MANAGEMENT OF AMD

A dexamethasone intravitreal implant (Ozurdex, Allergan, Inc.) may be a useful adjuvant for decreasing the treatment burden in patients with neovascular age-related macular degeneration (nAMD) persisting or recurring after initial anti-VEGF therapy.

Speaking at the 2015 annual meeting of the Association for Research in Vision and Ophthalmology in Denver, USA, Sandra Rezar MD presented the results of a pilot study conducted by the Vienna Study Centre at the Medical University of Vienna, Austria.

The study enrolled 40 consecutive patients presenting with subretinal and/or intraretinal fluid on optical coherence tomography (OCT) after receiving at least three monthly consecutive injections of ranibizumab (Lucentis, Genentech/Novartis).

They were randomised to receive a dexamethasone implant in combination with ranibizumab or continue anti-VEGF monotherapy and followed monthly. Repeat treatment was based on OCT and visual acuity criteria, and a second dexamethasone implant was allowed no sooner than six months.

During the 12-month study, both groups had stable mean visual acuity and macular sensitivity along with a significant reduction in central retinal thickness. There were no significant differences between groups at 12 months in any of those parameters.

However, time to first retreatment was significantly delayed in the combination group compared with eyes continuing on monotherapy. The difference corresponded to higher rates of complete resolution of macular oedema with the combination therapy. “We know that persistent and recurrent choroidal neovascularisation is common in eyes with nAMD and that persistent exudation leads to reduced visual acuity outcomes,” said Dr Rezar.

As nAMD is a multifactorial disease, monotherapy that focuses selectively on inhibiting angiogenesis may not be optimal. Combination therapy with a corticosteroid addresses the inflammatory component and may help limit VEGF upregulation, she explained.

The mean duration of anti-VEGF treatment prior to enrolment was about 12 months in both groups. The mean number of anti-VEGF injections administered during that period was 5.6 in the eyes randomised to monotherapy and 6.7 in the combination group.

Safety review showed that significant progression of lens opacity occurred in four eyes in the combination group and one eye treated with monotherapy.

“This pilot study showed that combination therapy with dexamethasone and ranibizumab resulted in delay in retreatment while functional parameter could be maintained. Further investigation is needed in order to identify those patients showing greatest benefit from adding corticosteroids to anti-VEGF,” added Dr Rezar.

Correspondence – Stefan Sacu: stefan.sacu@meduniwien.ac.at

Sandra Rezar: sandra.rezar@meduniwien.ac.at