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I. Zhitomirsky, J. P. Levine, K. B. Freund, J. A. Sorenson, R. F. Spaide, M. J. Cooney; Hemorrhagic Exudation in Neovascular Age-Related Macular Degeneration After Stabilization With Anti-Angiogenic Therapy. Invest. Ophthalmol. Vis. Sci. 2008;49(13):5575. doi: https://doi.org/.
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To present a case series of patients with neovascular age-related macular degeneration (AMD) who were stabilized with anti-angiogenic agents and experienced a subsequent hemorrhagic recurrence to highlight limitations of our current treatment strategies and propose how we can modify these regimens to better prevent disease progression.
A chart review was performed of 17 eyes of 16 patients with neovascular AMD previously treated with bevacizumab and/or ranibizumab at one eye center. All included eyes had a period of disease stabilization prior to a recurrence of hemorrhagic exudation. The following data were recorded: time interval between date of last injection prior to recurrence and date of recurrence; interval between last stable examination and recurrence; change in visual acuity before and after recurrence.
The average time between the date of the last injection and the onset of recurrence was 15.9 weeks (range 6.7-38.3 wks). The average time between the last stable examination and the onset of re-exudation was 7.7 weeks (range 1 day-19.6 weeks). One patient had a flat OCT of the macula one day prior to re-exudation.(Figure 1) The average decrease in vision of LogMar 0.31 ± 1.1 was statistically significant (P=0.017). Among the ten patients with better than 20/200 vision, four dropped to 20/200 or worse.
Recurrent hemorrhagic exudation may result in severe and irreversible vision loss for patients with neovascular AMD and is a significant concern for patients already on anti-angiogenic therapy. Furthermore, episodes can occur without detectable changes on fundus exam or OCT prior to the event. This raises concerns about treating all patients on an as needed basis or extending the interval of reinjection for some patients on a maintenance therapy beyond six weeks. Future studies are necessary to identify patients at risk for recurrence to optimize their dosing regimen accordingly.
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