Triple Therapy: A New Treatment Modality For Age-Related
Macular Degeneration
Over the last several years, there have been remarkable advances
in the treatment of age-related macular degeneration (AMD). The
first non-thermal treatments available to mitigate the terrible
visual outcomes of untreated subfoveal neovascularization due to
macular degeneration were ocular photodynamic therapy (OPT) or
Macugen injections every six weeks for two years or more.
Subsequently, the use of monthly intravitreal Avastin or Lucentis
monotherapy has led to stable vision for most patients and improved
vision for many. Even with these advances, monotherapy has
limitations, not the least of which is recurrence or the need for
prolonged treatment. I have had experience with combination therapy
for several years having used OPT with intraocular Kenalog,
stabilizing and often substantially improving vision with fewer
treatments. However, with that combination therapy, there were
common complications of glaucoma and cataracts.
Increasingly, it is thought that combination therapy may be more
advantageous than monotherapyfor wet macular degeneration: better
visual outcomes, greater duration of effect, prolonged stability,
fewer treatments, convenience, and safety. Various treatment
combinations have been tried and reported including alternating
Lucentis and Macugen, OPT and Macugen, and OPT and Kenalog (as
mentioned above). These combination treatments theoretically
address the vascular and extravascular components of subretinal
neovascularization better than monotherapy.
At the February 2006 meeting of the American Society of Retina
Specialists (ASRS), the Europeans reported amazing success with the
use of "triple therapy" for macular degeneration. These results
were updated and subsequently confirmed at annual meetings of the
ASRS.
"Triple therapy", consists of a modified OPT for all lesion
types, followed the next morning by a small gauge vitrectomy and
intravitreal dexamethasone and Avastin, and at least two subsequent
in-office intravitreal Avastin injections a month apart. This
results in increased vision and decreased retinal thickening
(indicating that the subretinal neovascular membrane has been
inactivated) for most patients, often with one treatment cycle.
About one third of patients have needed triple therapy
re-treatment. Complications are infrequent, and the risk of
cataract formation and seroid-induced glaucoma is substantially
lessened with the treatment modality.
Because of the multiple benefits and increased safety profile, I
am offering triple therapy to select patients. Every treatment
modality has its risks, benefits, and limitations, and extensive
discussion with patients and their families will be critical in
selecting the most appropriate treatment for each patient. If and
when new and better therapies become available, I will reassess
each patient for the most beneficial treatment option. Providing
the best care possible for all of our patients, and keeping them
and their referring physicians informed of new treatment options,
is of utmost importance to me.
David V. Poer, MD, FACS