Special Focus Medical Therapies for AMD Combined cataract surgery and anti-VEGF treatment promising

Stefanie Petrou-Binder MD in Heidelberg PATIENTS who undergo cataract surgery and IOL implantation combined with an anti-VEGF treatment appear to benefit from the approach, with few complications, according to a German study presented at the Congress of the DGII (German-speaking Society for Intraocular Lens Implantation, Interventional and Refractive Surgery). Susanne Billwitz MD investigated the safety and efficacy of a combined anti-VEGF/cataract surgical procedure in 20 patients, 13 of which had age- related macular degeneration and seven of which had diffuse diabetic macular oedema.The average patient age was 77 years. In addition to drying up 50 per cent of exudative macular disease with one shot, the combined approach improved vision in 16/20 patients, she reported. “At least half of the patients benefited from the combined approach. In particular, patients with persistent DME that underwent previous laser coagulation treatments can frequently experience a Courtesy of Susanne Billwitz MD rebound effect, and therefore benefit from combining cataract surgery with an intravitreal anti- VEGF injection. Re-injection was necessary in only that one anti-VEGF injection was effective in drying profited from the procedure, she observed. 50 per cent of the AMD patients,” said Dr Billwitz, out exudative maculopathy in a significant Furthermore, she noted no intra- or postoperative Vivantes Klinikum, Neukölln, Berlin, Germany. proportion of the patients, since Avastin therapy complications. All of the study participants had clinically generally requires a series of three interventions. VEGF inhibitors inhibit both angiogenesis and significant, sight-limiting cataracts.The AMD patients “Re-injection in only 50 per cent of the cases oedema development.This is particularly significant showed classic subfoveal choroidal means that half of the wet AMD patients were in in patients with diabetic macular oedema, as neovascularisation.The investigator diagnosed the fact treated with only one shot of Avastin,” he said. corroborated by the results, she noted.The DME exudative maculopathy using fluorescein Dr Billwitz postulated that since the fundus view patients underwent intensive therapy with grid- angiography. She followed the patients for 16 was occluded by cataract, it was conceivable that a laser coagulation prior to the study and had retinal weeks. number of cases were diagnosed as wet, when in thickening on HRT-retina module images.As Dr Billwitz performed phacoemulsification fact they were dry. Later, after cataract surgery and compared to laser coagulation, using intravitreal surgery and implanted a ‘blue-filter’ posterior anti-VEGF injection, they were in fact determined injections did not lead to visual field defects, she chamber lens, under topical anaesthesia.This was to be dry, clinically, she said. noted. followed by an intravitreal injection through the Albert Augustin MD, the DGII session’s The advantages of the combined therapy of pars plana at 3.5mm distance from the limbus, of chairperson, commented that although three phaco/PCL and anti-VEGF included a better fundus 0.3mg ranibizumab (Lucentis, Genentech/ Novartis) injections were generally applied, it was not a strict view for diagnostics and therapy, no additional or 1.25mg bevacizumab (Avastin® Genentech/ rule.An individual patient may present with a dry procedure for patients, and better visual results and Novartis). retina after one Avastin injection, as well, if that is therefore higher patient satisfaction. The overall preoperative visual acuity of the all he needs. AMD group improved from an average of 0.15 to Visual acuity results were very good, overall, Dr [email protected] 0.24 four weeks after surgery. In the DME patients, Billwitz emphasised.Vision improved in nine AMD [email protected] visual acuity improved from 0.1 preoperatively to patients, remained unchanged in one, and was [email protected] 0.31 after surgery. Both groups had visual acuity worse in three AMD patients. By contrast, visual improvements that were statistically significant, Dr acuity was better in all seven of the DME patients. Billwitz noted. Dr Billwitz explained that roughly half of the trial In 50 per cent of the patients with AMD, a dry patients had already undergone treatments with retina was documented.The other half of the anti-VEGF monotherapy, PDT monotherapy, patients were worse either angiographically or numerous PDT/triamcinolone treatments, or clinically, after roughly four weeks, requiring Avastin/ triamcinolone applications. Most of these additional anti-VEGF treatments. took place as off-label Lucentis treatments, she said. In the diabetic group, all of the patients improved Cataract and exudative maculopathy, due to a after four weeks from surgery, as documented by wet macular degeneration or diabetic macular both angiography results and visual acuity exams, oedema, are two common causes of visual loss in and treatment was not repeated. Rebound our older patients, Dr Billwitz maintained.A phenomena in pre-treated eyes have been combined treatment of cataract surgery and described in the literature, however, she said. intravitreal anti-VEGF can therefore be to their Wolfgang Schrader MD was intrigued to hear advantage. Overall, half of the patients clearly

EuroTimes,Vol 13, Issue 5, May 2008 – Not for reprinting