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M. H. Nelson; ICG-Directed PDT With Visudyne in Combination With Intra-Vitreal Lucentis /Triamcinolone Acetonide as Rescue Therapy for Non-VEGF Driven Processes in Exudative Age-Related Macular Degeneration. Invest. Ophthalmol. Vis. Sci. 2009;50(13):1901.
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This retrospective review of 40 patients with Exudative Age-Related Macular Degeneration (ARMD) describes the efficacy of ICG-directed PDT/triple therapy as an rescue strategy for persistent intraretinal, subretinal, and/or subRPE leakage following standard anti-VEGF therapy. ICG videoangiography allows for precise localization of anatomical processes responsible for these treatment failures.
40 patients with Exudative ARMD were treated with monthly intravitreal Lucentis (Ranibizumab) therapy and found to have persistent leakage on OCT/IVFA/ICG and determined to be clinical failures. ICG videoangiography revealed that these patients had non-VEGF driven processes which were classified as either arteriolarized high flow neovascularization or polypoidal vasculopathy. 30 patients did not have subRPE exudation and were classified as Group 1. 10 patients had retinal pigment epithelial detachments (RPED) and were classified as Group 2. Rescue therapy was initiated if all leakage did not resolve after 3 intravitreal injections and consisted of intravitreal Lucentis ( 0.5 mg) on day 1 followed by ICG-directed half-fluence PDT with Visudyne and intravitreal Triamcinolone Acetonide (4 mg) seven days later. Monthly OCT were obtained in follow up with IVFA/ICG being repeated every three months. Retreatment with triple therapy was performed if leakage recurred and ICG videoangiography demonstrated recurrent neovascularization. Exclusion criteria included previous PDT or Macugen therapy. Primary endpoints included reduction in OCT thickness and visual acuity.
Group 1 had a sustained post-treatment mean OCT reduction of 82 microns . Retreatment was necessary in all patients and was performed at a mean of 7.6 months. There was a mean visual improvement of 3 letters with 12% having 3 lines of visual improvement. Combination therapy in Group 2 patients resulted in a complete collapse of the RPED in 92% of patients. The duration of RPED resolution was 5.6 months. The mean reduction in OCT thickness was 258 microns, mainly due to RPED collapse. The mean vision improved by 5 letters. PDT was not associated with vision loss or RPE tear. Both groups were evaluated over a 18 month period.
ICG-directed PDT triple therapy is a safe and effective method for eliminating persistent leakage associated with failed anti-VEGF therapy in patients with Exudative ARMD. ICG videoangiography specifically identifies patients whose pathophysiologic processes are non-VEGF driven and therefore will not completely respond to standard therapy. Primary triple therapy should be considered for these patients.
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