Abstract
Purpose: :
To assess the outcomes of single agent anti-VEGF therapy combined with preservative free triamcinolone acetonide (TA) in the treatment of neovascular age-related macular degeneration that has previously been unresponsive to ranibizumab or bevacizumab alone.
Methods: :
This is a retrospective chart review of 49 eyes from 48 patients. After treatment failure with 5 or more injections of ranibizumab or bevacizumab, patients received injections of anti-VEGF followed by preservative free TA. Failure criteria included nonresolving choroidal neovascular membrane, persistent subretinal or intraretinal fluid, central macular thickening and worsening visual acuity. Conditions evaluated included pre-injection, 1 month, and 6 month visual acuity (VA) and central macular thickness (CMT); need for additional injections; and complication rates. Treatment success was monitored by stability or improvement in VA, decrease in CMT, and decrease in injection frequency.
Results: :
The age range of the study sample was 50-90 years with a mean of 77. Visual acuity improved or stabilized in 42 patients (88%) by 1 month and 36 patients (73%) by 6 months. Visual acuity improved from 1.01 logMar (date of first combination injection) to 0.87 logMar (p=.002) and .088 logMar (p=.006) at 1 and 6 months, respectively. SD-OCT CMT decreased in 39 (80%) and 35 (71%) patients at 1 and 6 months, respectively. At 1 and 6 month follow-up, OCT CMT decreased by an average of 78 (p<.001) and 84 (p<.001) microns. Twenty-two patients (44%) required no additional injection at 1 month follow-up. Fourteen patients (28%) experienced at least 1 episode of elevated intraocular pressure (>20mmHg) by tonometer. Of 17 phakic patients (35%) at time of initial combination treatment, 3 (6%) developed posterior subcapsular cataract requiring phacoemulsification.
Conclusions: :
Combination anti-VEGF and preservative free TA therapy demonstrated reasonable success in patients with refractory choroidal neovascular membranes. Many patients experienced visual improvement while also decreasing need for monthly injections. Although steroid-induced complications of elevated intraocular pressure and cataracts did arise in some patients, most were properly managed by pharmacologic intervention.
Keywords: age-related macular degeneration • vascular endothelial growth factor