We thank Drs Campa and Harding for their interest in our recently published paper. We retrospectively reviewed 31 Japanese women older than 50 years of age who had myopic choroidal neovascularization (mCNV) treated with either photodynamic therapy (PDT) (Visudyne [verteporfin]; Novartis Pharma, Basel, Switzerland) or intravitreal bevacizumab (IVB) (Avastin; Genentech, South San Francisco, California, USA). We found significantly better visual acuity (VA) in the patients treated with IVB than with PDT ( P < .01, 0.56 vs 0.92 mean logMAR units). The mean logMAR value also was significantly ( P < .01) worse than baseline in patients treated with PDT by 0.18 unit 24 months after treatment.
Because the Verteporfin in Photodynamic Therapy report no. 3 failed to show a statistical significance, it is still controversial whether PDT is beneficial over the long term. Several case series without controls mostly concluded that PDT is useful for maintaining vision. We agree with this hypothesis, which also was suggested by plot analysis in Figure 2 in our paper. However, several studies including ours have reported substantial visual improvement at least 12 months after IVB. Unfortunately, no study has done a head-to-head comparison of the 2 treatments. Interestingly, a recent prospective randomized study described substantially greater benefit with IVB and significant worsening with PDT after 24 months in juxtafoveal cases. These accumulating data suggest that IVB seems to be more beneficial overall for patients with mCNV. However, we agree that the evidence is not yet sufficiently strong, and more efforts must be made to support the superiority of anti–vascular endothelial growth factor drugs over PDT.
Another question that also arises is: are there any myopic patients who actually benefit more from IVB? VA outcomes after PDT vary widely among reports, likely because the VA depends on many factors including the CNV size, location, age, refractive error, myopic degeneration, and perhaps ethnicity. The long-term VA is also dependent on retinal pigment epithelial/choroidal degeneration even after CNV closure. Among the factors, aging is a strong negative factor, as indicated by several reports. For example, Pece reported the overall maintenance of VA 2 years after PDT ( P = .854), as suggested by the correspondent. However, subclass analysis has revealed that the VA significantly worsened in patients older than 55 years (0.54 vs 0.84, P < .001), which agreed with our results. This example indicates that the beneficial effect of PDT may be limited in older patients, resulting in the exaggerated difference between IVB and PDT in our study. This fact also indicates that IVB is more promising for older patients.
Our report had limitations because of its retrospective nature leading to patient heterogeneity or natural selection bias. In addition, the study included only older Asian patients. However, we wish to emphasize the benefit of IVB over PDT, at least under these specific conditions.