B. Fiore

Photodynamic therapy with verteporfin combined with intravitreal injection of bevacizumab for occult and classic CNV in AMD

PURPOSE The aim of this study is to discuss the effect and outcome of a combined photodynamic therapy and intravitreal injection of ranibizumab (0.5 mg) in occult CNV with recent disease progression and in classic choroidal neovascularization (CNV) due to AMD. METHODS In a pilot study in 28 patients (17 classic, 11 occult CNV) an intravitreal injection of ranibizumab was administered within 12 to 24 hours after standard PDT, followed by 2 injections of ranibizumab after 1 and 2 months. Before as well as 3 and 6 months after treatment visual acuity, OCT examinations (retinal thickness) and fluorescein angiography were performed. RESULTS Mean visual acuity was significantly improved compared to baseline after 3 months (VA baseline 20/80, after 3 months 20/50, and 20/63 after 6 months). We found no choroidal hypoperfusion and no RPE rip. OCT and fluorescein angiography in patients with occult and classic choroidal neovascularisation after the combination therapy showed a reduced retinal thickness (baseline: 307 microm, after 1 month: 210 microm, after 3 months: 228 microm and after 6 months 281 microm) and a reduction of leakage compared to baseline. CONCLUSIONS Photodynamic therapy combined with injection of intravitreal ranibizumab was well tolerated and is effective. We found a stabilisation of VA in 96% of patients. Our short-term results are very promising. Further studies are necessary to show the long-term effect of the PDT and anti-VEGF combination therapy.

Intravitreal Injection of Bevacizumab for Exsudative AMD with Occult or Minimal Classic Choroidal Neovascularisation (CNV)

PURPOSE Systemic anti-VEGF therapy with bevacizumab was effective in neovascular AMD in the SANA study. Intravitreal bevacizumab has the advantage that a high concentration can be achieved in the eye with a low dose. First clinical studies showed a good therapeutic effect. METHODS In a clinical study 93 patients with occult or minimal classic CNV due to neovascular AMD were treated with intravitreal injections of Bevacizumab (1.25 mg). Before, 1, 3 and 6 months after treatment visual acuity, intraocular pressure measurement, angiography and OCT examination were performed. After one day and after one week an eye examination was done and the intraocular pressure was measured. RESULTS Bevacizumab was well tolerated and we had no complications. Mean visual acuity was 20 / 80 at baseline. Visual acuity was stabilised but not significantly improved after 1, 3 and 6 months (20 / 80). 70 (75 %) patients showed reduced leakage in fluorescein angiography after 6 month. In OCT retinal thickness was reduced significantly after 1, 3 and 6 months (OCT: mean 323 microm at baseline, 260 microm after 1, 290 microm after 3 and 275 microm after 6 months). CONCLUSIONS Intravitreal therapy with bevacizumab was safe and well tolerated. It is a therapeutic option in treating occult choroidal neovascularisations and minimal classic CNV. Six months after intravitreal administration of bevacizumab mean visual acuity was stabilised. Retinal thickness and leakage were more reduced after 1 month than after 3 and 6 months. According to our results, a monthly injection schedule could give more favourable results.

Photodynamische Therapie kombiniert mit intravitrealer Injektion von Bevacizumab zur Behandlung okkulter und klassischer choroidaler Neovaskularisationen bei AMD

PURPOSE The aim of this study is to discuss the effect and outcome of a combined photodynamic therapy and intravitreal injection of bevacizumab (1.25 mg) in occult and classic choroidal neovascularisation (CNV) due to AMD. Especially cases of occult CNV with pigment epithelium detachment (PED) are not likely to respond positively to standard photodynamic therapy, often ending up in PED enlargement or tearing of the RPE. METHODS In a pilot study involving 23 patients, intravitreal injections of bevacizumab were administered within 12 to 24 hours after standard PDT to reduce the post-PDT increase of proangiogenic and inflammatory factors. Before and at 1, 3 and 6 month after treatment visual acuity and OCT examinations (retinal thickness) were performed. RESULTS Mean visual acuity was significantly improved compared to baseline. (VA baseline 20/125, after 1 month 20/80, after 3 months 20/80, and 20/80 after 6 months) and an enlargement of the PED in occult CNV was prevented. We found no RPE rip. OCT findings in patients with occult and classic choroidal neovascularisation 1, 3 and 6 months after combination therapy showed a reduced retinal thickness compared to baseline. CONCLUSIONS Photodynamic therapy combined with injection of intravitreal bevacizumab tends to be more effective compared to PDT monotherapy by reducing the post-PDT increase of vascular growth and inflammatory factors. Our short-term results are very promising. Further studies are necessary to show the long-term effect of PDT and anti-VEGF combination therapy.