Efficacy and Safety of Ranibizumab With or Without Verteporfin Photodynamic Therapy for Polypoidal Choroidal Vasculopathy : A Randomized Clinical Trial

Key Points

Question

Are there any differences in treatment outcomes between combination therapy with intravitreal ranibizumab and verteporfin photodynamic therapy compared with ranibizumab monotherapy in polypoidal choroidal vasculopathy?

Findings

In the multicenter EVEREST II randomized clinical trial, compared with ranibizumab monotherapy, treatment of polypoidal choroidal vasculopathy with ranibizumab plus verteporfin photodynamic therapy resulted in greater visual acuity improvement (8.3 vs 5.1 letters) than monotherapy and complete resolution of lesions with fewer ranibizumab injections.

Meaning

These data suggest ranibizumab plus verteporfin photodynamic therapy should be considered for treatment of eyes with polypoidal choroidal vasculopathy.

Abstract

Importance

Polypoidal choroidal vasculopathy (PCV) is a common subtype of exudative age-related macular degeneration among Asian individuals. To our knowledge, there are no large randomized clinical trials to evaluate intravitreal ranibizumab, with and without verteporfin photodynamic therapy (vPDT), for the treatment of PCV.

Objective

To compare the efficacy and safety of combination therapy of ranibizumab and vPDT with ranibizumab monotherapy in PCV.

Design, Setting, and Participants

A double-masked, multicenter randomized clinical trial of 322 Asian participants with symptomatic macular PCV confirmed by the Central Reading Center using indocyanine green angiography was conducted between August 7, 2013, and March 2, 2017.

Interventions

Participants were randomized 1:1 to ranibizumab, 0.5 mg, and vPDT (n = 168; combination therapy group) or ranibizumab, 0.5 mg, and sham PDT (n = 154; monotherapy group). All participants received 3 consecutive monthly ranibizumab injections, followed by a pro re nata regimen. Participants also received vPDT/sham PDT on day 1, followed by a pro re nata regimen based on the presence of active polypoidal lesions.

Main Outcomes and Measures

Step 1 assessed whether combination therapy was noninferior (5-letter margin) to monotherapy for change in best-corrected visual acuity from baseline and superior in complete polyp regression. If noninferiority was established, step 2 assessed whether combination therapy was superior to monotherapy measured by best-corrected visual acuity change at month 12.

Results

Baseline demographics of the 322 participants were comparable between the treatment groups. Mean (SD) age of the patients was 68.1 (8.8) years, and overall, 69.9% of the patients were men. At baseline, the overall mean best-corrected visual acuity and mean central subfield thickness were 61.1 letters and 413.3 μm, respectively. At 12 months, mean improvement from baseline was 8.3 letters with combination therapy vs 5.1 letters with monotherapy (mean difference, 3.2 letters; 95% CI, 0.4-6.1), indicating that combination therapy met the predefined criterion for noninferiority as well as being superior to monotherapy ( P = .01). Combination therapy was also superior to monotherapy in achieving complete polyp regression at month 12 (69.3% vs 34.7%; P < .001). Over 12 months, the combination therapy group received a median of 4.0 ranibizumab injections compared with 7.0 in the monotherapy group. Vitreous hemorrhage was the only ocular serious adverse event (combination therapy group, 1 [0.6%]; monotherapy group, 3 [2.0%]).

Conclusions and Relevance

After 12 months, combination therapy of ranibizumab plus vPDT was not only noninferior but also superior to ranibizumab monotherapy in best-corrected visual acuity and superior in complete polyp regression while requiring fewer injections. Combination therapy should be considered for eyes with PCV.

Trial Registration

clinicaltrials.gov Identifier: NCT01846273.

Abstract

This randomized clinical trial compares the efficacy and safety of combination therapy of ranibizumab and verteporfin photodynamic therapy with ranibizumab monotherapy in polypoidal choroidal vasculopathy.