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Anti-VEGF Injection Reduction with Radiotherapy for Wet AMD
- 1. Dr. Pravda Chaturvedi Dr S N Medical College Jodhpur
- 2. In Treatment of age related Macular Degeneration Anti VEGF injections played pivotal role since their discovery in mid 2000s. Earlier treatments merely slowed the on going visual loss, whereas with Anti VEGF injections, one could expect visual improvement.
- 3. Frequent intra ocular injections Pain Inflammation Vitreous floaters Traumatic cataract Retinal detachment Geographic atrophy Systemic- slightly increased risk of stroke, heart attack.
- 4. Clue taken from oncology Uses a low energy X ray source X ray is collimated to a narrow beam I. Enables rapid dose fall off II. Precise targeting III. Minimum radiation scatter During treatment, a vaccum coupled contact are used to stabilise globe Real time monitoring done
- 5. One year clinical trial, double blind prospective study. 230 patients of neovascular wet AMD * 3 years, already receiving anti VEGF injections. All received an initial dose of ranibizumab and were randomised to receive 16Gy radiation. Single 26 min radiotherapy treatment was given. Patients were evaluated monthly *12months
- 6. After 1 year- Injections were reduced by 1/3rd with comparable visual acuity. Then patients were returned to their original drug schedule After 2 years- Safety and efficacy data were collected. Injections were reduced by 26%. Vision changes were similar. After 3 years- Only safety data were collected. No significant difference visual outcome. Radiation retinopathy- 33/122 18 regressed 14% wet amd 8% dry amd
- 7. Radiations are anti-angiogenic, anti- inflammatory, anti-proliferative. Doesn’t treat scar tissue. Eyes with actively proliferative leisons, producing fluid leakage are more likely to respond. Fibers grow centrifugaly, so fibers remain proliferative at edges. Lesions with diameter <4mm, and/or macular volume >7.4mm^3 reqired fewer injections.
- 8. Radiation radiotherapy rare below 30 Gy. Develops within 7-36 months. Long term s/e like radiation radiotherapy and microvasculopathy. Simultaneous clinical trial of s/e was conducted.
- 9. Over 3 yrs, 30 % patients receiving radiations developed small localised microvascular abnormality. It didn’t modify visual outcome significantly. Few regressed themselves over time. Radiation exposure is 10% of CT Head & same as dental radiography. Fractioning total dose reduces the risk Radiation retinopathy is now treatable by Anti VEGF drugs.
- 10. Most tolerated the treatment well and were satisfied. Decreasing injections was most imp cause.