Author: Utku Limon (Turkey)
To report the efficacy of intravitreal bevacizumab and dexamethasone for vascularized serous retinal pigment epithelial detachments (PEDs) secondary to neovascular age-related macular degeneration (nAMD).
Retrospective and case-control series
In this single-centered, retrospective and case-control series; we reviewed the medical records of 20 patients who had neovascular serous PEDs secondary to nAMD between January 2019 and June 2020. Inclusion criteria are as follows; 1- Patients with a diagnosis of vascularized serous PED secondary to nAMD based on clinical, FFA and OCT findings, 2- Patients treated with 3 monthly consecutive intraviteral bevacizumab injections due to this diagnose, 3-Despite this treatment, the presence of new or persistant cystoid macular edema, intraretinal or subretinal fluid on optical coherence tomography (OCT), the presence of at least 250μm PED height or <10% decrease in PED height or greatest linear diameter, presence of active CNVM findings in FFA [the presence of dotted and slightly hypo-fluorescent "notch" at the border of the serous PED (indicative of CNVM with serous PED), new or persistant hemorrhage or exudates and loss of 5 letters or more. Exlusion criterias were; patients with nAMD without serous neovascular PED, patients with fibrovascular PED or hemorrhagic PED, polypoidal choroidal vasculopathy (PCV) and retinal angiomatous proliferation (RAP) in indocyanine green angiography (IGA), patients with glaucoma, uveitis, diabetes, vitreous hemorrhage, foveal hard exudate, epiretinal membrane, juxtafoveal telangiectasia, macular scar, ischemia shown in the FFA, cerebrovascular accident or myocardial infarction within 3 months and incomplete imaging or clinical data. We also excluded patients who previously treated with laser photocoagulation, submacular surgery, photodynamic therapy, and intravitreal injection of other anti-VEGF agents. These patients were randomly divided into two groups. Eight patients included in Group-1 were treated, first with simultaneous combined intravitreal injection of bevacizumab and dexamethasone implant, and then with Pro Re Nata (PRN) dosing bevacizumab with monthly visits for 6 months. Twelve patients included in Group-2 were treated with with PRN dosing bevacizumab with monthly visits for 6 months. Re-treatment for PRN dosing bevacizumab injections was determined according to the following criteria; the presence of new or persistant cystoid macular edema, intraretinal or subretinal fluid on OCT, presence of active CNVM findings in FFA, new or persistant retinal hemorrhage or exudates and visual acuity loss of 5 letters or more at monthly visits. The changes of maximum PED height and greatest linear diameter, CMT and the snellen BCVA were reviewed retrospectively at initial and 1st, 3rd and 6th month visits.
In Group-1 there were 6 (75%) male and 2 (25%) female patients with a mean age of 65.12 ± 10.4 (55-72) years. In Group-2 there were 8 (66.6%) male and 4 (33.4%) female patients with a mean age of 67.29 ± 11.2 (56-78) years. For all patients mean follow-up time was 6.5 ± 2.1 (6-7) months. Baseline characteristics of the patients were similar in both groups. The baseline characteristics and clinical data of the patients in both groups are shown in Table 1 and Table-2. In both groups all patients were diagnosed as having occult CNVM. While there was no significant increase in BCVA in both groups in the 1st month, there were a significant improvement in PED heights, PED greatest linear diameters and CMTs from baseline. Significant improvement was found at 3rd and 6th months in mean snellen BCVA, PED heights, PED greatest linear diameters and CMTs from baseline in both groups (p<0.05). Although improvement in BCVA and CMT in the 1st, 3rd and 6th months were better in Group-1 it was not significantly between two groups (p<0.05). However, improvement in mean PED heights and PED greatest linear diameters were significantly better in the first group at 1st, 3rd and 6th months. At 1st month 6 (75%) of the patients (case 1, 2, 3, 6, 7, 8) in Group-1 were treated with additional intravitreal bevacizumab again because of CNVM findings on FFA and OCT. In Group-2 all patients treated with additional bevacizumab at first month. The mean additional injections during the 6 month were 3.7±1.4 (3-6) in Group-1 and 5.4±1.8 (4-6) in Group-2 (p=0.041). OCT findings and sample fundus pictures of the patients in Group-1 are given in figures 1-5, respectively. In Group-1 complete resolution of PED was occurred in 5 (62.5%) patients at 6th month (case 1,3, 4, 6 and 8). Patients 2, 5 and 7 still had PED at 6 months, but they did not receive any additional treatment because there was no CNVM findings on FFA and OCT. In Group-2 complete resolution of PED was occurred in 6 (50%) patients at 6th month. Four (33.3%) patients had subretinal fluid at 6th month and was treated with intravitreal bevacizumab again. Retinal pigment epithelium rupture did not develop in any of the patients in Group-1. In Group-2, RPE rupture developed in 1 eye. All patients in Group-1 were psoudophakic. There was no intraocular pressure (IOP) elevation on the same day and at 1st day after injection in all patients. In Group-1 intraocular pressure increased over 21 mmHg in 2 of the patients at 2nd and 3th months. Intraocular pressure was controlled with topical anti-glaucoma medications. No serious systemic side effects developed in any of the patients.
Simultaneous intravitreal injection of bevacizumab and dexamethasone implant was safely and effectively improved vascularized serous PED. However, re-injection is required again. This treatment may become a treatment option for treatment-resistant PED secondary to nAMD. But further studies are necessary to establish efﬁcacy and safety.