Avastin plus steroid combined treatment of large pigment epithelial detachments Combined intravitreal triamcinolone acetonide (IVTA) injection with intravitreal Avastin (bevacizumab, IVB) is effective in the treatment of choroidal neovascularization (CNV) associated with large retinal pigment epithelial detachment (PED) in age-related macular degeneration (AMD), according to a new study.

A PED occurs when fluid enters the space between the retinal pigment epithelium (RPE) and choroid (Figure). PEDs are often seen in eyes with various types of choroidal vascular abnormalities in exudative AMD, such as choroidal neovascularization, polypoidal choroidal vasculopathy, and retinal angiomatous proliferation. There is currently no effective treatment for PED, although photodynamic therapy and anti-VEGF have been used with some success. Earlier short-term reports found that anti-VEGF therapy was superior to photodynamic therapy of PED. Treatment of large PEDs with anti-VEGF agents have been associated with RPE tears. A recent study found that treatment with Lucentis may temporarily decrease the volume of avascular PED secondary to AMD, however this effect was not maintained over a 1-year follow-up period.

In this prospective, consecutive, observational case series Seven eyes (five patients) with CNV associated with large PED in AMD were treated by IVTA (4 mg), followed by a IVB (1.25 mg) 1 week later. Patients were evaluated for best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) at baseline, at 1 week and every 6 weeks. Fluorescein angiography (FA) and indocyanine green angiography (ICG) were performed at baseline and every 3 months afterwards. Indications for retreatment by combined injection were defined as persistent PED with subretinal and/or intraretinal fluid on OCT. Patients with flattening of the PED and activity leakage demonstrated by OCT underwent subsequent IVB.

The mean duration of follow-up was 11 months (range 9–14 months). BCVA at baseline averaged 20/125, and 20/80 at the end of follow-up. FA showed no leakage from the lesion in four eyes at the end of follow-up, and three eyes showed a decrease in leakage. Average central foveal thickness was (CFT) 325.7 microns at baseline and 209.2 microns at the end. The average size of the PED was 2.34 disk diameters (range 1.33–3.25) at baseline, and the PED disappeared in four eyes, while it decreased in size at the end in the remaining three. The subretinal fluid disappeared in all patients at the end. The combined treatment (IVTA with IVB 1 week later) was repeated in four eyes, and the number of IVB after combined injection ranged from one to three. No RPE tear appeared during follow-up. Two eyes developed glaucoma controlled by topical medication. There were no other ocular or systemic complications

The investigators conclude that combined steroid plus Avastin therapy seems to be an effective and safe procedure to treat CNV associated with large PED in AMD.

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Graefes Arch Clin Exp Ophthalmol. 2010 Feb 19. [Epub ahead of print]