retinal angiomatous proliferation ( rap ) is a form of retinal - choroidal neovascularisation within the wet age - related macular degeneration ( amd ) category , characterised by intraretinal capillary proliferation , subretinal neovascularisation and a serous / vascularised pigment epithelial detachment including a retinal - choroidal anastomosis .
rap has been proved to be notoriously difficult to treat , with very few case reports and published articles on successful treatment .
we describe the case of a 67-year - old male with rap undergoing successful treatment with stabilised visual acuity .
rap is a distinct form of choroidal neovascularisation first recognised as a separate entity in 1992 as a deep retinal vascular anomalous complex .
rap was first used , describing a complex pathology of retinal choroidal anastomoses with / without pigment epithelial detachments .
this neovascularisation extends posteriorly , leading to subretinal neovascularization , which may lead to a neurosensory retinal detachment as well as to an associated serous pigment epithelial detachment .
stage 3 occurs when neovascularisation extends into the choroidal circulation , sometimes in association with a vascularised pigment epithelial detachment . during this process ,
a connection between the retinal and choroidal circulation may develop , leading to a retinal - choroidal anastomosis .
reports have shown that between 8 and 22%   of cases previously diagnosed as exudative amd are rap .
there is a distinct correlation between age and the development of rap , with a median patient age of 80 years .
females are at a higher risk of developing rap , with one report claiming a 90% tendency towards the female gender .
unfortunately , due to the nature of the disease , rates of second - eye rap are high . up to 80% of fellow eyes
develop neovascularisation after 1 year , and 100% of patients will have developed some form of neovascularisation before 3 years since first eye diagnosis . while most published data have focused on intravitreal ranibizumab injections as the mainstay of treatment , we discuss the case of a patient with rap undergoing successful treatment with intravitreal ranibizumab and intravitreal triamcinolone acetonide ( ivta ) .
a 67-year - old male presented to the eye casualty department in december 2008 with a 1-week history of distorted vision in his left eye .
his past ocular history was significant in that he had a disciform scar in his right eye leaving him with hand movement vision .
he has also been under the care of the medical retinal consultant since january 2008 with a left occult choroidal neovascular membrane for which he had received 5 intravitreal injections of bevacizumab .
his past medical history included peripheral vascular disease , essential hypertension , impaired glucose tolerance , early dementia and depression .
on examination at the casualty department , his visual acuity was 6/38 + 2 in the left eye with microaneurysms at the fovea with minimal oedema . a fundus fluorescein angiogram ( ffa ) and optical coherence tomography ( oct )
a decision was made with the patient to start intravitreal ranibizumab due to the presence of only one functioning eye .
the patient showed significant improvement after the first 3 injections , and his vision remained stable .
the patient received a total of 10 intravitreal ranibizumab injections within the first year , with stable vision at 6/24 ( 40 letters ) .
however , in may 2010 , during routine follow - up , the patient presented to the age - related macular degeneration ( armd ) clinic complaining of reduced vision .
visual acuity was 6/120 + 4 ( 8 letters ) , and his oct scans are shown in fig .
the decision was made to treat the patient with ivta , and the patient was given a single ivta injection .
the patient was given the ivta injection in the first week of june 2010 . during the subsequent visits , an immediate improvement in vision
his visual acuity improved to 6/48 ( 25 letters ) at the first visit and remained stable for the following 2 months .
he required no further intravitreal triamcinolone injections , and ranibizumab injections were continued based on oct appearances on a monthly basis . since the intravitreal triamcinolone injection , he has received a total of 7 intravitreal ranibizumab injections to the left eye over a 4-year period based on his oct appearances , with the last injection in october 2013 .
his vision fluctuates on a monthly basis but it has remained between 6/48 + 3 ( 28 letters ) and 6/30  1 ( 34 letters ) .
oct images at the 1- , 2- , 3- and 4-year follow - up are shown in fig .
his right eye shows no signs of rap and is being monitored with oct imaging .
as the patient had an almost immediate improvement with ivta injection based on vision and intra - retinal fluid , we are able to confirm the inflammatory nature of rap and the effects of ivta .
while there has been little research into rap as a separate entity ( often treated similar to other types of proliferative amd ) , the mainstay of treatment in most published articles was intravitreal ranibizumab injections .
although there have been some favourable results using ranibizumab alone , as shown by the study of inoue et al . , there has also been evidence indicating that ivta can be beneficial in treating rap . due to the inflammatory nature of rap
, ivta was used by the consultant after previous studies had proved the efficacy of ivta in combination with other therapies .
the majority of published studies have combined ivta treatment with photodynamic therapy ( pdt ) , including some mixed results . in 2012 , the study of rouvas et al .   showed an anatomical improvement ( geographic atrophy ) in patients with ivta and pdt treatment , suggesting , along with the study of mendis et al .
, that ivta and pdt can be considered as treatment for rap . however , this was contradicted by the study of saito et al . , highlighting anti - vascular endothelial growth factor and pdt therapy as a more favourable option . to our knowledge , there has been no evidence to suggest using a combination of ivta and ranibizumab injections for the treatment of rap .
while most studies have focused on using either treatment in combination with pdt , there have been no published data on the combined use of anti - vascular endothelial growth factor and ivta treatments . as this case report demonstrates , 1 dose of ivta with top - up injections of ranibizumab including a comprehensive follow - up can not only stabilise and improve vision , but also improve the geographic appearance of the macula .
we have successfully demonstrated a positive outcome in combined intravitreal treatment for this difficult condition .
 a 67-year - old male who presented to the eye casualty department with deterioration in his vision was diagnosed with retinal angiomatous proliferation . after initial deterioration with ranibizumab intravitreal injections , 
 we have demonstrated successful treatment and stabilised vision with ranibizumab and a single intravitreal triamcinolone injection . 
 stringent follow - up and top - up ranibizumab injections have stabilised his vision and have shown foveal improvement on optical coherence tomography imaging . 
Introduction
Background
Case Report
Discussion
Conclusion