Sir,

A review of the literature showed no published cases using a combination of intravitreal triamcinolone acetonide (IVTA) and antivascular endothelial growth factor agents for choroidal neovascularization (CNV) with associated retinal angiomatous proliferation (RAP).1, 2, 3, 4, 5 We present a case of RAP with a pigment epithelial detachment (PED) refractory to multiple treatment modalities, but which responded to the combination of intravitreal triamcinolone (Kenalog, Bristol-Myers-Squibb, Peapack, NJ, USA) and intravitreal bevacizumab (Avastin; Genentech, San Francisco, CA, USA).

An 80-year-old woman with bilateral AMD was referred for treatment of CNV. Her vision was 20/150 right eye (OD) and counting fingers at 5 feet left eye (OS). Clinical examination showed bilateral fibrovascular PEDs with overlying small coin-shaped geographic atrophy both eyes (OU). There was intraretinal haemorrhage and lipid associated with the PEDs. Fluorescein angiography and indocyanine green angiography showed leakage from minimally classic CNV with RAP lesions OU (Figure 1a and b). Optical coherence tomography (OCT) showed a PED, cystoid macular oedema (CME), and subretinal fluid OU (Figure 2).

Figure 1
figure 1

(a) Left eye: Late-phase fluorescein angiogram showing minimally classic CNV. (b) Left eye: Indocyanine green angiogram showing the RAP lesions within CNV.

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Figure 2
figure 2

Left eye: OCT showing a PED, cystoid macular oedema, and subretinal fluid with CNV.

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Over the previous 9 months before referral, the patient had been treated with three sessions of verteporfin photodynamic therapy (PDT), the last combined with intravitreal triamcinolone. Over the next 20 months, she underwent multiple treatments, including two PDTs with IVTA, pegaptanib (Macugen, Eyetech, New York NY, USA) OD, four bevacizumab OD, two bevacizumab OS, one ranibizumab (Lucentis; Genentech, San Francisco, CA, USA) OD and three ranibizumab OS. After the third bevacizumab OD, the OCT showed a flat PED, vision improved to 20/70, and the PED remained flat without further treatments for 9 months. However, the CME in the left eye continued to worsen on OCT despite the last three ranibizumab injections (Figure 3a). After a discussion with the patient on combination therapies, intravitreal triamcinolone 2 mg (0.05 ml) and intravitreal bevacizumab 1.25 mg (0.05 ml) were given. This dose allowed us to give a single 0.1-ml injection without the need for a paracentesis. One month later, the CME had resolved and the PED was flat (Figure 3b). The vision remained at counting fingers due to the areas of geographic atrophy. This effect was maintained the last follow-up 5 months later with no adverse treatment effects.

Figure 3
figure 3

(a) Left eye: Optical coherence tomography showing a pigment epithelial detachment, worse cystoid macular oedema, and subretinal fluid. (b) Left eye: Optical coherence tomography showing that the pigment epithelial detachment, cystoid macular oedema, and subretinal fluid have resolved after combination therapy with intravitreal triamcinolone and bevacizumab.

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Intravitreal bevacizumab and triamcinolone are used off-label as treatment options for CNV. This case illustrates that combination therapy with intravitreal triamcinolone and bevacizumab may be considered as an option for treatment of CNV.