COMBINED RANIBIZUMAB AND PHOTODYNAMIC THERAPY TO TREAT EXUDATIVE AGE-RELATED MACULAR DEGENERATION: An Option For Improving Treatment Efficiency

CHANGES IN VISUAL ACUITY IN PATIENTS WITH WET AGE-RELATED MACULAR DEGENERATION TREATED WITH INTRAVITREAL RANIBIZUMAB IN DAILY CLINICAL PRACTICE: The TWIN Study

PURPOSE

The real-life LUMIERE study on patients with wet age-related macular degeneration treated with intravitreal ranibizumab in 2006 to 2009 showed that failure to follow recommendations was associated with lower efficacy than had been observed in the development phase. The TWIN Study reviewed the situation in 2010 to 2011.

METHODS

Retrospective, descriptive purely observational study of data acquired after 12 months of treatment with intravitreal ranibizumab.

RESULTS

In 881 patients (68% women, mean age, 79 years) treated by 21 ophthalmologists, the mean gain in visual acuity was +4.3 ± 15.4 letters (up from 3.2 ± 14.8 in 2006-2009; NS). Significant improvements were documented in the mean interval between diagnosis and treatment initiation (down from 12.6 ± 26.4-7.7 ± 10.9 days; P < 0.001), and in the percentage of patients who received a full course of induction treatment (56.6 vs. 39.6%; P < 0.001). After induction, hardly any patients were monitored every month as recommended, although retreatment was more assiduous (5.6 ± 2.3 vs. 5.1 ± 2.1 injections; P < 0.001).

CONCLUSION

Despite improvements in key parameters, the effectiveness of intravitreal ranibizumab is still compromised by poor compliance with the guidelines, especially the frequency of postinduction monitoring that is now the most important determinant of successful treatment.

Visual acuity at presentation in the second eye versus first eye in patients with exudative age-related macular degeneration

PURPOSE

To assess the difference in best-corrected visual acuity (BCVA) at presentation between the first and second eye in patients with bilateral neovascular age-related macular degeneration (AMD).

METHODS

We reviewed the charts of all patients who had a clinical examination for neovascular AMD at the University Eye Clinic of Creteil in January 2013. We retrospectively analyzed demographic and clinical data for 264 patients.

RESULTS

In the fellow eye, choroidal neovascularization (CNV) developed in 75/264 patients (28.4%) with a time interval between the 2 events of 30.3 months (range 6-145). Data were available on 65 patients: 14/65 (21.5%) were asymptomatic, 24/65 (36.9%) had BCVA >20/40, whereas at the time of CNV diagnosis in the first eye, no patient was asymptomatic (p<0.0001), and 11/65 (16.9%) eyes had BCVA >20/40 (p<0.0001). The mean BCVA of the first affected eye was 0.68 (± 0.41) logarithm of minimum angle of resolution (logMAR) and the mean BCVA for the second eye was 0.36 (± 0.29) logMAR (p<0.0001).

CONCLUSIONS

The BCVA at the time of diagnosis of CNV was higher in the second eye than in the first affected eye. This was possibly due to several factors including systematic bilateral examination in follow-up of unilateral exudative AMD that allowed detection of 20% of cases.

Predictors of 1-year visual outcome in OCT analysis comparing ranibizumab monotherapy versus combination therapy with PDT in exsudative age-related macular degeneration

AIM

The aim of this study was to find predictive factors of 1-year visual outcome, analyzing novel optical coherence tomography (OCT) biomarkers in exsudative age-related macular degeneration (choroidal neovascularization (CNV)) in two groups of different treatment modalities.

METHODS

In all, 34 consecutive patients with new-onset CNV were randomized 1:1 to receive either ranibizumab monotherapy or ranibizumab combined with photodynamic therapy (PDT) with verteporfin. After three initial injections with ranibizumab, re-treatment was performed according to an as-needed scheme; PDT was performed once at baseline. Best-corrected visual acuity (BCVA) and OCT parameters like central macular volume (CMV), central macular thickness (or central retinal thickness (CRT)), subretinal and intraretinal fluid, fibrovascular lesion thickness, or inner segment/outer segment (IS/OS) junction were analyzed.

RESULTS

After 12 months, a visual gain of 6.1 letters was found in the monotherapy group, whereas patients in the combination therapy group lost - 4.8 letters from baseline to the 12-month visit. CMV and CRT decreased considerably between baseline and month 2-3 in both groups, with a following slight increase until month 12. Additional application of PDT had negative effect to 12-month BCVA, whereas higher baseline BCVA and integrity of the IS/OS junction at month 12 had positive effect to 12-month BCVA.

CONCLUSIONS

Better baseline BCVA and the integrity of IS/OS junction at 12-month visit were the most important predictive factors for final BCVA. Combination therapy caused worse final BCVA and a higher degree of IS/OS disruption.

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.

Combined intravitreal ranibizumab and photodynamic therapy for retinal angiomatous proliferation

PURPOSE

To clarify the efficacy of combined therapy with intravitreal ranibizumab injections and photodynamic therapy (PDT) in patients with symptomatic retinal angiomatous proliferation.

DESIGN

Retrospective, interventional, consecutive case series.

METHODS

We retrospectively reviewed 20 treatment-naïve eyes of 16 patients (8 men, 8 women; age range, 79 to 92 years; mean age, 84.8 years) treated with 3 consecutive monthly intravitreal injections of ranibizumab (0.5 mg/0.05 mL) and PDT and followed up for at least 12 months. PDT was applied 1 or 2 days after the initial injection. Retreatment was performed as a combined therapy of a single intravitreal ranibizumab injection and PDT.

RESULTS

The mean best-corrected visual acuity (BCVA) levels significantly improved from 0.24 at baseline to 0.43 at 12 months (P < .001). The mean improvement in BCVA at 12 months from baseline was 2.51 lines. The BCVA at 12 months improved in 10 eyes (improved by 3 lines or more) and was stable (defined as a loss of less than 3 lines of vision) in 10 eyes. No patient had a decrease in the BCVA of 3 lines or more during any 12 months. The central retinal thickness decreased significantly from 444 μm at baseline to 143 μm at 12 months (P < .0001). Complete occlusion of the retinal-retinal anastomosis was achieved in 17 of the 19 eyes at 12 months. The mean numbers of PDT treatments and injections during 12 months, including the treatments in the initial regimen, were 1.8 and 3.8, respectively. No complications or systemic adverse events developed.

CONCLUSIONS

Combined intravitreal ranibizumab and PDT for patients with retinal angiomatous proliferation effectively maintained or improved visual acuity and reduced the exudation without adverse events.

One-year results of photodynamic therapy combined with intravitreal ranibizumab for exudative age-related macular degeneration

Purpose. To evaluate the effects of photodynamic therapy (PDT) combined with intravitreal injection of ranibizumab (IVR) for exudative age-related macular degeneration (AMD). Methods. Retrospective case series. Thirty eight eyes of 38 patients with exudative AMD underwent combined therapy consisting first of IVR, followed by PDT within a week and the second IVR at 1 month. All patients were followed up for more than 12 months. The best corrected visual acuity (BCVA) and central macular thickness (CMT) were examined. Results. The mean number of IVR and PDT sessions were 2.9 ± 1.3 and 1.1 ± 0.3, respectively. The mean BCVA and CMT were significantly improved to 0.38 logMAR units (P < 0.01) and 240 μm (P < 0.01) at 12 months, respectively. Thirty-six of 38 eyes (94.8%) improved or maintained BCVA at 12 months. Conclusion. PDT combined with IVR for exudative AMD was effective at improving visual acuity and CMT with a low recurrence rate for 12 months.