Combined Intravitreal Pharmacosurgery in Patients with Occult Choroidal Neovascularization Secondary to Wet Age-Related Macular Degeneration

Abstract

Aim: The aim was to investigate the efficacy and safety of combined intravitreal therapy in patients with occult choroidal neovascularization (CNV) secondary to wet age-related macular degeneration (AMD) over 6 months. Methods: In this prospective pilot study of a case series, 106 patients (mean age 75.4 years) with predominantly occult CNVs were treated with a 1.5-ml core pars plana vitrectomy with intravitreal injections of triamcinolone (8 mg), bevacizumab (1.25 mg) and balanced salt solution. The best-corrected visual acuity (BCVA; logMar), central macular thickness (optical coherence tomography), and intraocular pressure (IOP; Goldmann tonometry) were assessed at baseline and follow-up visits. Results: Statistically significant increases in BCVA (vs. baseline) were observed at 2 months (mean +0.9; standard deviation ±0.6 lines), 4 months (+1.3; ±0.7), and 6 months (+1.2; ±0.7) after the initial combined intravitreal therapy in 96/106 patients. At 6 months, BCVA had deteriorated in 20 of 96 (20.8%) patients by <2.5 lines, remained stable in 38 of 96 (39.6%) and improved in 31 (32.3%) patients by 1–3 lines, and in 7 (7.3%) patients by >3 lines. The mean central retinal thickness decreased by –41.2% (–195; ±46 µm) over 6 months. 55% demanded intravitreal anti-vascular endothelial growth factor (VEGF) treatment after initial therapy. Increases in IOP were managed by eye drops in 11 (10%) patients with no other adverse event occurring. Conclusion: After the combined intravitreal therapy, including two drugs and a limited core vitrectomy, a significant and sustained improvement in vision of patients with occult CNVs was observed over 6 months. In 45% of the initially treated patients, anti-VEGF therapy did not have to be continued, which might be attributed to both the pharmacological effects of the drugs and the physiological changes induced by the vitrectomy (posterior vitreous detachment, liquefaction, and oxygen redistribution).

Intravitreal Functional Plasminogen Is Elevated in Central Retinal Vein Occlusion

“…No adverse events or serious side effects occurred and sampling vitreous fluids with either technique was revealed to be a safe procedure. Previous studies confirm those observations [12,13,14] although serious complications may occur and sampling aqueous humor was declared as a safer way to collect intraocular specimens [15,16]. Nevertheless, we decided to analyze vitreous samples instead of aqueous humor samples because intraocular plasminogen activity within the eye is low [17] and there is a substantial dilution effect between the anterior and posterior segments of the eye [11,18,19].…”

Proteomics of Vitreous Humor of Patients with Exudative Age-Related Macular Degeneration

“…Vitreous samples were acquired at the beginning of an intravitreal combination treatment for wet AMD, which involved a 23-gauge core vitrectomy of at least 4 cc vitreous, before the application of bevacizumab, triamcinolone, and dexamethasone [22]. The same surgical technique was applied for the removal of idiopathic vitreous floaters, substituting balanced salt solution (BSS Plus, Alcon, Freiburg, Germany).…”

“…This automated, sensitive, fast proteome analysis technique [21] using CE as a front-end fractionation coupled to mass spectrometry, separates peptides and small proteins (<20 kDa) based on migration in the electrical field with high resolution in a single step. It enables analysis of thousands of peptides per sample using a sub-microliter sample volume and it has been used in numerous clinical biomarker studies, mostly examining urine as the specimen of interest [22], [23].…”

Intravitreal Bevacizumab Versus Combined Intravitreal Bevacizumab and Triamcinolone for Neovascular Age-Related Macular Degeneration

“…5 It has been proposed that triamcinolone acetonide may provide an additive effect when combined with anti-VEGF agents and may reduce the need for retreatment. [6][7][8] The synergy of angiogenic and inflammatory pathways in the pathogenesis of neovascular AMD suggests that combination treatment may be more effective than monotherapy. [9][10][11] This randomized clinical trial was conducted to compare the efficacy of three consecutive intravitreal bevacizumab (IVB) injections with that of the same regimen combined with intravitreal triamcinolone (IVT) during the initial injection.…”