Combination Of Ranibizumab With Photodynamic Therapy In The Treatment Of Wet Age-related Macular Degeneration

Background and ObjectiveAge-related macular degeneration(AMD) is one of the major cause of blindness, the etiology of this disease has not been fully elucidated. Quit smoking, or intake of antioxidants may reduce the risk of progression of AMD. Wet age-related macular degeneration (wAMD) is characterized by an imbalance between proangiogenic and angiogenic inhibitory factors, which lead to the mass production of vascular endothelial growth factor (VEGF), resulting in the formation of choroidal neovascularization(CNV). And wAMD accounts a small portion of all cases of AMD, but is responsible for most of cases resulting in severe visual loss. Photodynamic therapy(PDT) may affect the physiologic choriocapillary bed surrounding the pathologic CNV lesion, in addition to causing CNV closure, and then may lead to hypoxia, thereby inducing a reproducible angiogenic response and indirectly upregulating VEGF and stimulating further CNV growth; the shortcoming of intravitreal anti-VEGF is that repeated injections are necessary. Combination therapy may have the tendency to reduce the overall need for AMD treatments while improve vision. We review the potential long-term benefit and safety of combination of ranibizumab with photodynamic therapy treated for wAMD.MethodsA retrospective review was conducted on 11 eyes from 11 patients that received intravitreal ranibizumab(IVR) 0.5 mg combined with PDT within 7 days, and thereafter retreated as required with ranibizumab monotherapy. Ranibizumab was injected if there was retinal thickness>100μm, or subretinal fluid and retinal edema according to OCT examination; fluorescein angiography(FA) will be performed under new retinal hemorrhage or an equivalent visual acuity decrease exceeding five letters, and ranibizumab was injected if CNV leakage was detected. Patients were followed up every 6 months after initial monthly visit for initial 3 months and clinical visit was required if any abnormality was found during the regular self-monitoring between routine visits. Regular self-monitoring includes VA testing and sensitivity of Amsler grid testing of the study eyes. Complete ophthalmic examinations were conducted at each visit, consisting of distance best-corrected visual acuity (BCVA), intraocular pressure (IOP), standardized ophthalmic examination after pupil dilation, FA and optical coherence tomography(OCT),and indocyanine green angiography(ICGA) should be done in the initial or being suspicious of PCV during the total treatment period. Collected data included:BCVA, IOP, central retinal thickness(CRT) and retreatment number of IVR.ResultsThe study eyes received an average of 1.55 times(range:0 to 8) of intraocular anti-VEGF reagent injection during the total 18 months period after initial combination therapy. The mean change from baseline in CRT at month 1,2,3,6,12 and 18 was 136.09 ± 100.61 microns,-147.00 ± 110.42 microns,-134.91 ＋ 96.70 microns,-145.09 ± 88.51 microns,-123.05 ± 118.61 microns and-144.82 ± 86.34 microns respectively. The mean CRT of the study eyes decreased significantly from baseline in the early 1 month and remained stable in the subsequent follow-up period. The BCVA at baseline ranged from 0.02 to 0.8 (decimal visual acuity), the mean logMAR visual acuity at baseline was 0.85 ± 0.56, corresponding approximatively to the decimal visual acuity 0.1-0.15. The mean logMAR visual acuity was 0.72 ± 0.51 after eighteen months of follow-up, and the mean difference of ETDRS visual acuity change from baseline was 7.31 ± 15.00 letters. Some patients were followed for up to 30 months and maintained a stabilization of vision. No serious adverse events.ConclusionCombination therapy reduced times of anit-VEGF reagent injection and maintained long-lasting effect on wAMD.