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D. B. Roth, J. L. Prenner; Combination Triple Therapy (Photodynamic Therapy, Bevacizumab, and Dexamethasone) for Persistent Exudative Age-Related Macular Degeneration. Invest. Ophthalmol. Vis. Sci. 2008;49(13):276.
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Despite the excellent outcomes obtained with ranibizumab or bevacizumab monotherapy for exudative age-related macular degeneration (ARMD), patients find frequent injections difficult and some eyes will have persistent exudation despite monthly injections. Combination therapy with photodynamic therapy, intravitreal bevacizumab, and intravitreal dexamethasone may suppress the choroidal neovascular membrane (CNVM) in ARMD and allow for long remissions without the requirement for ongoing treatment, while maintaining comparable visual results to ranibizumab monotherapy. We sought to determine whether triple combination therapy would induce a resolution of active, persistent CNVM fluid exudation in eyes being treated with anti-VEGF monotherapy.
Eyes previously treated with either ranibizumab or bevacizumab monotherapy that expressed persistent intraretinal or subretinal fluid on ocular coherence tomography (OCT) were included. Triple therapy consisted of reduced-fluence photodynamic therapy (83 seconds of 25 joules/cm2), followed the next day by consecutive intravitreal injections of bevacizumab (1.25 mg) and dexamethasone (0.5 mg). Patients were followed at 1 week, 1 month, 3 months and 6 months. OCT was used to determine persistence or quiescence of the CNVM based upon the presence or absence of fluid in the macula. If significant fluid was present on the OCT at 1 month or future follow-up, repeated treatment, typically ranibizumab injections, were administered.
Twenty eyes of 19 patients were identified. The mean age was 82 years. The mean logMAR visual acuity at baseline was 1.18 (Snellen equivalent 20/303). Two eyes experienced an initial drop of 3 or more lines of visual acuity at 1 week after treatment, however, both eyes recovered to baseline by 1 month. No significant improvement in mean visual acuity was seen at the 3-month follow-up. A reduction of >50 microns on OCT was seen in only 6 (30%) eyes. All 20 eyes were within 2 Snellen lines of baseline visual acuity at the 3-month follow-up. Eight eyes were retreated with ranibizumab by 3 months of follow-up for persistent fluid on OCT and 3 additional eyes were retreated by 6 months of follow-up.
Although triple combination therapy (photodynamic therapy, intravitreal bevacizumab, and intravitreal dexamethasone) for eyes with persistent leakage on anti-VEGF monotherapy may reduce the number of injections required in the immediate follow-up period, recurrent leakage will typically occur in most eyes.
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