Combined photodynamic therapy and intravitreal triamcinolone for neovascular age-related macular degeneration: effect of initial visual acuity on treatment response

  • Ramin Schadlu
  • Steven M. Kymes
  • Rajendra S. Apte
Retinal Disorders

Abstract

Purpose

To evaluate visual outcomes in combination therapy with photodynamic therapy (PDT) and intravitreal triamcinolone acetonide (IVTA) for subfoveal choroidal neovascularization (CNV) from age-related macular degeneration (AMD).

Methods

Charts of 39 eyes from 38 patients with exudative AMD treated with PDT and 4 mg of triamcinolone acetate injected intravitreally were reviewed retrospectively. Visual data, angiographic lesion type, prior PDT exposure, number of treatments, and follow-up were recorded. Snellen visual acuities were converted to LogMAR for all calculations. Lines of vision lost or gained pertain to calculated ETDRS lines of vision (via LogMAR).

Results

Twenty-two of the choroidal neovascular membranes were occult, and 17 were classified as predominantly classic. Mean follow-up was 43 weeks. The average number of treatments was 2.23. At final follow-up, 11 eyes (28.21%) experienced improved visual acuity, 8 eyes (20.51%) were stable, and 20 eyes (51.28%) had worsened. No significant difference in treatment response was found between angiographic subtypes (p > 0.59). Lack of previous PDT exposure did not improve treatment outcomes (p > 0.77). Pre-treatment visual acuity (PTVA) was determined as a strong predictor of treatment outcome in our study cohort. Visual acuity of 20/200 or worse was associated with a 40.9% chance of some improvement and a 35.75% chance of three or more lines of improvement. Visual acuity better than 20/200 was associated with an 89.4% chance of no improvement and a 58.8% chance of three or more lines of visual loss.

Conclusion

Counter to previously reported results with combination therapy, the majority of our patients (72%) did not demonstrate improved vision and 51% lost vision. When PTVA was accounted for, selected patients benefitted significantly from treatment. PTVA may be a useful and simple patient selection tool for combination treatment with PDT and IVTA.

Keywords

AMD PDT Verteporfin Triamcinolone 

References

  1. 1.
    Smith W, Assink J et al (2001) Risk factors for age-related macular degeneration: Pooled findings from three continents. Ophthalmology 108(4):697–704PubMedCrossRefGoogle Scholar
  2. 2.
    Macular Photocoagulation Study Group (1991) Subfoveal neovascular lesions in age-related macular degeneration: guidelines for evaluation and treatment in the macular photocoagulation study. Arch Ophthalmol 109:1242–1257Google Scholar
  3. 3.
    Pauleikhoff D, Bornfeld N et al (2005) Konsenspapier der Retinologischen Gesellschaft, der Deutschen Ophthalmologischen Gesellschaft und des Berufsverbandes der Augenarzte-Stellungnahme zur aktuellen Therapie der neovaskularen AMD. Klinische Monatsblatter fur Augenheilkunde 222(5):381–388PubMedCrossRefGoogle Scholar
  4. 4.
    Chakravarthy U, Soubrane G et al (2006) Evolving European guidance on the medical management of neovascular age related macular degeneration. Br J Ophthalmol 90(9):1188–1196PubMedCrossRefGoogle Scholar
  5. 5.
    Rosenfeld PJ, Rich RM, Lalwani GA (2006) Ranibizumab: Phase III clinical trial results. Ophthalmol Clin North Am 19(3):361–372PubMedGoogle Scholar
  6. 6.
    Brown DM, Kaiser PK, Michels M, Soubrane G, Heier JS, Kim RY, Sy JP, Schneider S, ANCHOR Study Group (2006) Ranibizumab versus verteporfin for neovascular age-related macular degeneration. N Engl J Med 355(14):1432–1444PubMedCrossRefGoogle Scholar
  7. 7.
    Bressler NM (2001) Treatment of age-related macular degeneration with photodynamic therapy study. Photodynamic therapy of subfoveal choroidal neovascularization in age-related macular degeneration with verteporfin: two-year results of 2 randomized clinical trials-tap report 2. Arch Ophthalmol 119(2):198–207PubMedGoogle Scholar
  8. 8.
    Verteporfin In Photodynamic Therapy Study Group (2001) Verteporfin therapy of subfoveal choroidal neovascularization in age-related macular degeneration: two-year results of a randomized clinical trial including lesions with occult with no classic choroidal neovascularization–verteporfin in photodynamic therapy report 2. Am J Ophthalmol 131(5):541–560CrossRefGoogle Scholar
  9. 9.
    Bressler NM (2002) Verteporfin therapy of subfoveal choroidal neovascularization in age-related macular degeneration: two-year results of a randomized clinical trial including lesions with occult with no classic choroidal neovascularization-verteporfin in photodynamic therapy report 2. Am J Ophthalmol 133(1):168–169PubMedCrossRefGoogle Scholar
  10. 10.
    Bressler NM et al; Treatment of Age-Related Macular Degeneration with Photodynamic Therapy (TAP) Study Group (2002) Verteporfin therapy of subfoveal choroidal neovascularization in patients with age-related macular degeneration: additional information regarding baseline lesion composition’s impact on vision outcomes-TAP report no. 3. Arch Ophthalmol 120(11):1443–1454PubMedGoogle Scholar
  11. 11.
    Augustin AJ, Schmidt-Erfurth U (2006) Verteporfin therapy combined with intravitreal triamcinolone in all types of choroidal neovascularization due to age-related macular degeneration. Ophthalmology 113(1):14–22PubMedCrossRefGoogle Scholar
  12. 12.
    Augustin AJ, Schmidt-Erfurth U (2006) Verteporfin and intravitreal triamcinolone acetonide combination therapy for occult choroidal neovascularization in age-related macular degeneration. Am J Ophthalmol 141(4):638–645PubMedCrossRefGoogle Scholar
  13. 13.
    Spaide RF, Sorenson J et al (2003) Combined photodynamic therapy with verteporfin and intravitreal triamcinolone acetonide for choroidal neovascularization. Ophthalmology 110(8):1517–1525PubMedCrossRefGoogle Scholar
  14. 14.
    Spaide RF, Sorenson J et al (2005) Photodynamic therapy with verteporfin combined with intravitreal injection of triamcinolone acetonide for choroidal neovascularization. Ophthalmology 112(2):301–304PubMedCrossRefGoogle Scholar
  15. 15.
    Nicolo M, Ghiglione D et al (2006) Occult with no classic choroidal neovascularization secondary to age-related macular degeneration treated by intravitreal triamcinolone and photodynamic therapy with verteporfin. Retina 26(1):58–64PubMedCrossRefGoogle Scholar
  16. 16.
    Spaide RF, Sorenson J et al (2005) Combined photodynamic therapy and intravitreal triamcinolone for nonsubfoveal choroidal neovascularization. Retina 25(6):685–690PubMedCrossRefGoogle Scholar
  17. 17.
    Chan WM, Lai TY et al (2006) Combined photodynamic therapy and intravitreal triamcinolone injection for the treatment of subfoveal choroidal neovascularisation in age related macular degeneration: a comparative study. Br J Ophthalmol 90(3):337–341PubMedCrossRefGoogle Scholar
  18. 18.
    Ergun E, Maar N et al (2006) Photodynamic therapy with verteporfin and intravitreal triamcinolone acetonide in the treatment of neovascular age-related macular degeneration. Am J Ophthalmol 142(1):10–16PubMedCrossRefGoogle Scholar
  19. 19.
    Holladay JT (1997) Proper method for calculating average visual acuity. J Refract Surg 13:388–391PubMedGoogle Scholar
  20. 20.
    Blyth CR, Still HA (1983) Binomial confidence intervals. J Am Stat Assoc 78:108–116Google Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • Ramin Schadlu
    • 1
  • Steven M. Kymes
    • 1
  • Rajendra S. Apte
    • 1
  1. 1.Department of Ophthalmology and Visual SciencesWashington University in St. Louis School of Medicine, Barnes Retina InstituteSt. LouisUSA

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