Combination therapy with intravitreal tissue plasminogen activator and ranibizumab for wet age-related macular degeneration with subretinal hyperreflective material

Abstract

Purpose : Subretinal hyperreflective material (SHRM) sometimes causes vision loss in spite of anti-vascular endothelial growth factor therapy in eyes with wet age-related macular degeneration (wAMD). The purpose of this study is to evaluate the impacts of intravitreal ranibizumab (IVR) with tissue plasminogen activator (tPA), a fibrinolytic compound on visual outcomes in eyes with wAMD accompanying SHRM.

Methods : Twenty-one eyes of 21 patients (14 men and 7 women) with wAMD accompanying SHRM underwent intravitreal injection of ranibizumab and tPA (40 kIU) (IVR/tPA). Eight eyes were treatment-naïve. Twelve eyes had SHRM associated with type 2 choroidal neovascularization, 5 eyes polypoidal choroidal vasculopathy, and 4 eye fibrovascular pigment epithelial detachment (PED). For retreatment, IVR or intravitreal aflibercept was performed in the pro re nata regimen. Best-corrected visual acuity (BCVA) were measured. Optical coherence tomography was periodically performed.

Results : Averaged observation period was 56.0 months (range: 14-99). For 6 months after IVR/tPA, mean injection number was 2.3 (range: 0-5). Central retinal thickness after IVR/tPA was significantly thinner than that immediately before IVR/tPA throughout the observation period (p<0.01). The thickness of SHRM decreased by 58% immediately after IVR/tPA and 82% at the last visit. The mean BCVA significantly improved from 0.77 at baseline to 0.57 in month 6 (p=0.016) and 0.60 in month 12 (p=0.048) in the logarithm of minimum angle of resolution unit, while the mean BCVA slightly deteriorated to 0.67 at the last visit. Eyes with SHRM related to fibrovascular PED tended to have severe vision loss at baseline, while intraretinal fluid or subretinal hemorrhage might be associated with severe vision loss at baseline or decrease of once-improved BCVA. There were no complications associated with tPA.

Conclusions : The combination therapy of tPA and ranibizumab may be effective to treat wAMD with SHRM.

This abstract was presented at the 2019 ARVO Annual Meeting, held in Vancouver, Canada, April 28 - May 2, 2019.