CMT) reduction occurred at all-time points as compared to baseline in both groups which was comparable between the study arms. There was no significant difference between the study arms in terms of retreatment rate (P = 0.1) and survival to the first repeat IVB injection (P = 0.065).

CONCLUSION

Additional low-dose IVT to a PDT/IVB regimen for neovascular AMD provided no beneficial effects in terms BCVA or CMT, yet demonstrated a trend toward extending the injection-free period.

Intravitreal steroids for the treatment of retinal diseases

Diabetic macular edema (DME), pseudophakic cystoid macular edema (CME), age-related macular degeneration (AMD), retinal vascular occlusion (RVO), and uveitis are ocular conditions related to severe visual impairment worldwide. Corticosteroids have been widely used in the treatment of these retinal diseases, due to their well-known antiangiogenic, antiedematous, and anti-inflammatory properties. Intravitreal steroids have emerged as novel and essential tools in the ophthalmologist's armamentarium, allowing for maximization of drug efficacy and limited risk of systemic side effects. Recent advances in ocular drug delivery methods led to the development of intraocular implants, which help to provide prolonged treatment with controlled drug release. Moreover, they may add some potential advantages over traditional intraocular injections by delivering certain rates of drug directly to the site of action, amplifying the drug's half-life, contributing in the minimization of peak plasma levels of the drug, and avoiding the side effects associated with repeated intravitreal injections. The purpose of this review is to provide an update on the use of intravitreal steroids as a treatment option for a variety of retinal diseases and to review the current literature considering their properties, safety, and adverse events.

Drug safety evaluation of intravitreal triamcinolone acetonide

INTRODUCTION

Triamcinolone acetonide (TA) is a steroidal drug that has been widely administered intravitreally for retinal and choroidal conditions. Safety of steroidal products for intraocular use is essential because of their risk of ocular adverse events. This review comprehensively discusses the safety of intravitreal administration of TA.

AREAS COVERED

This paper analyzes the mechanisms of action and key pharmacokinetic attributes and provides a discussion of the main clinical trials investigating clinical applications of intravitreal TA. The safety of intravitreal TA is evaluated through a search of the Medline database from 1980 to 2011. The most relevant literature on the safety of intravitreal TA is also discussed.

EXPERT OPINION

The complications of intravitreal TA therapy include secondary ocular hypertension in about 20 - 40% of eyes, steroid-induced cataract in about 15 - 20% of cases and postinjection infectious endophthalmitis and pseudoendophthalmitis in less than 1%. TA is an effective drug for various retinal and choroidal diseases when delivered intravitreally. It may imply an off-label use and it may be associated with ocular adverse events. Intravitreal TA is not associated with significant systemic safety risks.

Review of combination therapies for neovascular age-related macular degeneration

While angiogenesis is one of the factors associated with the development of CNV due to age-related macular degeneration (AMD), inflammation and oxidative stress also appear to play a role. Treatment of CNV with intravitreal anti-vascular endothelial growth factor monotherapy is currently the standard of care. However, not all patients respond to monotherapy, and combination therapy may target the CNV through multiple mechanisms, thus reducing treatment frequency or improving visual outcome. Photodynamic therapy (with regular or reduced fluence), as well as intravitreal steroids are used in combination with anti-VEGF therapy. This paper reviews the many clinical trials that have been performed utilizing several combinations of double and triple therapy. While combination therapy is biologically justifiable, further study is required to determine correct combinations and dosage.

Combined treatment of exudative age related macular degeneration with photodynamic therapy and intravitreal triamcinolone

Choroidal neovascularization (CNV) secondary to age related macular degeneration is among the leading causes of legal blindness in developed countries. Photodynamic therapy (PDT) with verteporfin induces CNV closure causing little damage to healthy tissue, but the need to re-treat may lead to low final visual acuity at an unacceptable cost. The association of intravitreous triamcinolone or antiangiogenic drugs with PDT has been used in order to reduce these limitations of the therapy. The combination of PDT and intravitreous triamcinolone, its complications and outcome at one and two-year follow-up are discussed.

Focal macular electroretinograms after photodynamic therapy combined with intravitreal bevacizumab

BACKGROUND

Retinal function is transiently depressed after photodynamic therapy (PDT) alone. One of the reasons for this functional impairment is a reduction of choroidal circulation caused by the PDT. The purpose of this study was to determine whether PDT combined with intravitreal bevacizumab (PDT+IVB) can reduce or prevent the transient impaired macular function. In addition, we examined whether a significant correlation existed between the changes in the focal macular electroretinograms (FMERGs), optical coherence tomography (OCT)-determined morphology, and changes in choroidal circulation.

METHODS

Thirty-eight eyes that were treated by full fluence PDT+IVB were studied. FMERGs, OCT, and indocyanine green angiography (ICGA) were performed before and after the PDT. The intensity of the diffuse fluorescence within the PDT site was measured by densitometry (I/N ratio).

RESULTS

The macula was significantly thinner 1 week after PDT+IVB (P < 0.01). The mean a- and b-wave amplitudes of the FMERGs were not significantly decreased 1 week after PDT+IVB. The mean b-wave amplitudes 3 months after PDT+IVB were significantly increased (P < 0.01). The I/N ratio of ICGA 3 months after PDT+IVB was 0.88 ± 0.1. The correlation between the FMERGs and I/N ratio was not significant.

CONCLUSION

The use of IVB with PDT mitigates the reduction of the FMERGs and reduces the macular thickness soon after PDT, regardless of the degree of impairment of choroidal circulation caused by PDT. Finally, the macular retinal function 3 months after PDT+IVB were better than that before the treatment.

Effect of photodynamic therapy alone or combined with posterior subtenon triamcinolone acetonide or intravitreal bevacizumab on choroidal hypofluorescence by indocyanine green angiography

PURPOSE

Choroidal hypofluorescence has been reported beneath the photodynamic therapy (PDT) site in clinical studies. We evaluated the choroidal hypofluorescence after combined PDT with posterior subtenon injection of triamcinolone acetonide or PDT with an intravitreal injection of bevacizumab for age-related macular degeneration.

METHODS

Two hundred and forty-two eyes with a subfoveal choroidal neovascularization caused by age-related macular degeneration were studied. Ninety-two eyes underwent PDT alone, 90 eyes underwent PDT with sub-Tenon injection of triamcinolone acetonide, and 60 eyes underwent PDT with intravitreal injection of bevacizumab. Verteporfin-induced choroidal hypoperfusion was determined by indocyanine green angiograms. The intensity of the diffuse fluorescence within the PDT site away from the choroidal neovascularization lesion and from the normal retina just peripheral to the optic disk was measured by densitometry (Topcon IMAGEnet computer system, Topcon, Tokyo, Japan) in the indocyanine green angiogram images obtained at 10 minutes 3 months after the PDT. The ratio of the average brightness of the retina within the PDT area to that of the retina peripheral to the optic disk (irradiated/nonirradiated retinal brightness ratio) was calculated for each angiogram.

RESULTS

The irradiated/nonirradiated retinal brightness ratio of the angiograms was 0.96 in the PDT-alone group, 0.85 in the sub-Tenon injection of triamcinolone acetonide-PDT group, and 0.89 in the intravitreal injection of bevacizumab-PDT group (Kruskal-Wallis H test, P < 0.05).

CONCLUSION

The degree of choroidal hypofluorescence in the indocyanine green angiogram images 3 months after PDT in the sub-Tenon injection of triamcinolone acetonide and intravitreal injection of bevacizumab group was higher than that of PDT-alone group. Sub-Tenon injection of triamcinolone acetonide and intravitreal injection of bevacizumab can prolong the duration of the choroidal hypofluorescence after PDT.

Long-term follow-up of full macular translocation for choroidal neovascularization

PURPOSE

To report the long-term (>5 years) results of full macular translocation in patients with choroidal neovascularization (CNV).

DESIGN

Retrospective, interventional case series.

METHODS

This study involved 32 eyes of 32 patients who had undergone full macular translocation for CNV. The median follow-up was 6.5 years (range, 5.2 to 7.7 years). We evaluated the best-corrected visual acuity, fundus examination results obtained before and 1 and 5 years after operation, and postoperative complications.

RESULTS

At the 1-year follow-up, foveal retinal pigment epithelium atrophy was observed in only 3 eyes (12%), and the mean logarithm of the minimal angle of resolution (logMAR) visual acuity (VA) at that time (1.39 +/- 0.67) was not significantly changed from that before surgery (logMAR, 1.31 +/- 0.66) in 25 eyes with age-related macular degeneration (AMD). However, at 5-year follow-up, foveal retinal pigment epithelium atrophy increased (18 eyes; 72%), and final mean logMAR VA (1.88 +/- 0.76) was significantly lower (P < .01). Five eyes with myopic CNV maintained their VA from before operation (mean logMAR, 0.88 +/- 0.35) until final follow-up (mean logMAR, 0.73 +/- 0.31). The final VA was significantly better in myopic CNV than in exudative age-related macular degeneration on multiple regression analysis (P = .019).

CONCLUSIONS

Long-term follow-up of full macular translocation showed that the final VA was poor in age-related macular degeneration, but relatively better in myopic CNV.

Time-course and characteristic morphology of retinal changes following combination of verteporfin therapy and intravitreal triamcinolone in neovascular age-related macular degeneration

PURPOSE

To identify characteristic morphological changes of the retina over time and the association with visual function after combined photodynamic therapy (PDT) and intravitreal triamcinolone (IVTA).

METHODS

In this retrospective study, 40 patients (40 eyes) were treated with PDT and same-day IVTA. Optical coherence tomography (OCT), fluorescein angiography (FA) and evaluation of distance visual acuity (VA) were performed. The anatomical changes within intra- and subretinal compartments and their detailed analysis and grading were the main outcome measures.

RESULTS

Intraretinal fluid (IRF) and subretinal fluid (SRF) by OCT decreased until 3 months (p < 0.01). At month 3, intraretinal cystoid spaces (ICS) had resolved or decreased in 84% of eyes, SRF in 58% and pigment epithelial detachment (PED) in 50%. Mean best-corrected VA (BCVA) improved significantly at month 1 (p < 0.01). Mean central retinal thickness (CRT) increased from 334 microm at baseline to 439 microm at day 1 (p = 0.03) before decreasing to 286 microm at day 7 (p = 0.06), 233 microm at month 1 (p = 0.001) and 255 microm at month 3 (p = 0.001).

CONCLUSION

Combined verteporfin/IVTA therapy induces distinct time-related effects on the retina within the different intra- and subretinal compartments.

Photodynamic therapy with and without adjunctive intravitreal triamcinolone acetonide: a retrospective comparative study

BACKGROUND AND OBJECTIVE

To compare photodynamic therapy (PDT) with and without adjunctive intravitreal triamcinolone acetonide (IVTA) in the treatment of choroidal neovascularization secondary to age-related macular degeneration.

PATIENTS AND METHODS

Sixty-six eyes received PDT with IVTA and 73 eyes received PDT only. Outcome measures included changes in visual acuity and greatest linear dimension (GLD), the presence of angiographic leakage, the re-treatment rate, and adverse events.

RESULTS

Patients treated with PDT with IVTA had reduced mean GLD compared to patients treated with PDT only at all study time points (3 [P = .0049], 6 [P = .003], and 12 [P = .05] months). Forty-four percent of patients in the PDT with IVTA group and 22% of patients in the PDT only group achieved angiographic closure at 3 months (P = .027). There were no significant differences in the final visual acuity outcome or the re-treatment rate between the two groups.

CONCLUSION

PDT with IVTA therapy has a favorable outcome on GLD. There is a modest improvement in visual acuity with PDT with IVTA therapy, which diminishes over time.

Anti-vascular endothelial growth factor activity in the bevacizumab and triamcinolone acetonide combination for intravitreal use

PURPOSE

To find out if the combination for intravitreal use of the antibody bevacizumab (AvastinTM; Genentech, Inc., San Francisco, CA) and triamcinolone acetonide (TA) (Kenacort; Bristol-Myers Squibb, Anagni, Italy) could affect over time the anti -vascular endothelial growth factor (VEGF) activity of bevacizumab.

METHODS

Two different combined preparations were obtained, drawing up together 1.25 mg/0.05 mL of bevacizumab and 2 mg/0.05 mL (B+TA(2mg)) or 4 mg/0.05 mL (B+TA(4mg)) of TA into insulin syringes with 29-G needle. Control preparations were obtained with bevacizumab and an injectable solution (B). The syringes were stored refrigerated at 4 degrees C. The bevacizumab concentration was measured, through its binding to VEGF-165 isoform, at 48 hours and at 1 week.

RESULTS

No preparations showed statistically significant changes in bevacizumab concentration with time (p=0.74 for B+T(2mg), p=0.92 for B+T(4mg), p=0.57 for B). The B+TA(2mg) preparations showed a larger percentage of degradation of bevacizumab than the B+TA(4mg) preparations (28.4% versus 17.6% at 48 hours; 26.4% versus 18% at 1 week). The B control preparations showed the lowest drug degradation: 9.6% at 48 hours and 14.8% at 1 week.

CONCLUSIONS

After storage at 4 degrees C for 48 hours and 1 week, the combined preparations showed a larger reduction in bevacizumab concentration than the control preparations. No significant change was observed with the length of storage. The preparations obtained mixing 4 mg/0.05 mL of TA and 1.25 mg/0.05 mL of bevacizumab maintained the highest anti-VEGF activity over time.

Intravitreal injection of therapeutic agents

BACKGROUND

Intravitreal injection (IVI) with administration of various pharmacological agents is a mainstay of treatment in ophthalmology for endopthalmitis, viral retinitis, age-related macular degeneration, cystoid macular edema, diabetic retinopathy, uveitis, vascular occlusions, and retinal detachment. The indications and therapeutic agents are reviewed in this study.

METHODS

A search of the English, German, and Spanish language MEDLINE database was conducted. A total of 654 references spanning the period through early 2008 were individually evaluated.

RESULTS

The advantage of the IVI technique is the ability to maximize intraocular levels of medications and to avoid the toxicities associated with systemic treatment. Intravitreal injection has been used to deliver several types of pharmacological agents into the vitreous cavity: antiinfective and antiinflammatory medications, immunomodulators, anticancer agents, gas, antivascular endothelial growth factor, and several others. The goal of this review is to provide a detailed description of the properties of numerous therapeutic agents that can be delivered through IVI, potential complications of the technique, and recommendations to avoid side effects.

CONCLUSION

The IVI technique is a valuable tool that can be tailored to the disease process of interest based on the pharmacological agent selected. This review provides the reader with a comprehensive summary of the IVI technique and its multitude of uses.

The effect of the first application of verteporfin photodynamic therapy on lesion growth in choroidal neovascularisation and its potential impact on combination therapy

PURPOSE

To evaluate the impact of lesion size on the observed growth of the choroidal neovascularisation (CNV) following the first application of photodynamic therapy (PDT).

METHODS

A retrospective study of consecutive patients with subfoveal classic CNV or predominantly classic CNV undergoing first verteporfin photodynamic therapy (VPDT) according to treatment of age-related macular degeneration with photodynamic therapy (TAP) protocol between June 2005 and September 2005. Patients were classified into two groups according to baseline greatest linear dimension (GLD) at the time of VPDT monotherapy. Group 1 comprised patients with lesion GLD less then 2000 microm and Group 2, patients with lesion GLD 2000 microm or larger. Difference between the mean GLD at baseline and at three months post-treatment were investigated for clinical significance using the paired t-test.

RESULTS

Group 1 (n = 16) showed a mean change in GLD from 1380.25 microm to 2031.25 microm, while Group 2 (n = 26) showed a mean change of 2909.26 microm to 3023.07 microm. Data of mean percentage change in GLD for Group 1 showed a 51.97 per cent increase in the lesion size [95% CI, 22.93 - 81.01%] in comparison to Group 2, which showed only 5.8 per cent increase in the lesion [95% CI, -9.65 - 21.61%]. Comparison of the mean percentage change in GLD between the two groups showed a statistically significant difference (p = 0.003).

CONCLUSIONS

Our study demonstrates that following the first application of VPDT, smaller lesions enlarge disproportionately more than larger lesions. As we have entered into the era of using angiostatic agents in combination with VPDT, it may be important to evaluate this effect with regards to the timing of VPDT commencement.

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.

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

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. Twenty-eight 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.

Economic implications of current age-related macular degeneration treatments

PURPOSE

To measure the cost versus benefit of age-related macular degeneration (AMD) treatment strategies, existing and proposed, in the postranibizumab era.

DESIGN

Cost-effectiveness model.

PARTICIPANTS

None.

METHODS

University with hospital-based practice modeling of clinical examination, imaging, and treatment schedules were constructed considering published protocols where available, or by estimating usual practices. Medicare-allowable reimbursement schedules for a hospital-based, south Florida practice in 2007 were used to calculate costs of treatment. The lines of vision saved were deduced from published reports or using identified assumptions. This information was used to calculate cost per lines saved and, using actuarial tables data, costs per line-year saved were calculated.

MAIN OUTCOME MEASURE

Cost ($US) per line-year.

RESULTS

Consensus control values of expected lines loss if untreated (natural history) were established from published reports (2.5 lines at 1 year; 3.5 at 2 years) and photodynamic therapy (2.0 lines at 1 year; 3.0 at 2 years) for use in calculating lines of vision saved in studies without untreated control groups. The cost per line-year for 1 year of treatment ranged from a low of $84 with as-needed bevacizumab to $766 for protocol-style use of ranibizumab. Combination treatment regimens yielded a range of $71 to $269. The pharmaceutical proportion of treatment costs is higher than professional or facility costs, ranging to 83% for protocol-style ranibizumab.

CONCLUSIONS

Pharmaceutical-based treatments of AMD have markedly improved visual outcomes, but also have escalated costs markedly. Treatment regimens involving as-needed dosing, alternate medications, and combination therapy may preserve benefit for substantially lower costs. Disparate safety profiles would require consideration in choosing treatment regimens. Cost-benefit issues must be considered in AMD treatment regimens.

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.

Use of intravitreal injection of triamcinolone acetonide in the treatment of age-related macular degeneration

Age-related macular degeneration (AMD) is now considered an important and leading cause of blindness among elderly patients in developed and developing countries. AMD has two forms, dry and wet; both can lead to visual loss. However, occurrence of subfoveal choroidal neovascular (CNV) membrane in the wet form results in severe visual impairment.

Treatment options for choroidal neovascularization are available in order to maintain and in some cases improve vision. Photodynamic therapy (PDT) has been used to treat both classic and occult membranes. It has known to cause choroidal hypoperfusion and production of vascular endothelial growth factor.

Intravitreal steroid can possibly reduce the damage caused due to these undesirable effects. In the recent past, intravitreal injection of triamcinolone acetonide (IVTA) has been used extensively as an adjunct to PDT in AMD in order to reduce the number of PDT sessions and evaluate possible beneficial effects on vision.

This article reviews the pharmacological attributes of triamcinolone, available evidence of its use as monotherapy or combination therapy to treat AMD, ocular side-effects thereof and ongoing clinical trials on IVTA.

Effect of posterior juxtascleral triamcinolone acetonide on the efficacy and choriocapillaris hypoperfusion of photodynamic therapy

PURPOSE

To evaluate the effect of posterior juxtascleral triamcinolone acetonide (TA) injection combined with photodynamic therapy with verteporfin (PDT) for treating exudative age-related macular degeneration (AMD), the best-corrected visual acuity (BCVA), the retreatment rates and the rate of choroidal hypoperfusion were investigated.

METHODS

A total of 67 eyes with subfoveal choroidal neovascularization (CNV) due to AMD were included. Forty-four eyes underwent PDT alone (PDT-alone group), and 23 eyes underwent PDT with the posterior juxtascleral injection of TA (PDT+TA group). Every 3 months after the PDT, the eyes were evaluated with regard to BCVA and requirement for retreatment by fluorescein angiography (FA) with the aid of optical coherence tomography (OCT). Choroiocapillaris hypoperfusion was assessed by indocyanine green angiography (ICGA) at 3 and 12 months. All patients completed a 1-year follow-up.

RESULTS

At the baseline, there was no difference in lesion type, size or visual acuity between the two groups. At 1 year, the change in BCVA was -0.0811 logarithm of the minimum angle of resolution (LogMAR) in the PDT-alone group, compared with -0.0432 logMAR in the PDT+TA group. There was no significant difference in the change in BCVA between the two groups (P = 0.6910). The PDT+TA group required a lower mean number of treatments (1.64 compared with 2.34 [P = 0.0223]) and showed a higher rate of choriocapillaris occlusion at 3 months, but no significant difference at 1 year (P = 0.9243)

CONCLUSIONS

Fewer retreatments were required in the TA+PDT group. There was no significant difference in the change in BCVA between the two groups. Adjacent TA may promote short-term choriocapillaris hypoperfusion.

Efficacy of Photodynamic Therapy in the Management of Occult Choroidal Neovascularization Associated with Serous Pigment Epithelium Detachment

AIMS

To evaluate the efficacy of photodynamic therapy (PDT) in the treatment of subfoveal occult choroidal neovascularization (CNV) associated with serous pigment epithelium detachment (PED) in eyes with age-related macular degeneration.

METHODS

Hundred and fifty-three patients (161 eyes) with subfoveal occult CNV due to age-related macular degeneration, were divided into two groups. The first group (70 patients, 75 eyes) included eyes with occult CNV associated with serous PED of at least 1 disc diameter in size and the second (83 patients, 86 eyes) eyes with late leakage of undetermined source. All the patients were treated with PDT. The follow-up time ranged from 12 to 48 months.

RESULTS

At the last examination, in the first group, the visual acuity (VA) improved or remained stable in 17 (22.7%) and decreased in 58 (77.3%). In the second group, the VA improved or remained stable in 37 (43%) and decreased in 49 (57%). The difference in the change (decrease) in the VA between the two groups was statistically very significant (p = 0.0075). Retinal pigment epithelium tear occurred in 15 eyes (20%) of the first group.

CONCLUSION

Our study showed that the visual prognosis of eyes treated with PDT due to subfoveal occult CNV associated with serous PED is not favorable. We believe that the distinction between the two forms of occult CNV is essential, as they carry a different prognosis.

Retinal angiomatous proliferation: combined therapy of intravitreal triamcinolone acetonide and PDT versus PDT alone

BACKGROUND

The objective of the study was to investigate whether combined treatment with photodynamic therapy (PDT) and triamcinolone acetonide intravitreally applied is superior to PDT alone in eyes with retinal angiomatous proliferation (RAP).

METHODS

Between July 2004 and June 2005 eyes with RAP in age-related macular degeneration were included in a prospective study and were treated with 4 mg of triamcinolone acetonide followed by PDT (group 1). Eyes with RAP treated with PDT alone before June 2004 were retrospectively reviewed (group 2). Distance visual acuity (VA) with Early Treatment Diabetic Retinopathy Study (ETDRS) charts, greatest diameter of the lesion (measured by fluorescein angiography), and retinal thickness (measured by optical coherence tomography) were performed at baseline and at 6 weeks, 3 months, 6 months and 12 months thereafter.

RESULTS

Fifty-eight eyes in 58 patients were included: 27 eyes in the combined treatment group and 31 eyes in the PDT monotherapy group. The groups were comparable with regard to age, gender and RAP stage. VA decreased from 65.6 to 52.0 and from 60.7 to 44.0 letters, and lesion size increased from 3.2 mm to 3.5 mm and from 3.3 mm to 3.5 mm in the combined and monotherapy groups respectively. There was a trend towards a better outcome in the combined group. Significantly (p = 0.01) fewer complications occurred in the combined group (22.2%) than in the monotherapy group (54.8%).

CONCLUSION

No significant differences could be found in the time course of distance VA, retinal thickness, and lesion size between the PDT monotherapy group and the combined PDT and IVTA group. However, significantly fewer complications occurred in the combined treatment group. New therapeutic strategies might be required in RAP lesions, probably including therapy with anti-angiogenic agents.

Intravitreales Bevacizumab vs. Verteporfin und intravitreales Triamcinolon Acetonid bei Patienten mit neovaskulärer AMD

AIM

The aim of this study was to compare intravitreal bevacizumab (IVB) and verteporfin therapy in combination with 4 mg intravitreal triamcinolone (PDT-IVTA) in patients with neovascular age-related macular degeneration (AMD).

PATIENTS AND METHODS

A total of 30 eyes of 30 patients with neovascular AMD were included in a prospective, randomized study. Ten eyes received PDT-IVTA with a standard light fluence of 50 J/cm(2) (SPDT-IVTA), ten were treated with PDT-IVTA with a reduced light fluence of 25 J/cm(2) (RPDT-IVTA) and ten received IVB. The main outcome was evaluated using early treatment diabetic retinopathy study (ETDRS) visual acuity, fluorescein angiography and optical coherence tomography (OCT) at baseline as well as at day 1, week 1, 1 month and 3 months after therapy.

RESULTS

At the beginning of therapy, the distribution of the groups was balanced. After 3 months, the SPDT-IVTA group showed a non-significant vision loss of seven letters (p<0.3) while a vision loss of 0.5 letters (p<0.9) was found in the RPDT-IVTA group. At the same time, the IVB group had a vision improvement of 11.8 letters (p<0.001). This vision improvement was statistically significant compared to the results of both PDT-IVTA groups (p<0.005). Central retinal thickness (CRT) decreased up to month 3 in the SPDT-IVTA group by 132 microm, in the RPDT-IVTA group by 78 mum and in the IVB group by 138 microm, (p<0.05 in the three groups). No significant difference in the decrease of CRT was found between the treatment groups after 3 months.

CONCLUSION

IVB shows significantly better results in vision improvement in the short-term compared to the two PDT-IVTA groups. Within 3 months, all groups showed a comparable decrease in CRT. Long-term follow-up is required to evaluate the safety and treatment efficacy of all treatment modalities.

INFLUENCE OF VERTEPORFIN PHOTODYNAMIC THERAPY ON INFLAMMATION IN HUMAN CHOROIDAL NEOVASCULAR MEMBRANES SECONDARY TO AGE-RELATED MACULAR DEGENERATION

PURPOSE

To examine the short- and long-term consequences of verteporfin photodynamic therapy (PDT) on inflammation with regard to infiltration of macrophages and leukocytes and expression of thy-1 in human choroidal neovascularization membranes (CNV) secondary to age-related macular degeneration (AMD).

METHODS

Retrospective review of an interventional case series of 43 patients who underwent removal of CNV. Twenty patients were treated with PDT 3 to 246 days preoperatively. Twenty-three CNV without previous treatment were used as control. CNV were stained for CD34, CD105, cytokeratin 18, Ki-67, thy-1, an endothelial cell glycoprotein known to be upregulated only by inflammatory cytokines, CD68 (macrophages), and CD45 (common leukocyte antigen).

RESULTS

Specimens treated by PDT 3 days previously showed significantly reduced endothelial thy-1 expression (P = 0.008), leukocyte (P=0.04) and macrophage (P=0.0063) infiltration, and proliferative activity (P=0.02) compared to control CNV. Specimens at longer intervals after PDT, in contrast, disclosed a significantly increased expression of thy-1 (P=0.004), infiltration with leukocytes (P=0.044) and macrophages (P=0.01), and proliferative activity (P=0.03) compared to CNV excised 3 days after PDT.

CONCLUSIONS

The rebound effect after PDT seems to be based on an inflammatory response that contributes to enhanced proliferation. These data support the need for an anti-inflammatory therapy as adjuvant to PDT.

Current Treatment of Age-Related Macular Degeneration

PURPOSE

To review proved and experimental treatments for exudative and nonexudative complications of age-related macular degeneration (AMD), to consider the impact of current therapy on the structure of future clinical trials, and to consider the role of improved diagnostic imaging techniques on the effectiveness of current therapy as well as the structure of future clinical trials in AMD patients.

RESULTS

Defining the cell biology of choroidal new vessel (CNV) formation and geographic atrophy will lead to identification of different biochemical pathways that are the target of AMD treatment. Many treatments and treatment combinations are under study for AMD, but all work through a finite number of pathways. Currently, the most effective proved therapy for AMD-associated CNVs is administered by repeated intravitreal injection of agents that inhibit vascular endothelial growth factor, e.g., ranibizumab. Improved drug delivery will enhance patient satisfaction and possibly will enhance the effectiveness and reduce the risk of current pharmacotherapy for AMD-associated CNVs. Combination therapy (e.g., verteporfin-photodynamic therapy + ranibizumab) appears to reduce the risk and enhance the effectiveness of CNV treatment compared with monotherapy with currently available agents. Improved noninvasive diagnostic imaging may lead to better visual outcomes with existing therapeutic modalities. Improved imaging also may alter favorably the design of future clinical trials for AMD-associated CNVs and thus reduce cost and increase the diversity of sight-saving treatments.

CONCLUSIONS

Delineation of the biochemical basis for CNV formation has led to development of pathway-based pharmacotherapy for AMD patients. Areas of investigation that will advance the field further include combination therapy, improved drug delivery, and improved noninvasive, high-resolution diagnostic imaging. The logistics of future clinical trials will be complicated by the need for an active treatment control group, more stringent definition of successful treatment, and the increased numbers of patients required for combination therapy studies.

Combined photodynamic therapy and intravitreal triamcinolone for neovascular age-related macular degeneration: effect of initial visual acuity on treatment response

PURPOSE

To evaluate visual outcomes in combination therapy with photodynamic therapy (PDT) and intravitreal triamcinolone acetonide (IVTA) for subfoveal choroidal neovascularization (CNV) from age-related macular degeneration (AMD).

METHODS

Charts of 39 eyes from 38 patients with exudative AMD treated with PDT and 4 mg of triamcinolone acetate injected intravitreally were reviewed retrospectively. Visual data, angiographic lesion type, prior PDT exposure, number of treatments, and follow-up were recorded. Snellen visual acuities were converted to LogMAR for all calculations. Lines of vision lost or gained pertain to calculated ETDRS lines of vision (via LogMAR).

RESULTS

Twenty-two of the choroidal neovascular membranes were occult, and 17 were classified as predominantly classic. Mean follow-up was 43 weeks. The average number of treatments was 2.23. At final follow-up, 11 eyes (28.21%) experienced improved visual acuity, 8 eyes (20.51%) were stable, and 20 eyes (51.28%) had worsened. No significant difference in treatment response was found between angiographic subtypes (p > 0.59). Lack of previous PDT exposure did not improve treatment outcomes (p > 0.77). Pre-treatment visual acuity (PTVA) was determined as a strong predictor of treatment outcome in our study cohort. Visual acuity of 20/200 or worse was associated with a 40.9% chance of some improvement and a 35.75% chance of three or more lines of improvement. Visual acuity better than 20/200 was associated with an 89.4% chance of no improvement and a 58.8% chance of three or more lines of visual loss.

CONCLUSION

Counter to previously reported results with combination therapy, the majority of our patients (72%) did not demonstrate improved vision and 51% lost vision. When PTVA was accounted for, selected patients benefitted significantly from treatment. PTVA may be a useful and simple patient selection tool for combination treatment with PDT and IVTA.

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

Background

To 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).

Methods

In 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.

Results

This 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.

Conclusion

Initial 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.

Relative Cost of a Line of Vision in Age-Related Macular Degeneration

PURPOSE

To quantitate the relative cost of new therapies for age-related macular degeneration (AMD) versus saved vision.

DESIGN

Systematic review.

METHODS

Landmark AMD treatment studies were reviewed to quantitate the visual benefit. For comparison, representative treatment studies for common retinal conditions including retinal detachment, macular hole (MH), epiretinal membrane (ERM), and diabetic retinopathy were also reviewed.

MAIN OUTCOME MEASURES

Several parameters to estimate Snellen lines of vision saved were defined and tabulated for each condition. A regimen of office visits, ancillary testing, and treatments was outlined. Costs for this were tabulated using Medicare-allowable costs, and costs of visual benefit (per line of vision) for each condition were calculated. Life expectancy was factored in to calculate the cost of a line of vision for each year (line-year). The proportions of costs allocated to professional, technical, and pharmaceutical expenses were tabulated for each therapy.

RESULTS

The cost per line of vision saved for AMD therapies ranged from $997 for laser for extrafoveal choroidal neovascularization, to $5509 for photodynamic therapy for occult lesions, to $12 482 for pegaptanib injections. This compares to $651 for retinal detachment repair, $1658 for MH repair, $2411 for ERM peeling, $5458 for diabetic macular edema laser, $594 for panretinal photocoagulation, and $2984 to $4178 for diabetic vitrectomy. The costs per line-years ranged from $77 to $1248 for AMD, and $21 to $194 for the comparison conditions. The proportion of costs for pegaptanib treatment was 17% for professional fees and 70% for pharmaceutical fees. Assumptions incorporated in estimating costs for pegaptanib could easily have doubled because second-year costs might approximate first-year costs and the maintenance of treatment effect has not been well established.

CONCLUSIONS

Although correctly heralded as a breakthrough in macular degeneration treatment, new pharmacologic therapies for AMD are extremely expensive and some yield marginal visual dividends. As in all fields of medicine that provide care to elderly patients, these costs should be considered as they relate to health care costs for the individual patient and payors, and must be considered in a larger perspective of health care benefit apportionment.