Triple therapy for neovascular age-related macular degeneration (verteporfin photodynamic therapy, intravitreal dexamethasone, and intravitreal bevacizumab)

Abstract

Objective: Age-related macular degeneration is a multifactorial disease involving inflammation, neovascularization, and vascular leakage. As a result, a rationale exists for investigating combination treatments that target the different pathological processes involved in this disease. We propose triple therapy consisting of verteporfin photodynamic therapy (PDT), intravitreal bevacizumab, and intravitreal dexamethasone. Design: Retrospective chart review. Participants: Thirty-two eyes of 30 patients were included. None of the patients demonstrated concurrent eye pathology, and none ofthe patients had received previous treatment for their choroidal neovascularization. Methods: One cycle of triple therapy consisted of reduced-fluence PDT (300 mW/cm2 for 83 seconds to deliver 25 J/cm2) followed immediately by an 800 mg (0.08 mL) intravitreal dexamethasone (IVD) injection. At 1 and 7 weeks after PDT and IVD, patients received a 1.25 mg (0.05 mL) bevacizumab injection. At 13 weeks after PDT and IVD, each patient had a repeat optical coherence tomography and fluorescein angiography to assess choroidal neovas-cularization activity. Patients were followed for 12 months. Results: The mean number of treatment cycles was 1.4. The mean number of bevacizumab injections was 2.8. Visual acuity improved from 0.74 (SD 0.33) logMAR (20/100) to 0.53 (SD 0.32) logMAR (20/70) ( p > 0.005). Foveal thickness decreased from 328 (SD 116) mm to 216 (SD 85) μm ( p > 0.001). Ninety-four percent of patients lost fewer than 3 lines, 31% gained more than 3 lines, and 6% lost more than 3 lines. Conclusions: By combining agents with complementary mechanisms of action, triple therapy could maintain visual acuity and macular anatomy while allowing a reduction in the number of anti-vascular endothelial growth factor injections required.