J Korean Ophthalmol Soc.  2009 Jun;50(6):877-886. 10.3341/jkos.2009.50.6.877.

Combination Treatment for Choroidal Neovascularization Associated With Large Retinal Pigment Epithelial Detachment

• Ryu JW
• Jung JH
• Lee WK

• KMID: 2212365
• DOI: http://doi.org/10.3341/jkos.2009.50.6.877

Abstract

PURPOSE: To evaluate the efficacy of the combination therapy of intravitreal bevacizumab injection and photodynamic therapy in neovascular age-related macular degeneration associated with large retinal pigment epithelial detachment.
METHODS
A total of 13 eyes were reviewed, with 9 eyes diagnosed with definite choroidal neovascularization (CNV) and 4 eyes diagnosed with CNV or polypoidal choroidal vasculopathy (PCV) becausethe exact type could not be determined. Photodynamic therapy was performed within 1 week after bevacizumab injection according to indocyanine green angiography (ICGA). Additional bevacizumab injections were performed within a 4 to 6 week interval. Additional photodynamic therapy was performed within 4 months.
RESULTS
The visual acuity on final examination had improved in 3 eyes (23.1%), was maintained in 7 eyes (53.8%), and decreased in 3 eyes (23.1%). The change of the PED before and after treatment showed regression in 5 eyes (38.5%), recurrence after regression in 2 eyes (15.4%), persistence in 4 eyes (30.8%), and retinal pigment epithelial tear in 2 eyes (15.4%). The maintained or improved visual acuity rate was 66.7% (6/9) and 100% (4/4) in the CNV and CNV or PCV group, respectively.
CONCLUSIONS
The combination therapy in neovascular age-related macular degenerationassociated with large retinal pigment epithelial detachment is a viable alternative treatment in the stabilization and improvement of vision. However, further studies with long-term follow up and controlled studies with anti-vascular endothelial growth factor antibody monotherapy are required.

Keyword

Bevacizumab; Choroidal neovascularization; Combination treatment; Photodynamic therapy; Retinal pigment epithelial detachment

MeSH Terms

Angiography
Antibodies, Monoclonal, Humanized
Choroid
Choroidal Neovascularization
Endothelial Growth Factors
Eye
Follow-Up Studies
Indocyanine Green
Macular Degeneration
Photochemotherapy
Recurrence
Retinal Detachment
Retinaldehyde
Vision, Ocular
Visual Acuity
Bevacizumab
Antibodies, Monoclonal, Humanized
Endothelial Growth Factors
Indocyanine Green
Retinaldehyde

Figure

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  Figure 1. Indocyanine green angiography (ICGA) of case 11 (A, B) and case 13 (C, D) at the initial visit (A, C) and before combined treatment of intravitreal bevacizumab injection and photodynamic therapy (PDT) (B, D). At the initial visit of case 11, ICGA demonstrates neovascular nets with pigment epithelial detachment (PED) (A). After second treatment of PDT, persisted neovascular net mixed with newly appearing polypoidal like lesion on ICGA (B). At initial visit of case 13, ICGA demonstrates a cluster of polypoidal lesion with large PED (C). After singlecombined treatment of intravitreal triamcinolone injection and PDT, noted the regression of cluster of polypoidal lesion with PED, and then recurred the lesion changed typical neovascular nets with PED on ICGA (D).

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  Figure 2. Distribution of final visual outcome for patients having previous treatment and no previous treatment; VA=visual acuity.

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  Figure 3. Fundus photographs, fluorescein angiography (FA), optical coherence tomography (OCT) and indocyanine green angiography (ICGA) of case 2 at baseline (A-C) and at 3 months after single combined treatment and consecutive two additional bevacizumab injection (D-F). Note the resolution of the choroidal neovascularization and pigment epithelial detachment on FA, OCT and ICGA.

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  Figure 4. Fundus photographs, fluorescein angiography (FA) and indocyanine green angiography (ICGA) of case 6 at baseline (A-C), at 3 months after first combined treatment (D-F) and at 3 months after second combined treatment and one additional bevacizumab injection (G-I). Note the persistent of pigment epithelial detachment and choroidal neovascularization on FA and ICGA, but visual acuity remained stable.

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  Figure 5. Fundus photographs, fluorescein angiography (FA), optical coherence tomography (OCT) and indocyanine green angiography (ICGA) of case 8. At baseline, showing choroidal neovascularization with pigment epithelial detachment (PED) (A-B). At 2 months after single combined treatment and consecutive two additional bevacizumab injection, showing the retinal pigment epithelial (RPE) tear on fundus photograph, FA, OCT, and ICGA (C-E). The arrowhead on OCT demonstrates RPE rip at the edge of detached RPE (C), but visual acuity was decreased within the 2 lines. At the 15 months, showing the subretinal fluid on OCT and marked decrease of visual acuity (F).

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  Figure 6. Distribution of final visual outcome of CNV group and CNV or PCV group; CNV=choroidal neovascularization; PCV=polypoidal choroidal vasculopathy; VA= visual acuity.

Reference

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