Surgical implantation of steroids with antiangiogenic characteristics for treating neovascular age-related macular degeneration.
BACKGROUND
Neovascular age-related macular degeneration (AMD) is associated with rapid vision loss due to choroidal neovascularization (CNV), leakage, and scarring. Steroids have gained attention in their role for the treatment of neovascular AMD for their antiangiogenic and anti-inflammatory properties.


OBJECTIVE
This review aims to examine effects of steroids with antiangiogenic properties in the treatment of neovascular AMD.


METHODS
We searched for trials in CENTRAL, MEDLINE, EMBASE, and LILACS on 2 October 2006.


METHODS
We included randomised controlled clinical trials of intra- and peri-ocular steroids in people diagnosed with neovascular AMD.


METHODS
Review authors extracted the data and assessed trial quality independently. We did not pool data since the included studies evaluated difference comparisons.


RESULTS
We report the risk of losing three or more lines vision at 12 months - "vision loss". One trial (139 people randomized) reported that a single dose of intravitreal triamcinolone (n = 75) (4 mg) had no significant effect on the risk of vision loss compared to placebo (n = 76). (Risk ratio vision loss 0.97, 95% confidence interval (CI) 0.74 to 1.26). Eyes treated with triamcinolone were more likely to develop cataracts and experience increased intraocular pressure (IOP) compared to untreated eyes. One trial (128 people randomized) reported the effects of anecortave acetate (3 mg (n = 32), 15 mg (n = 33) or 30 mg (n = 33) single dose with retreatment every six months if indicated) compared to placebo (n = 30). Risk ratio vision loss 0.80 (95% CI 0.45 to 1.45) in the 3 mg group, 0.45 (95% CI 0.21 to 0.97) in the 15 mg group and 0.91 (95% CI 0.52 to 1.58) in the 30 mg group. Side effects were similar in all treatment groups with the anecortave group having a slightly higher incidence of foreign body sensation compared to placebo. There was a high loss to follow-up. The final analysis may have been subject to selection bias as participants who were not selected for retreatment, possibly with worsening disease, were excluded. There was also a possibility of type I error due to multiple statistical comparisons. The sample size was estimated on the basis of a single 2-way comparison but three 2-way comparisons were analysed and presented. One trial reported that anecortave acetate (n = 263) (15 mg administered at beginning of study and six months) gave similar results to photodynamic therapy (n = 267) (risk ratio vision loss 1.08, 95% CI 0.91 to 1.29).


CONCLUSIONS
Overall there is weak evidence as to the benefits and harms of steroids with antiangiogenic properties for treating neovascular AMD with only three published trials of variable quality. Intravitreal triamcinolone injection for neovascular AMD does not appear to prevent severe vision loss and is associated with increased IOP and higher risk of cataract formation. Anecortave acetate 15 mg may have a mild benefit in stabilizing vision, but further better quality evidence is needed. The role of steroids in combination with other treatment modalities is yet to be determined.
Geltzer
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Brown University, 389 Benefit Street, Providence, Rhode Island 02906, USA. youngheeart@mac.com
Turalba
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Vedula
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D020533:Angiogenesis Inhibitors / Q000008:administration & dosage*; D020256:Choroidal Neovascularization / Q000150:complications / Q000188:drug therapy*; D004343:Drug Implants; D006801:Humans; D008268:Macular Degeneration / Q000188:drug therapy* / Q000209:etiology; D011244:Pregnadienediols / Q000008:administration & dosage; D016032:Randomized Controlled Trials as Topic; D014222:Triamcinolone Acetonide / Q000008:administration & dosage
D020533:Angiogenesis Inhibitors; D004343:Drug Implants; D011244:Pregnadienediols; D014222:Triamcinolone Acetonide; C418047:anecortave acetate