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Gisela Velez; Intravitreal triamcinolone acetonide with anti-VEGF therapy for the management of polypoidal choroidal vasculopathy. Invest. Ophthalmol. Vis. Sci. 2014;55(13):3905. doi: https://doi.org/.
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Polypoidal choroidal vasculopathy (PCV), considered by some a variant of exudative age-related macular degeneration (wet ARMD), is particularly resistant to management with anti-VEGF therapy alone. Although responsive to anti-VEGF agents, complete resolution of subretinal fluid can be a challenge. We explore the use of intravitreal triamcinolone acetonide in a subset of patients resistant to therapy with anti-VEGF agents.
We performed a retrospective review of all patients with wet ARMD in our practice. Patients with PCV were confirmed by indocyanine green (ICG) angiography (Spectralis, Heidelberg). Nine patients were identified, with a total of 12 eyes treated. Failure to treatment was defined as (1) persistent subretinal fluid (SRF) on SD-OCT (Cirrus 4000, Zeiss); or (2) loss of more than 1 line of Snellen visual acuity (VA).
Seven patients (10 eyes) were treated with a variety of anti-VEGF agents alone, including bevacizumab (1.25mg), ranibizumab (0.5mg) and aflibercept (2 mg). Two patients (2 eyes) were treated with low dose intravitreal triamcinolone acetonide (2mg) in addition to anti-VEGF therapy. Median VA pre and post-treatment was 20/50, with a range from 20/25 to CF. Five eyes (5 patients) responded to anti-VEGF therapy alone. Two eyes (2 patients) were maintained on bevacizumab q 4 weeks. Three eyes (3 patients) were stabilized with intravitreal aflibercept q 4 weeks. Of the 7 eyes (5 patients) that failed treatment, 6 failed as a result of persistent SRF while maintaining stable VA, while 1 eye failed due to loss of vision secondary to hemorrhage. Of these eyes, 3 (2 patients) were treated with aflibercept, while 4 eyes (3 patients) were treated with bevacizumab. Two eyes (2 patients) were treated with supplemental intravitreal triamcinolone acetonide while continuing monthly anti-VEGF treatments. Both patients received 2 injections an average of 14 weeks apart. Both patients achieved complete but temporary resolution of SRF, with a sustained effect of up to 11 weeks. Injections of intravitreal triamcinolone acetonide were tolerated well with no evidence of increased intraocular pressure.
Low dose intravitreal triamcinolone acetonide can be successfully and safely used as a supplement to anti-VEGF therapy in the treatment and management of PCV. Further studies are warranted.
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