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B. D. Gerwin, J. A. Kimble; Salvage Treatment for AMD With Triple Combination Therapy. Invest. Ophthalmol. Vis. Sci. 2008;49(13):543.
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In 2007, Augustin et al. reported a prospective trial of "triple therapy" for newly diagnosed CNV utilizing verteporfin photodynamic therapy (PDT) combined with 25 gauge single port vitrectomy and intravitreous bevacizumab (IVB) and dexamethasone (IVD). However, this study did not address previously treated patients whose leakage had failed to resolve. We believe triple therapy may offer the best chance for disease quiescence in this sub-set of patients who progress despite standard treatment.The purpose of this study is to report our results utilizing triple therapy with PDT, IVB, and either IVD or triamcinolone (IVT). This regimen was used primarily in patients who had failed previous treatment with either IVB, and/or PDT/IVT. We also utilized this regimen in several patients when the presentation was particularly severe and to minimize treatment cycles.
Charts were reviewed of patients with AMD who underwent triple therapy. Patients were typically treated in clinic with IVB first, followed by PDT and IVD or IVT. No vitrectomy was done. Initial follow-up was scheduled at 4-6 weeks post-treatment, and usually at 6 week intervals thereafter. Repeat treatment was initiated based on signs of recurrence as seen clinically, angiographically, and on OCT.Demographic, diagnostic, and treatment information was collected from patient charts. Analysis was done in Excel spreadsheet software.
19 eyes of 19 patients were identified for analysis with a mean age of 78.8 years. 63.2% of these patients had failed prior treatment with either IVB, PDT/IVT, or both. Mean acuity pre-treatment was 0.89±0.39 logMAR. This improved to 0.87±0.53 logMAR at the first follow-up visit and was 0.9±0.58 logMAR at the last follow-up visit. Mean follow-up was 3.9 months. Three patients had other unrelated ocular disease and these three had unusual drops in vision following treatment, averaging about a 3.1 line loss despite successful resolution of leakage. Excluding these 3 patients from analysis, the mean acuity improved by 0.9±3.2 lines at the first follow-up and improved by 0.5±3.8 lines at the last follow-up visit. 79% of patients showed no signs of leakage at the first follow-up visit and the retinal thickness decreased by an average 175.5±97.1 microns on OCT. Only 47.4% of patients required re-treatment, and the mean interval to re-treatment was about 3 months.
Triple therapy shows reasonable promise for maintaining or improving vision while reducing treatment frequency in patients with continued leakage on standard therapy.
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