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D. N. Sang, M. S. Hughes; Triple Therapy (Reduced Duration PDT with Same Day Dexamethasone and Bevacizumab) as Rescue Treatment in Patients with Previously Treated Exudative AMD: One Year Follow-up. Invest. Ophthalmol. Vis. Sci. 2009;50(13):1927.
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To evaluate the efficacy and safety of same day triple therapy with reduced duration PDT/verteporfin, intravitreal dexamethasone, and intravitreal bevacizumab, in the rescue treatment of exudative wet ARMD found to have failed previous therapy, with1 year follow-up.
40 sequential patients with exudative macular degeneration with failure to respond to anti-VEGF monotherapy, with or without previous history of PDT or TTT (transpupillary thermal therapy), and with or without previous steroid injection, were included in this prospective, non-comparative, interventional case series, with 12 month follow-up. Failed treatment was defined as worsening Snellen acuity with progression of activity or persistence of activity of CNV, with active leakage, fibrosis, or RPE detachment, as assessed by OCT and/or FA, despite previous therapy. Treatment protocol included reduced duration PDT (42 secs., 600mW/cm2) followed by 500µg of intravitreal dexamethasone and 1.25mg of intravitreal bevacizumab 1 hour after PDT. Subjects were monitored prospectively with best corrected Snellen visual acuity, slit lamp biomicroscopy, dilated fundus exam, FA and OCT. Re-treatment with bevacizumab within 1-2 months or triple therapy at 3 months was performed for recurrences, including any increase in central thickness >75 microns, any subretinal fluid on OCT, or any new hemorrhage. Patients were followed for 12 months or more. The one-year data is presented.
All patients received an initial triple therapy session. The sizes of lesions at presentation ranged from 3.8 to 6.2mm. 46% of patients presented with RPE detachment >300 microns thickness. 60% of eyes showed >50% fibrosis. At 12 months, 67.7% of patients had required additional treatment. Increased Snellen visual acuity was found in 57% of eyes with 92% the same or better. 80% showed improvement in OCT central thickness. The presence of >50% fibrosis or RPE detachment >300 microns thickness was associated with less favorable outcome. There was no correlation with lesion type. Anatomical improvement could occur without improvement in visual acuity. No adverse events were noted.
Eyes with wet ARMD previously poorly responsive to anti-VEGF monotherapy with or without previous PDT, TTT, or steroid, may be candidates for additional treatment approaches. A triple regimen of reduced duration PDT/verteporfin with same day intravitreal Avastin and dexamethasone may improve anatomical and visual outcomes as rescue therapy, despite previous failure to respond.
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