Combination therapy of intravitreal triamcinolone and photodynamic therapy with verteporfin for subfoveal choroidal neovascularization

Corticosteroids in ophthalmology: drug delivery innovations, pharmacology, clinical applications, and future perspectives

Corticosteroids remain the mainstay of the treatment for various ocular conditions affecting the ocular surface, anterior and posterior segments of the eye due to their anti-inflammatory, anti-oedematous, and anti-neovascularization properties. Prednisolone, prednisolone acetate, dexamethasone, triamcinolone acetonide, fluocinolone acetonide, and loteprednol etabonate are amongst the most widely used ophthalmic corticosteroids. Corticosteroids differ in their activity and potency in the eye due to their inherent pharmacological and pharmaceutical differences. Different routes and regimens are available for ocular administration of corticosteroids. Conventional topical application to the eye is the route of choice when targeting diseases affecting the ocular surface and anterior segment, while periocular, intravitreal, and suprachoroidal injections can be potentially effective for posterior segment diseases. Corticosteroid-induced intraocular pressure elevation and cataract formation remain the most significant local risks following topical as well as systemic corticosteroid administration. Invasive drug administration via intracameral, subconjunctival, and intravitreal injection can enhance ocular bioavailability and minimize dose and dosing frequency of administration, yet may exacerbate ocular side effects of corticosteroids. This review provides a critical appraisal of the ophthalmic uses of corticosteroid, routes of administration, drug delivery fundamentals and novel ocular implantable steroid delivery systems, factors influencing side effects, and future perspectives for ocular corticosteroid therapy.

Two years follow-up outcome of verteporfin therapy for subfoveal choroidal neovascularization in pathologic myopia in Indian eyes

CONTEXT

In India, refractive errors are a major cause of treatable blindness. Population surveys in southern India have shown prevalence of high myopia to be 4.32-4.54%. Photodynamic therapy (PDT) for choroidal neovascularization (CNV) caused by pathologic myopia is beneficial.

AIMS

To report the 24 months outcome of PDT with verteporfin for subfoveal CNV caused by pathologic myopia in Indian eyes.

SETTINGS AND DESIGN

Prospective case series.

MATERIALS AND METHODS

Review of prospectively collected data of Indian patients with pathologic myopia and subfoveal CNV treated with verteporfin therapy between 2001 and 2005 using standard regimen for PDT.

STATISTICAL ANALYSIS USED

Wilcoxon signed rank test was used to see the difference in the mean letter acuity at intervals compared to baseline. Kaplan Meier Survival analysis was done to estimate the success rate of verteporfin therapy for CNV caused by pathologic myopia.

RESULTS

Fifteen patients (15 eyes) treated with standard fluence PDT and who had completed 24 months follow-up were analyzed. The mean spherical equivalent was -13.36 +/- 5.88 diopter. Five out of 15 eyes in six months, three out of 15 eyes at 12 months and four eyes out of 15 at 24 months had improved vision by > 10 letters. The mean number of treatment session was 2.2 in two years.

CONCLUSIONS

PDT with verteporfin for subfoveal CNV caused by pathologic myopia in Indian eyes is effective.

Combination photodynamic therapy and intravitreal ranibizumab in neovascular AMD in a north Indian population: a pilot study

PURPOSE

To evaluate photodynamic therapy (PDT) with verteporfin along with intravitreal Ranibizumab in treatment of neovascular age related macular degeneration.

METHODS

This prospective interventional care series included 16 patients (17 eyes) of choroidal neovascularization secondary to neovascular AMD, who were treated with PDT with verteporfin followed by an injection of 0.5mg Ranibuzimab on the same day. The main outcome measures were best corrected visual acuity (VA) as recorded by both Snellen's and ETDRS charts (logMAR), contrast sensitivity (Pelli-Robson Chart), retreatment frequency and frequency of side effects.

RESULTS

Seventeen eyes underwent PDT with verteporfin and intravitreal 0.5mg Ranibizumab, following PDT. Patients were followed up every month for a total period of 6 months. Initial VA ranged from CF to 20/32 and final acuity ranged from CF to 20/20. VA stabilizes (gain/loss <2 lines) in 14 out of 17 eyes (82.24%) and improved in 3 out of 17 (17.65%). Contrast sensitivity improved in 15 out of 17 eyes (82.24%) Lesion type, patient age had no influence on the outcome. There were no cases of ocular/systematic adverse events. Retreatment was required in only 2 out of 17 cases (11.76%) with only a single injection of ranibizumab.

CONCLUSION

The combination of PDT with intravitreal Ranibizumab improves contrast sensitivity and stabilizes vision and reduces the number of retreatments, without significant ocular and/or systematic risks.

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.