Topical nepafenac for treatment of exudative age‐related macular degeneration (2009)

Editor, Intravitreal injections of anti-vascular endothelial growth factor (VEGF) drugs have become the standard therapy of exudative age-related macular degeneration (ARMD) (Gillies et al. 2003; Gragoudas et al. 2004; Rosenfeld et al. 2005, 2006; Jonas et al. 2007; Schmidt-Erfurth et al. 2007; Virgili et al. 2007; Algvere et al. 2008; Frimpong-Boateng et al. 2008). However, intravitreal injections can be complicated by injection-related complications such as infectious endophthalmitis and iatrogenic trauma to intraocular structures (Jonas 2005; Jonas et al. 2007, 2008). In an attempt to avoid such side-effects and to be as non-invasive as possible, a topical application of anti-VEGF drugs with sufficient penetration to the back of the eye would harbour the advantage of avoiding injection-related complications. Based on a report by Takahashi et al. (2003), it was the purpose of our study to describe the clinical course of a patient with exudative ARMD who received topical therapy for his disease. A 74-year-old phakic patient experienced a decrease in central visual acuity caused by exudative ARMD. Best-corrected central visual acuity was reduced from 20/30 (as measured 5 months previously) to 20/200. Optical coherence tomography and fluorescein angiography showed a subretinal and intraretinal oedema and a subfoveal neovascular membrane in the foveal region (Fig. 1). Because the patient refused the recommended intravitreal injection of anti-angiogenic drugs, she received a topical therapy of nepafenac 0.1% (Nevanac® eyedrops; Alcon, Forth Worth, TX, USA) three times a day. Informed consent was obtained. Fluorescein angiograms (from the top to bottom: infrared image, early, middle and late phase) and optical coherence tomograms (at bottom) prior to (left column) and at 8 weeks (right column) after initiation of topical application of nepafenac eyedrops as treatment of exudative age-related macular degeneration. At the follow-up examination 1 week after initiation of the therapy, visual acuity improved from 20/200 to 20/80 and the metamorphopsias disappeared. Two weeks later, central visual acuity increased to 20/60 and the therapy was tapered to two applications a day. Eight weeks after start of the therapy, central visual acuity improved to 20/40 and fluorescein leakage subsided completely (Fig. 1). Optical coherence tomography showed a minor fluid accumulation in the subretinal space, while the intraretinal oedema disappeared. Intraocular pressure was 17 mmHg. The clinical course suggests that the topical application of nepafenac may have been associated with a regression of intraretinal and subretinal macular oedema and a reduction of fluorescein extravasation in exudative ARMD. Our findings are in accordance with those of previous studies on the inhibition of ocular neovascularization by nepafenac in rats with experimental diabetes mellitus (Kern et al. 2007; Takahashi et al. 2003) and with reports on celecoxib as another cox-2 inhibitor exhibiting a marked antiproliferative effect in cell cultures of adult retinal pigment epithelial and choroidal endothelial cell lines (Amrite & Kompella 2008).