Triamcinolone-enhanced photodynamic therapy of retinal angiomatous proliferation in exudative age-related macular degeneration: One year follow-up

Purpose: Retinal angiomatous proliferation (RAP) is a peculiar form of choroidal neovascularization in age related macular dedeneration (AMD) that poorly responds to photodynamic therapy (PDT) or other treatments. Recently, triamcinolone acetonide (TA) has been introduced as a novel therapeutical option to enhance the effects of PDT. The aim of our study was to evaluate angiographic and morphologic outcomes of a combined treatment (TA plus PDT) of RAP compared to only PDT. Methods: A consecutive series of 23 eyes of 21 patients (68+10 years) with RAP and pigment epithelial detachment (PED) underwent an intravitreal injection of 0.1 ml (4.0 mg) of purified TA followed by PDT within 2 weeks. A control group of 15 eyes from 14 patients (65+7 years) with AMD and RAP was treated with only PDT, according to standard procedure. Dynamic fluorescein (FA) and indocyanine green (ICG) angiography, and optical coherence tomography (OCT) were performed in all patients before treatment, immediately after, and at a 3,6,12 month interval. Results: In the study group all eyes, after TA but before PDT, already showed a PED flattening, confirmed by OCT. One week after PDT, 22 out of 23 eyes of TA–PDT group showed RAP closure, which was apparent in only 3 eyes of the control group. At 3 months, 2 eyes from the TA–PDT required retreatment due to reperfusion of the RAP, whilst all eyes of controls were retreated within 6 months. No other patient in TA–PDT group needed further treatment during the one–year follow–up. Despite the application of a mean of 3.4 PDT sessions, most eyes (14 out of 15) of controls showed still patent and exudant RAP lesions at the end of the study. Conclusions: It is common experience that thermal laser or PDT fails to demonstrate efficacy to close RAP lesions in exudative AMD. This could be related to the pathophysiology of RAP which, being connected to retinal circulation, seems to be less vulnerable to PDT photothrombosis. A combined treatment TA–PDT seems to produce stronger and long–lasting closing effect with more durable stabilization of the lesion, flattening of PED and less PDT retreatments. Further larger randomized studies are needed to assess the visual outcomes of this promising strategy.