To evaluate the efficacy of photodynamic therapy (PDT) with verteporfin and intravitreal injection of triamcinolone to treat choroidal neovascularization (CNV) with flat submacular hemorrhage in age-related macular degeneration (ARMD).
Methods
A prospective, consecutive, noncomparative, interventional case series study was performed at the Instituto Oftalmologico de Alicante, Spain. Ten consecutive eyes from 10 patients with flat submacular hemorrhage secondary to ARMD were treated by PDT followed by intravitreal injection of 19.4±2.1 mg/0.1 mL triamcinolone 5 days later. PDT was repeated if leakage from the CNV appeared on fluorescein angiography (FA) at 3 months follow-up intervals. Main outcome measures were best-corrected visual acuity (BCVA) before and after treatment, post-treatment FA, results, and complications.
Results
Stable or improved BCVA was achieved in seven eyes at 6 months follow-up. Complete absence of leakage in FA was observed in five and in eight eyes at 3 and 6 months follow-up, respectively. Intraocular pressure rose in seven eyes.
Conclusions
PDT followed by intravitreal triamcinolone seems useful to treat CNV with flat submacular hemorrhage in ARMD. However, further studies with longer follow-up and randomized controlled trials are necessary to assess its efficacy in the management of this difficult clinical problem.
LeguayJ., GastaudP.Subretinal hematoma in age-related macular degeneration: treatment with intravitreal injection of tPA and gas [in French].J Fr Ophtalmol2000; 23: 797–801.
2.
AveryR.L., FekratS., HawkinsB.S., BresslerN.M.Natural history of subfoveal subretinal hemorrhage in age-related macular degeneration.Retina1996; 16: 183–9.
3.
GlattH., MachemerR.Experimental subretinal hemorrhage in rabbits.Am J Ophthalmol1982; 94: 762–73.
4.
ScheiderA., GundischO., KampikA.Surgical extraction of subfoveal choroidal new vessels and submacular haemorrhage in age-related macular degeneration: results of a prospective study.Graefes Arch Clin Exp Ophthalmol1999; 237: 10–5.
OlivierS., ChowD.R., PackoK.H., MacCumberM.W., AwhC.C.Subretinal recombinant tissue plasminogen activator injection and pneumatic displacement of thick submacular hemorrhage in age-related macular degeneration.Ophthalmology2004; 111: 1201–8.
7.
HattenbachL.O., KlaisC., KochF.H., GumbelH.O.Intravitreous injection of tissue plasminogen activator and gas in the treatment of submacular hemorrhage under various conditions.Ophthalmology2001; 108: 1485–92.
8.
HandwergerB.A., BlodiB.A., ChandraS.R., OlsenT.W., StevensT.S.Treatment of submacular hemorrhage with low-dose intravitreal tissue plasminogen activator injection and pneumatic displacement.Arch Ophthalmol2001; 119: 28–32.
9.
KreplerK., KrugerA., TittlM., SturM., WedrichA.Intravitreal injection of tissue plasminogen activator and gas in subretinal hemorrhage caused by age-related macular degeneration.Retina2000; 20: 251–6.
10.
HesseL., KrollP.Successful treatment of acute subretinal hemorrhage in age-related macular degeneration by combined intravitreal injection of recombinant tissue plasminogen activator and gas.Adv Ther1997; 14: 275–80.
11.
HesseL., SchroederB., HellerG., KrollP.Quantitative effect of intravitreally injected tissue plasminogen activator and gas on subretinal hemorrhage.Retina2000; 20: 500–5.
12.
JonasJ.B., JagerM.Perfluorohexyloctane endotamponade for treatment of subfoveal hemorrhage.Eur J Ophthalmol2002; 12: 534–6.
13.
DaneshvarH., KertesP.J., LeonardB.C., PeymanG.A.Management of submacular hemorrhage with intravitreal sulfur hexafluoride: a pilot study.Can J Ophthalmol1999; 34: 385–8.
RechtmanE., DanisR.P., PrattL.M., HarrisA.Intravitreal triamcinolone with photodynamic therapy for subfoveal choroidal neovascularisation in age related macular degeneration.Br J Ophthalmol2004; 88: 344–7.
16.
SpaideR.F., SorensonJ., MarananL.Combined photodynamic therapy with verteporfin and intravitreal triamcinolone acetonide for choroidal neovascularization.Ophthalmology2003; 110: 1517–25.
17.
SpaideR.F., SorensonJ., MarananL.Photodynamic therapy with verteporfin combined with intravitreal injection of triamcinolone acetonide for choroidal neovascularization.Ophthalmology2005; 112: 301–4.
18.
BresslerN.M., Treatment of Age-Related Macular Degeneration with Photodynamic Therapy (TAP) Study Group. 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 Ophthalmol2001; 119: 198–207.
19.
Schmidt-ErfurthU.M., ElsnerH., TeraiN., BeneckeA., DahmenG., MichelsS.M.Effects of verteporfin therapy on central visual field function.Ophthalmology2004; 111: 931–9.
20.
BloomS.M., BruckerA.J.Laser Surgery of the Posterior Segment.Philadelphia: Lippincott-Raven Publications; 1997; 3–36.
21.
Schmidt-ErfurthU., Schlotzer-SchrehardU., CursiefenC.Influence of photodynamic therapy on expression of vascular endothelial growth factor (VEGF), VEGF receptor 3, and pigment epithelium-derived factor.Invest Ophthalmol Vis Sci2003; 44: 4473–80.
22.
WangY.S., FriedrichsU., EichlerW., HoffmannS., WiedemannP.Inhibitory effects of triamcinolone acetonide on bFGF-induced migration and tube formation in choroidal microvascular endothelial cells.Graefes Arch Clin Exp Ophthalmol2002; 240: 42–8.
23.
CiullaT.A., CriswellM.H., DanisR.P.Choroidal neovascular membrane inhibition in a laser treated rat model with intraocular sustained release triamcinolone acetonide microimplants.Br J Ophthalmol2003; 87: 1032–7.
24.
JonasJ.B., DegenringR.F., KreissigI., FriedemannT., AkkoyunI.Exudative age-related macular degeneration treated by intravitreal triamcinolone acetonide. A prospective comparative nonrandomized study.Eye2005; 19: 163–70.
25.
LevineS.M., ChakrabartyA.The role of iron in the pathogenesis of experimental allergic encephalomyelitis and multiple sclerosis.Ann NY Acad Sci2004; 1012: 252–66.
26.
PadehS., PasswellJ.H.Intraarticular corticosteroid injection in the management of children with chronic arthritis.Arthritis Rheum1998; 41: 1210–4.
27.
MassinP., AudrenF., HaouchineB.Intravitreal triamcinolone acetonide for diabetic diffuse macular edema: preliminary results of a prospective controlled trial.Ophthalmology2004; 111: 218–24; discussion 224–5.
28.
MajoriM., VachierI., GodardP.Superoxide anion production by monocytes of corticosteroid-treated asthmatic patients.Eur Respir J1998; 11: 133–8.
29.
DweikR.A., LewisM., KavuruM.Inhaled corticosteroids and beta-agonists inhibit oxidant production by bronchoalveolar lavage cells from normal volunteers in vivo.Immunopharmacology1997; 37: 163–6.
30.
FukushimaK., AndoM., ItoK., SugaM., ArakiS.Stimulusand cumulative dose-dependent inhibition of O2- production by polymorphonuclear leukocytes of patients receiving corticosteroids.J Clin Lab Immunol1990; 33: 117–23.
31.
WeinerF.R., CzajaM.J., JeffersonD.M.The effects of dexamethasone on in vitro collagen gene expression.J Biol Chem1987; 262: 6955–8.
32.
MerrillP.T., LoRussoF.J., LomeoM.D.Surgical removal of subfoveal choroidal neovascularization in age-related macular degeneration.Ophthalmology1999; 106: 782–9.
33.
HassanA.S., JohnsonM.W., SchneidermanT.E.Management of submacular hemorrhage with intravitreous tissue plasminogen activator injection and pneumatic displacement.Ophthalmology1999; 106: 1900–6; discussion 1906–7.
34.
SteinhorstU.H., TheischenM., WinterR.Subretinal lavage: a technique of continuous subretinal irrigation for removal of traumatic submacular hemorrhage.Ophthalmologica1997; 211: 399–401.
35.
MillerJ.W., WalshA.W., KramerM.Photodynamic therapy of experimental choroidal neovascularization using lipoprotein-delivered benzoporphyrin.Arch Ophthalmol1995; 113: 810–8.
36.
DanisR.P., BingamanD.P., YangY., LaddB.Inhibition of pre-retinal and optic nerve head neovascularization in pigs by intravitreal triamcinolone acetonide.Ophthalmology1996; 103: 2099–104.
37.
TanoY., ChandlerD., MachemerR.Treatment of intraocular proliferation with intravitreal injection of triamcinolone acetonide.Am J Ophthalmol1980; 90: 810–6.
38.
AntoszykA.N., GottliebJ.L., MachemerR., HatchellD.L.The effects of intravitreal triamcinolone acetonide on experimental pre-retinal neovascularization.Graefes Arch Clin Exp Ophthalmol1993; 231: 34–40.
39.
WeishauptK., GomerC., DoughertyT.Identification of singlet oxygen as the cytotoxic agent in photo-inactivation of murine tumor.Cancer Res1976; 36: 2326–9.
40.
Schmidt-ErfurthU., MichelsS., BarbazettoI., LaquaH.Photodynamic effects on choroidal neovascularization and physiological choroids.Invest Ophthalmol Vis Sci2002; 43: 830–41.
