being retrospective in nature , the ethics committee approval for this study was not sought , as per institutional policy . however , all the procedures followed were in accordance with the helsinki declaration of 1975 , as revised in 2000 . only eyes with cnv secondary to pathological myopia , defined as an eye with a minimum refractive error of 6 diopters , were included . evaluation of the patients included recording the best corrected visual acuity ( bcva ) , fundus photography , digital fluorescein angiography , using the visupac system and the ff 450 fundus camera ( carl zeiss meditec ag gschwitzer strae 51 - 52 d-07745 jena , germany ) , and a macular scan with optical coherence tomography ( oct ) using stratus oct 3.0 ( carl zeiss meditec ag goschwitzer strae 51 - 52 d-07745 jena , germany ) . treatment was administered only if there was evidence of active cnv , that is , presence of leakage on fluorescein angiography and intra - retinal or sub - retinal fluid on oct . eleven eyes underwent pdt as per tap protocol { treatment of age - related macular degeneration with photodynamic therapy ( tap ) study } [ group 1 , fig . three eyes were treated with a combination of pdt and ivta [ group 2 , fig . 2 ] . twelve eyes were treated with a combination of pdt and intravitreal anti - vegf agents ( bevacizumab 1.25 mg/0.05 ml , fig . 3 or ranibizumab 0.5 mg/0.05 ml , fig . 4 ) administered within 48  72 hours of pdt ( group 3 ) . three eyes in group 3 received verteporfin - pdt with reduced - fluence of 25 j / cm followed by intravitreal ranibizumab ( 0.5 mg/0.05 ml ) within 48 - 72 hours [ fig . follow - up examinations were performed at two - month intervals after the first visit , and at monthly intervals , thereafter . the wilcoxon signed ranks test was used to evaluate the difference between pre- and post - treatment visual acuity . top ( left to right ) : pretreatment color fundus photograph , fluorescein angiography ( early and late phases ) showing active leakage and optical coherence tomography revealing increased retinal thickness in a case in group 1 ( photodynamic monotherapy ) . bottom ( left to right ) : post - treatment color fundus photograph , fluorescein angiography ( early and late phases ) showing resolution of the leakage with staining of the scar and optical coherence tomography showing a hyper - reflective scar with resolution of fluid in the same case as above top ( left to right ) : pretreatment color fundus photograph , fluorescein angiography ( early and late phases ) showing active leakage and optical coherence tomography revealing increased retinal thickness in a case in group 2 ( photodynamic therapy + triamcinolone acetonide ) . bottom ( left to right ) : post - treatment color fundus photograph , fluorescein angiography ( early and late phases ) showing resolution of the leakage with staining of the scar and optical coherence tomography showing a hyper - reflective scar with resolution of fluid in the same case mentioned above top ( left to right ) : pretreatment color fundus photograph , fluorescein angiography ( early and late phases ) showing active leakage and optical coherence tomography revealing increased retinal thickness in a case in group 3 ( photodynamic therapy and intravitreal bevacizumab ) . bottom ( left to right ) : post - treatment color fundus photograph , fluorescein angiography ( early and late phases ) showing resolution of the leakage with staining of the scar and optical coherence tomography showing a hyper - reflective scar with resolution of fluid in the same case mentioned above top ( left to right ) : pretreatment color fundus photograph , fluorescein angiography ( early and late phases ) showing active leakage and optical coherence tomography revealing increased retinal thickness in a case in group 4 ( combination photodynamic therapy and intravitreal ranibizumab ) . bottom ( left to right ) : post - treatment color fundus photograph , fluorescein angiography ( early and late phases ) shows resolution of the leakage with staining of the scar and optical coherence tomography showing a hyper - reflective scar with resolution of fluid in the same case mentioned above top ( left to right ) : pretreatment color fundus photograph , fluorescein angiography ( early and late phases ) showing active leakage and optical coherence tomography revealing increased retinal thickness in a case in group 5 ( reduced - fluence photodynamic therapy with ranibizumab ) . bottom ( left to right ) : post - treatment color fundus photograph , fluorescein angiography ( early and late phases ) showing resolution of the leakage with staining of the scar and optical coherence tomography showing a hyper - reflective scar with resolution of fluid in the same case mentioned above the clinical profiles , visual outcomes , and follow - up of different groups are summarized in table 1 . all groups were statistically comparable in terms of age , presenting bcva , greatest linear diameter ( gld ) , and refractive error ( kruskal - wallis test ) . visual improvement , defined as any improvement of 0.2 logmar , was seen in five ( n = 11 ) eyes in group 1 , two ( n = 3 ) eyes in group 2 , and eleven ( n = 12 ) eyes in group 3 [ fig . 6 ] . no correlation between age at onset and final visual acuity was seen in any group . at the last follow - up , no ocular or systemic adverse reaction was noted in any of the treated eyes till the last follow - up . pretreatment clinical features and visual outcomes of different groups bar diagram shows a comparison of pretreatment and post - treatment visual acuities in all the five groups this study reveals better visual outcomes and reduced retreatment rates in eyes treated with combination pdt and anti - vegf agents . for such eyes treated with pdt alone , the vip study demonstrated no statistical treatment benefit at the end of two years . krebs et al , reported that following pdt , the distance visual acuity improved from 43 letters to 53 letters at one year , and was stable thereafter up to three years . a better visual outcome as compared to the vip study was attributed to fewer numbers of retreatments , as repeated treatments with pdt were associated with hypoxic stress and release of vegf . better visual outcome in our study was again attributable to the same reason . in group 1 , even though the retreatment rate was 0.16 , the degree of visual improvement was less than expected because lacquer cracks were noted to be extending under the fovea in four of these 11 eyes [ fig . 7 ] . ( a ) pretreatment fluorescein angiography ( arteriovenous phase ) showing classic choroidal neovascularization ( arrow - head ) with lacquer cracks ( arrows ) in a case in group 1 ( photodynamic monotherapy ) . ( b ) six months post - treatment fluorescein angiography ( arteriovenous phase ) showing complete regression of choroidal neovascularization , with extension of lacquer cracks under the fovea ( arrow ) montero et al , stated that as the complications with intravitreal triamcinolone were greater in younger individuals , the combination of pdt and ivta should be reserved for the elderly who show a poorer response to pdt and have a lower visual acuity , or for patients with recurrent cnvs . treatment results for group 2 in our study also reiterate the fact that this modality does not result in a significantly better visual outcome compared to pdt monotherapy . this study is the first of its kind in analyzing the treatment outcomes of combination pdt with ranibizumab / bevacizumab , for the treatment of myopic cnv . both combinations are effective in both older and younger age groups with far lesser complications . the average number of treatments in both groups per month can be translated to 0.18 and 0.16 , respectively , which is less as compared to those reported in the published studies on bevacizumab monotherapy . the combined regime is postulated to have a beneficial synergistic effect that can reduce the need for repeated injections . selectivity of verteporfin - pdt has been achieved with reduced light dosage that not only causes reduced choroidal occlusion , but also avoids collateral alteration of the physiological choroid and obtains complete cnv closure . our results with reduced fluence pdt and intravitreal ranibizumab show that the average number of injections required to cause complete cnv regression was 1.33 at 296 days of follow - up . however , the average number of injections required with standard fluence pdt and ranibizumab in our study was two , thus validating the above claim , in principle . , a combination therapy of pdt with anti - vegf agents appears efficacious in the treatment of eyes with cnv secondary to pathological myopia , and may afford better visual outcomes as compared to pdt monotherapy . however , a larger study with a longer follow - up is required to validate these results .