Photodynamic therapy with verteporfin combined with intravitreal injection of bevacizumab for exudative age‐related macular degeneration

Abstract

Editor, Photodynamic therapy (PDT) with verteporfin significantly reduces the risk of vision loss in patients with choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD) (Treatment of Age-related Macular Degeneration with Photodynamic Therapy (TAP) Study Group; Verteporfin in Photodynamic Therapy Study Group 2001; Verteporfin Roundtable Participants 2005). However, the results of large, randomized clinical trials showed that mean visual acuity (VA) declined over the course of treatment (Treatment of Age-related Macular Degeneration with Photodynamic Therapy (TAP) Study Group; Verteporfin in Photodynamic Therapy Study Group 2001). Bevacizumab is a humanized monoclonal antibody to vascular endothelial growth factor (VEGF) that results in both visual and anatomic improvement in CNV when used intravitreally in the short-term (Rosenfeld et al. 2005; Avery et al. 2006). We report two cases of CNV secondary to AMD treated with combined PDT and intravitreal bevacizumab. A 74-year-old man had subfoveal occult with no classic CNV secondary to AMD in his left eye (OS). He complained of low VA OS for 1 month. Tomographic signs of intra- and subretinal fluid, as well as retinal pigment epithelium−choriocapillaris (RPE−cc) band thickening were seen (Fig. 1A). He had undergone two previous sessions of PDT with partial improvement of tomographic appearance, without any change in VA (20/200). Fluorescein angiography (FA) revealed an increase in the lesion's greatest linear dimension to 2554 µm. The subject was offered combined PDT with intravitreal bevacizumab. The potential risks and benefits of the therapy were extensively discussed, as well as the off-label use of bevacizumab. After informed consent had been obtained, PDT was conducted and was followed 5 days later by intravitreal injection of 1.25 mg (0.05 ml) bevacizumab. One week later, VA remained unchanged. Optical coherence tomography (OCT) revealed total resorption of fluid (Fig. 2A) and no signs of leakage were seen on FA. Three months later, VA was 20/400, FA revealed leakage in the inferotemporal aspect of the lesion and OCT disclosed increased thickening of the RPE−cc band and the reappearance of intra- and subretinal fluid (Fig. 3A). Optical coherence tomography 6-mm cross-sectional images at 60 degrees through the fovea at initial presentation. (A) Signs of intra- and subretinal fluid and retinal pigment epithelium−choriocapillaris (RPE−cc) band thickening were seen in patient 1. (B) Foveal neurosensory retinal elevation and RPE−cc band thickening were noted in patient 2. Optical coherence tomography 6-mm cross-sectional images at 60 degrees through the fovea 7 days after intravitreal bevacizumab injection. (A) Total resorption of fluid was noted in patient 1. (B) Total resorption of subretinal fluid was noted in patient 2. Optical coherence tomography 6-mm cross-sectional images at 60 degrees through the fovea 3 months after intravitreal bevacizumab injection. (A) Increased thickening of the retinal pigment epithelium−choriocapillaris band and reappearance of intra- and subretinal fluid were seen in patient 1. (B) Stable tomographic findings were observed in patient 2. A 76-year-old man had subfoveal predominantly classic CNV due to AMD OS. Optical coherence tomography showed foveal neurosensory retinal elevation, along with fusiform RPE−cc band thickening (Fig. 1B). The subject had undergone combined PDT with intravitreal triamcinolone, with worsening of VA to 20/400. After the potential risks and benefits of the therapy had been carefully explained, the patient assented to the proposed combination therapy of PDT with intravitreal bevacizumab. Informed consent was obtained, photodynamic therapy was performed and intravitreal bevacizumab was administered 7 days later. One week later, VA was 20/200, no signs of subretinal fluid were elicited by OCT (Fig. 2B) and FA revealed late staining of the lesion. Three months later, the picture was unchanged (Fig. 3B). Although combined PDT with intravitreal bevacizumab was successful, at least transiently, in the anatomic improvement of CNV as assessed by OCT and FA, it was not equally efficacious in VA amelioration in either case. One possible explanation for this fact may be the duration of the retinal changes, which we were unable to establish, due to inexact explanations by the patients. Previous studies have shown that both repeated PDT and natural history may lead to chorioretinal atrophy as well as to progressive destruction of choroidal integrity by fibrosis in eyes with exudative AMD (Schmidt-Erfurth & Michaels 2003). Our findings may suggest that reduction of the exudative changes associated with AMD may not be sufficient to improve VA in these eyes.