Sandwich therapy combining photodynamic therapy and adjunctive anti-VEGF for juxtapapillary retinal capillary hemangioblastoma

PURPOSE: To report the outcomes of verteporfin photodynamic therapy (PDT) with adjuntive pre- and post-PDT intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections ("Sandwich PDT") for juxtapapillary retinal capillary hemangioblastoma (RCH). METHODS: A retrospective case review of eyes with juxtapapillary RCH that underwent "Sandwich PDT" in a national referral center. The clinical features were evaluated with fundus photography, optical coherence tomography, and ultrasonography. RESULTS: Five eyes were analyzed. The median follow-up time was 42 (range, 12-77) months. Adjunctive anti-VEGFs were given 4.0 weeks (range, 1 day-12 weeks) before PDT and 6.0 weeks (3 days to 8 weeks) after PDT. One of the five eyes (20%) that had anti-VEGF injection 8 weeks before PDT developed macular exudation after PDT but resolved within 1 month. Following Sandwich PDT, tumor size regressed in 3/5 eyes (60%) and stabilized in 2/5 eyes (40%). Subretinal fluid and exudates completely resolved in the three eyes that had these features before PDT, whereas intraretinal fluid stabilized or partially responded in 4/5 (80%). Reactivation of disease activity was noted in two eyes (40%), one resolved after a second Sandwich PDT. At the last follow-up, visual acuity improved 10 ETDRS letters or more in one eye (20%), stabilized in two (40%), and worsened 10 ETDRS letters or more in two (40%). CONCLUSION: The treatment of juxtapapillary RCH remains challenging. PDT with adjunctive anti-VEGF injections achieved anatomical control, but the functional outcomes were guarded. Based on the pharmacokinetics, we propose that anti-VEGF be given 1 week before PDT for maximal coverage.