We read with great interest the article by Barikian et al1 entitled, “Intravitreal dexamethasone implant as adjuvant treatment for bevacizumab- and ranibizumab-resistant neovascular age-related macular degeneration” published in Retina 2016, Doi:10.1097/IAE.0000000000001388, October 20, 2016, which prospectively evaluated the benefit of the sustained release intravitreal dexamethasone implant (Ozurdex; Allergan, Irvine, CA) as an adjuvant to anti–vascular endothelial growth factor (VEGF) therapy for the management of neovascular age-related macular degeneration (AMD) resistant to bevacizumab (Avastin; Genentech, Inc, South San Francisco, CA) and ranibizumab (Lucentis; Genentech, Inc). The authors concluded that dexamethasone implant in conjunction with as-needed ranibizumab improved central retinal thickness related to intraretinal fluid and stabilized visual acuity. We would like to address several challenges arising from the study, which can be specifically summarized as follows:
Altogether, regardless of the intravitreal pharmacotherapy chosen, for example, specific (bevacizumab/ranibizumab/aflibercept) or nonspecific (dexamethasone implant) anti-VEGF agents, the efficacy of treatment depends primarily on the precociousness of the therapy after AMD onset. Therefore, therapy with antiangiogenic agents has to be promptly applied as soon as possible after AMD onset. Every delay of therapy adversely influences the deterioration of visual functions, which is difficult to restore even with subsequent treatment. Both groups of anti-VEGF substances (specific and nonspecific drugs) provide similar rates of vision improvement but with superior anatomical outcomes and fewer injections in the dexamethasone implant-treated eyes. However, more patients receiving the dexamethasone implant lose vision mainly because of cataract.