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Richard D. Pesavento, John P. Carlson, Sharon Dyer, James Pesavento; Combined Therapy With Photodynamic Therapy, Intravitreal Dexamethasone And Bevacizumab In The Treatment Of Patients With Neovascular Age Related Macular Degeneration Failing Monotherapy. Invest. Ophthalmol. Vis. Sci. 2012;53(14):862.
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Some patients fail to show an adequate clinical response to VEGF inhibitors alone when treating exudative AMD. Our purpose was to determine whether combined therapy with reduced fluence photodynamic therapy using verteporfin, intravitreal dexamethasone and intravitreal bevicizumab is a useful alternative therapy for choroidal neovascularization associated with AMD when monotherapy with VEGF inhibitors alone fails.
This is a retrospective, chart review study. All patients that were treated with combined therapy after failure of monotherapy between 2006 and 2011 were included. Patients were included only if there was evidence of persistent exudation in the macula. Combined therapy consisted of reduced fluence photodynamic therapy (25 J/cm2 for 83 sec) using vertaporfin followed by intravitreal dexamethasone (400 micrograms/ 0.1 cc) on the same day, and intravitreal bevacizumab (1.25 mg/ 0.05 cc) within one week. The exudation was evaluated using the Zeiss Stratus OCT 3. The results of all studies were read by one experienced vitreoretinal specialist. The primary end point was to determine whether there was partial or complete resolution of exudation within the first 6 to 12 weeks following treatment. The secondary end point was the duration following successful treatment with combined therapy before additional therapy was needed.
57 eyes treated between August 2006 and March 2011 were included. Age ranged from 62 to 95. 35 females and 22 males. The patients received an average of 6 intravitreal injections with VEGF inhibitors before being considered treatment failures. 38 of 57 (67%) showed a significant improvement in exudation defined as a decrease in macular thickness of > 50 microns within 6-12 weeks post-treatment. 24 of 57 (42%) showed complete resolution of exudation within 6 to 12 weeks following combined therapy. 21 patients with complete resolution required additional treatment either with a VEGF inhibitor or with additional combined therapy due to recurrence (defined as recurrent exudation, subretinal hemorrhage or decreasing visual acuity). The average interval between combined therapy and additional treatment was 31 weeks, ranging from 8 to 95 weeks, with a median of 21 weeks.
Combined therapy can be a valuable alternative in the treatment of exudative AMD when monotherapy with VEGF inhibitors alone fails. The use of combined therapy may decrease the treatment burden by increasing the interval between treatments.
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