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Gonzalez A, Khurshid G. Treatment of retinal pigment epithelial detachment secondary to exudative age-related macular degeneration. Am J Ophthalmol Case Rep 2018; 9:18-22. [PMID: 29468211 PMCID: PMC5786863 DOI: 10.1016/j.ajoc.2017.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 12/14/2017] [Accepted: 12/15/2017] [Indexed: 12/26/2022] Open
Abstract
Purpose This pilot study evaluated the combination of photodynamic therapy (PDT) and anti-vascular endothelial growth factor (anti-VEGF) as a treatment in patients with a pigment epithelial detachment (PED) due to exudative age-related degeneration (AMD). Methods We analyzed seven consecutive patients between September 1, 2015 and September 1, 2017 with a PED secondary to exudative AMD who were treated with full fluence standard PDT and a series of monthly intravitreal anti-VEGF injections. Follow-up ranged between 3 and 24 months. Variables collected for the purpose of this study included baseline best-corrected visual acuity converted to logMAR (logarithm of minimum angle of resolution), central macular thickness, and maximum PED height. This information was then reviewed at subsequent follow-ups. Results The PED completely resolved in 4/7 eyes while three patients had a significant improvement in PED size with a corresponding improvement in visual acuity. Initial PED heights ranged from 147 to 423 μm and was reduced by an average of 255.7 μm (83.2% average reduction, range -143 to - 405 μm). Initial CMT ranged from 223 to 719 μm and was reduced by an average of 225.7 μm (54.4% average reduction, range -88 to - 529 μm). Mean logMAR VA improved from 0.669 (Snellen equivalent 20/93, [20/40 to 20/200]) to 0.269 (Snellen equivalent 20/37, [20/25 to 20/80]) at last follow-up. No complications were observed in our patients. Conclusions and Importance PED in the setting of exudative AMD showed an excellent response to a combined multimodal approach that includes PDT with intravitreal anti-VEGF injection followed by a monthly anti-VEGF schedule. Most importantly, visual acuity showed a significant improvement from baseline. If confirmed by future studies, this would offer another treatment avenue for this difficult-to-treat consequence of exudative AMD.
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Affiliation(s)
- Andres Gonzalez
- Department of Ophthalmology, University of Florida, Gainesville, FL, United States
| | - Gibran Khurshid
- Department of Ophthalmology, University of Florida, Gainesville, FL, United States
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Parmeggiani F, Costagliola C, Semeraro F, Romano MR, Rinaldi M, Gallenga CE, Serino ML, Incorvaia C, D’Angelo S, De Nadai K, Dell’Omo R, Russo A, Gemmati D, Perri P. Effect of Factor XIII-A G185T Polymorphism on Visual Prognosis after Photodynamic Therapy for Neovascular Macular Degeneration. Int J Mol Sci 2015; 16:19796-811. [PMID: 26307969 PMCID: PMC4581326 DOI: 10.3390/ijms160819796] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 07/23/2015] [Accepted: 08/11/2015] [Indexed: 01/31/2023] Open
Abstract
Macular degenerations represent leading causes of central blindness or low vision in developed countries. Most of these severe visual disabilities are due to age-related macular degeneration (AMD) and pathologic myopia (PM), both of which are frequently complicated by subfoveal choroidal neovascularization (CNV). Photodynamic therapy with verteporfin (PDT-V) is still employed for CNV treatment in selected cases or in combined regimen. In Caucasian patients, the common polymorphism G185T of factor XIII-A gene (FXIII-A-G185T; rs5985) has been described as predictor of poor angiographic CNV responsiveness to PDT-V. Nevertheless, the prognostic implications of this pharmacogenetic determinant on long-term visual outcome after a PDT-V regimen have not been evaluated. We retrospectively selected Caucasian patients presenting with treatment-naive CNV and receiving standardized PDT-V protocol for two years. The study population included patients affected by subfoveal CNV secondary to AMD or PM. We assessed the correlations between the polymorphic allele T of FXIII-A-G185T and: (1) total number of photodynamic treatments; and (2) change in visual acuity from baseline to the end of the follow-up period. Considering a total study population of 412 patients with neovascular AMD or PM, the carriers of 185 T-allele of FXIII-A (GT or TT genotype) received a higher number of photodynamic treatments than patients without it (GG wild-type genotype) (p < 0.01; mean number of PDT-V: 5.51 vs. 3.76, respectively). Moreover, patients with 185 T-allele of FXIII-A had a more marked worsening of visual acuity at 24 months than those with the GG-185 wild genotype (p < 0.01; mean difference in logMAR visual acuity: 0.22 vs. 0.08, respectively). The present findings show that the G185T polymorphism of the FXIII-A gene is associated with significant differences in the long-term therapeutic outcomes of patients treated with standardized PDT-V protocol. The comprehensive appraisal of both anti-thrombophilic effects due to FXIII-A G185T variant and photo-thrombotic action of PDT-V toward CNV provides several clues about the rationale of this intriguing pharmacogenetic correlation. Further investigations are warranted to outline the appropriate paradigm for guiding PDT-V utilization in the course of the combined therapeutic protocol for neovascular macular degeneration.
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Affiliation(s)
- Francesco Parmeggiani
- Eye Clinic, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Via Aldo Moro 8, 44124 Cona-Ferrara, Italy; E-Mails: (C.E.G.); (C.I.); (S.D.A.); (K.D.N.); (P.P.)
| | - Ciro Costagliola
- Eye Clinic, Department of Health Sciences, University of Molise, Via Francesco de Sanctis 1, 86100 Campobasso, Italy; E-Mails: (C.C.); (R.D.O.)
| | - Francesco Semeraro
- Eye Clinic, Department of Neurological and Vision Sciences, University of Brescia, Piazzale Spedali Civili 1, 25123 Brescia, Italy; E-Mails: (F.S.); (A.R.)
| | - Mario R Romano
- Eye Clinic, Department of Neuroscience, Reproductive and Odonto-Stomatological Sciences, “Federico II” University of Naples, Via Pansini 5, 80131 Napoli, Italy; E-Mail:
| | - Michele Rinaldi
- Department of Ophthalmology, Second University of Naples, Via Pansini 5, 80131 Napoli, Italy; E-Mail:
| | - Carla Enrica Gallenga
- Eye Clinic, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Via Aldo Moro 8, 44124 Cona-Ferrara, Italy; E-Mails: (C.E.G.); (C.I.); (S.D.A.); (K.D.N.); (P.P.)
| | - Maria Luisa Serino
- Center of Hemostasis and Thrombosis, Department of Medical Sciences, University of Ferrara, Corso Giovecca 203, 44121 Ferrara, Italy; E-Mails: (M.L.S.); (D.G.)
| | - Carlo Incorvaia
- Eye Clinic, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Via Aldo Moro 8, 44124 Cona-Ferrara, Italy; E-Mails: (C.E.G.); (C.I.); (S.D.A.); (K.D.N.); (P.P.)
| | - Sergio D’Angelo
- Eye Clinic, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Via Aldo Moro 8, 44124 Cona-Ferrara, Italy; E-Mails: (C.E.G.); (C.I.); (S.D.A.); (K.D.N.); (P.P.)
| | - Katia De Nadai
- Eye Clinic, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Via Aldo Moro 8, 44124 Cona-Ferrara, Italy; E-Mails: (C.E.G.); (C.I.); (S.D.A.); (K.D.N.); (P.P.)
| | - Roberto Dell’Omo
- Eye Clinic, Department of Health Sciences, University of Molise, Via Francesco de Sanctis 1, 86100 Campobasso, Italy; E-Mails: (C.C.); (R.D.O.)
| | - Andrea Russo
- Eye Clinic, Department of Neurological and Vision Sciences, University of Brescia, Piazzale Spedali Civili 1, 25123 Brescia, Italy; E-Mails: (F.S.); (A.R.)
| | - Donato Gemmati
- Center of Hemostasis and Thrombosis, Department of Medical Sciences, University of Ferrara, Corso Giovecca 203, 44121 Ferrara, Italy; E-Mails: (M.L.S.); (D.G.)
| | - Paolo Perri
- Eye Clinic, Department of Biomedical and Specialty Surgical Sciences, University of Ferrara, Via Aldo Moro 8, 44124 Cona-Ferrara, Italy; E-Mails: (C.E.G.); (C.I.); (S.D.A.); (K.D.N.); (P.P.)
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Parmeggiani F, Gemmati D, Costagliola C, Semeraro F, Perri P, D'Angelo S, Romano MR, De Nadai K, Sebastiani A, Incorvaia C. Genetic predictors of response to photodynamictherapy. Mol Diagn Ther 2012; 15:195-210. [PMID: 21913742 DOI: 10.1007/bf03256411] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
In Western countries, therapeutic management of patients affected by choroidal neovascularization (CNV) secondary to different typologies of macular degeneration represents a major health care problem. Age-related macular degeneration is the disease most frequently associated with CNV development. Schematically, CNVs can be distinguished into classic and occult subtypes, which are characterized by variable natural history and different responsiveness to some therapeutic procedures. At present, the dramatic vision loss due to CNV can be mainly treated by two interventional strategies, which are utilizable in either single or combined modalities: photodynamic therapy with verteporfin (PDT-V), and intravitreal administration of drugs acting against vascular endothelial growth factor. The combined use of PDT-V and anti-angiogenic drugs represents one of the most promising strategies against neovascular macular degeneration, but it unavoidably results in an expensive increase in health resource utilization. However, the positive data from several studies serve as a basis for reconsidering the role of PDT-V, which has undergone a renaissance prompted by the need for a more rational therapeutic approach toward CNV. New pharmacogenetic knowledge of PDT-V points to exploratory prospects to optimize the clinical application of this intriguing photothrombotic procedure. In fact, a Medline search provides data regarding the role of several single nucleotide polymorphisms (SNPs) as genetic predictors of CNV responsiveness to PDT-V. Specifically, correlations between SNPs and different levels of PDT-V efficacy have been detected by examining the gene variants influencing (i) thrombo-coagulative pathways, i.e. methylenetetrahydrofolate reductase (MTHFR) 677C>T (rs1801133), factor V (F5) 1691G>A (rs6025), prothrombin (F2) 20210G>A (rs1799963), and factor XIII-A (F13A1) 185G>T (rs5985); (ii) complement activation and/or inflammatory processes, i.e. complement factor H (CFH) 1277T>C (rs1061170), high-temperature requirement factor A1 (HTRA1) promoter -512G>A (rs11200638), and two variants of the C-reactive protein (CRP) gene (rs2808635 and rs876538); and (iii) production and bioavailability of vascular endothelial growth factor (VEGFA -2578C>A [rs699947] and rs2146323). This article critically evaluates both the clinical plausibility and the opportunity to utilize the most important SNP-response interactions of PDT-V for an effective upgrade of the current anti-CNV therapeutic scenario. In addition, the pharmacogenetics of a very severe post-PDT-V adverse event, i.e. a decrease in acute vision, is briefly discussed. A comprehensive appraisal of the findings reviewed in this article should be carefully considered to design future trials aimed at verifying (after proper genotypic stratification of the enrolled patients) whether these innovative pharmacogenetic approaches will be able to improve the multifaceted interventional management of neovascular macular degeneration.
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Abstract
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.
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Affiliation(s)
- Steven M Couch
- Mayo Clinic, Department of Ophthalmology, Rochester, MN 55905, USA
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Kim HW, Kim JL, Lee MH, Yoo HG, Chung IY, Lee JE. Combined treatment of photodynamic therapy and bevacizumab for choroidal neovascularization secondary to age-related macular degeneration. KOREAN JOURNAL OF OPHTHALMOLOGY 2011; 25:231-7. [PMID: 21860568 PMCID: PMC3149132 DOI: 10.3341/kjo.2011.25.4.231] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Accepted: 11/12/2010] [Indexed: 11/23/2022] Open
Abstract
Purpose To evaluate the outcome of a combined photodynamic therapy and intravitreal injection of bevacizumab in choroidal neovascularization secondary to age-related macular degeneration. Methods Photodynamic therapy (PDT) was administered to 28 eyes followed by 3 consecutive bevacizumab injections. Patients were followed-up for more than 12 months. At baseline, 1, 3, 6, and 12 months post PDT, visual acuity (VA) and central macular thickness were measured using optical coherence tomography. Results The mean VA was significantly improved from logarithm of the minimal angle of resolution 0.86 at baseline to 0.69 at 1 month (p = 0.011), 0.63 at 3 months (p = 0.003), 0.64 at 6 months (p = 0.004) and 0.60 at 12 months (p < 0.001). Central macular thickness decreased significantly from 328.3 µm at baseline to 230.0 µm at 6 months and 229.9 µm at 1 year (p < 0.001). Reinjection mean number was 0.4 for 6 months and 0.8 for 12 months. By 1 year, retreatment was performed in 10 eyes (36%). Conclusions PDT combined with three consecutive intraviteal bevacizumab injections was effective in improving VA and reducing central macular thickness.
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Affiliation(s)
- Hyun Woong Kim
- Department of Ophthalmology, Inje University College of Medicine, #1-10 Ami-dong, Seo-gu, Busan, Korea
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Combined therapy: photodynamic therapy and bevacizumab to treat myopic neovascular membranes. One-year follow-up. Retina 2011; 31:475-81. [PMID: 20966825 DOI: 10.1097/iae.0b013e3181f201a6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE The purpose of this study was to evaluate whether combined customized photodynamic therapy (PDT) and bevacizumab in myopic choroidal neovascularization can improve vision and whether it is possible to decrease the frequency and number of intravitreal antiangiogenic injections. METHODS A prospective, consecutive, noncomparative, interventional case series of 36 patients with myopic choroidal neovascularization, treated with an initial dose of PDT and intravitreal bevacizumab 48 hours to 60 hours afterward. Retreatments were carried out as required with monthly bevacizumab and PDT every 3 months if there were relapses. Follow-up lasted 1 year in all cases. RESULTS The mean best-corrected visual acuity increased from 44 letters before the initial treatment to 59.5 letters at the 12-month follow-up (P < 0.01). Compared with initial vision, 94.5% of the eyes had the same or better vision and 5.5% lost fewer than 6 lines of vision. The mean number of PDT treatments was 1.1 per patient, and the mean number of bevacizumab injections was 1.5 per patient. Only 1 initial treatment with PDT + bevacizumab was necessary in 28 cases (77.8%). CONCLUSION Combined personalized PDT + bevacizumab therapy makes it possible to obtain visual results similar to those obtained in monotherapy studies but with fewer intravitreal injections. It appears to be an interesting option for this type of patient.
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A RETROSPECTIVE ANALYSIS OF TRIPLE COMBINATION THERAPY WITH INTRAVITREAL BEVACIZUMAB, POSTERIOR SUB-TENON'S TRIAMCINOLONE ACETONIDE, AND LOW-FLUENCE VERTEPORFIN PHOTODYNAMIC THERAPY IN PATIENTS WITH NEOVASCULAR AGE-RELATED MACULAR DEGENERATION. Retina 2011; 31:446-52. [DOI: 10.1097/iae.0b013e3181f6391f] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Reply. Retina 2011. [DOI: 10.1097/iae.0b013e318203ed45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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COMBINED RANIBIZUMAB AND PHOTODYNAMIC THERAPY TO TREAT EXUDATIVE AGE-RELATED MACULAR DEGENERATION. Retina 2010; 30:1190-6. [PMID: 20539256 DOI: 10.1097/iae.0b013e3181d2f172] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gomi F, Sawa M, Wakabayashi T, Sasamoto Y, Suzuki M, Tsujikawa M. Efficacy of intravitreal bevacizumab combined with photodynamic therapy for polypoidal choroidal vasculopathy. Am J Ophthalmol 2010; 150:48-54.e1. [PMID: 20609707 DOI: 10.1016/j.ajo.2010.02.008] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Revised: 02/01/2010] [Accepted: 02/03/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE To compare the efficacy of photodynamic therapy (PDT) with or without intravitreal bevacizumab injection for polypoidal choroidal vasculopathy. DESIGN Retrospective, comparative, interventional case series. METHODS We included 146 eyes of 146 patients with treatment-naïve polypoidal choroidal vasculopathy including the subfoveal region treated with PDT monotherapy or combined with intravitreal bevacizumab injection. Treatments were chosen according to the time period. For eyes that received combination therapy, bevacizumab (1.25 mg) was administrated 1 day before PDT. All eyes were followed up for at least 12 months. Ophthalmic evaluations, including measurement of the best-corrected visual acuity and optical coherence tomography, were performed at every visit. Indocyanine green angiography and fluorescein angiography were performed every 3 months. RESULTS Sixty-one eyes were treated with PDT combined with bevacizumab and 85 eyes were treated with PDT monotherapy. The mean best-corrected visual acuity was significantly better in the combined treatment group than in the monotherapy group at 3 months (P = .0016), 6 months (P = .028), 9 months (P = .038), and 12 months (P = .048). However, lesions resolved in 78.7% of eyes in the combined group and in 75.3% in the monotherapy group; the recurrence rates were 43.8% and 40.6%, respectively, and did not differ significantly. The rate of development of subretinal hemorrhage within 1 month from the initial treatment was significantly lower in the combined group than in the PDT monotherapy group (4.5% vs 17.7%; P = .023). CONCLUSIONS Photodynamic therapy combined with bevacizumab injection offers significantly better early visual outcomes than PDT alone. Combined treatment did not affect the resolution and recurrence of lesions; however, it decreased the rate of development of PDT-related hemorrhages.
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Ehmann D, García R. Triple therapy for neovascular age-related macular degeneration (verteporfin photodynamic therapy, intravitreal dexamethasone, and intravitreal bevacizumab). Can J Ophthalmol 2010; 45:36-40. [DOI: 10.3129/i09-243] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Jyothi S, Chowdhury H, Elagouz M, Sivaprasad S. Intravitreal bevacizumab (Avastin) for age-related macular degeneration: a critical analysis of literature. Eye (Lond) 2009; 24:816-24. [PMID: 19680279 DOI: 10.1038/eye.2009.219] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
PURPOSE The current medical environment demands that quality health care is delivered at an affordable cost through the use of objective, unbiased clinical data. This study was undertaken to review the current literature on bevacizumab for age-related macular degeneration and its value in determining best clinical practice. METHODS Randomised controlled trials (RCTs) and observational studies that met the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) criteria were identified from the current literature for further analysis. Data concerning treatment dosing regimens, response to treatment, complications, and factors influencing outcome and safety were extracted and compiled into a database. RESULTS As of January 2009, there were 5 RCTs that compared the outcomes of bevacizumab to other treatment options and 50 studies that met the STROBE criteria with similar visual and anatomical outcomes between RCTs and observational studies. Although the doses and dosing frequencies varied between the studies, the mean gain in vision at 3 months was +7.76+/-5.4 ETDRS letters (range +2 to +14.4); an effect that was maintained at 6 months in studies with longer follow-up. Predominantly classic lesions were the most responsive of all lesion subtypes. The complication profiles/rates were similar to those reported with other anti-vascular endothelial agents. CONCLUSIONS There is sufficient scientific and statistical evidence to advocate the effective use of OCT-guided administration of intravitreal bevacizumab for neovascular AMD. This is reflected in our study outcome measures that are comparable to findings published from recent well-conducted RCTs on intravitreal ranibizumab at the same time point.
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Affiliation(s)
- S Jyothi
- Department of Ophthalmology, King's College Hospital, London, UK
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