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Shin YU, Hong EH, Lim HW, Kang MH, Seong M, Cho H. Quantitative evaluation of hard exudates in diabetic macular edema after short-term intravitreal triamcinolone, dexamethasone implant or bevacizumab injections. BMC Ophthalmol 2017; 17:182. [PMID: 28974211 PMCID: PMC5627478 DOI: 10.1186/s12886-017-0578-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 09/25/2017] [Indexed: 12/28/2022] Open
Abstract
Background To quantitatively compare short-term hard exudates (HEs) alteration in patients with diabetic macular edema (DME) after intravitreal triamcinolone, dexamethasone implant or bevacizumab injections. Methods This retrospective study enrolled DME eyes with HEs that underwent a single-dose intravitreal injection of triamcinolone (25 eyes), dexamethasone implant (20 eyes), or three monthly injections of bevacizumab (25 eyes) and completed at least three months of follow-up. All patients were examined before and after 1, 2 and 3 months of injections. Using color fundus photographs, the amount of HEs was quantified by two masked graders. The difference in HEs area between baseline and each follow-up visit was compared among the three groups. Results After three months, HEs area was reduced to 52.9 ± 4.21% (P < 0.001) in the triamcinolone group, 63.6 ± 6.08% (P = 0.002) in the dexamethasone implant group, and 85.2 ± 5.07% (P = 0.198) in the bevacizumab group. A significant reduction in HEs appeared at one month in the triamcinolone group (53.5 ± 4.91%, P < 0.001) and at two months in the dexamethasone implant group (70.1 ± 5.21%, P = 0.039). Conclusions Our study suggests intravitreal steroids (triamcinolone, dexamethasone implants) significantly reduce HEs in DME patients on short-term follow-up, whereas intravitreal bevacizumab does not. Therefore, intravitreal steroids may be useful in DME with HEs in the fovea.
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Affiliation(s)
- Yong Un Shin
- Department of Ophthalmology, Hanyang University College of Medicine, Seoul, South Korea
| | - Eun Hee Hong
- Department of Ophthalmology, Hanyang University College of Medicine, Seoul, South Korea
| | - Han Woong Lim
- Department of Ophthalmology, Hanyang University College of Medicine, Seoul, South Korea
| | - Min Ho Kang
- Department of Ophthalmology, Hanyang University College of Medicine, Seoul, South Korea
| | - Mincheol Seong
- Department of Ophthalmology, Hanyang University College of Medicine, Seoul, South Korea
| | - Heeyoon Cho
- Department of Ophthalmology, Hanyang University College of Medicine, Seoul, South Korea.
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Abstract
The risk of severe eye problems has been found to increase significantly with age, particularly between the fifth and sixth decades of life. Cataracts, dry eye, neovascular age-related macular degeneration, diabetic retinopathy and retinal vein occlusion (RVO) are very common and very different age-related ocular diseases that reduce the patient's quality of life. The rationale for using corticosteroids to treat anterior and posterior ocular segment diseases is driven by inflammation. Dexamethasone, one of the most powerful corticosteroids available, is widely used for topical or intravitreal administration. Topical dexamethasone has proven efficacy for the management of postoperative inflammation in the anterior segment after cataract surgery and symptom relief in dry-eye disease. A new sustained-release 700 µg dexamethasone intravitreal implant (DEX) was recently approved for the treatment of macular edema following RVO, diabetic macular edema, or non-infectious uveitis, and its use is increasing, especially when other therapeutic agents have failed. The most common side effects are increased intraocular pressure and cataract formation. The potency of DEX, alone or in combination with other agents, makes DEX a promising option for treating several retinal diseases.
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Real-world experience with 0.2 μg/day fluocinolone acetonide intravitreal implant (ILUVIEN) in the United Kingdom. Eye (Lond) 2017; 31:1707-1715. [PMID: 28737758 PMCID: PMC5733285 DOI: 10.1038/eye.2017.125] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 05/29/2017] [Indexed: 01/25/2023] Open
Abstract
Aims To compare safety outcomes and visual function data acquired in the real-world setting with FAME study results in eyes treated with 0.2 μg/day fluocinolone acetonide (FAc). Methods Fourteen UK clinical sites contributed to pseudoanonymised data collected using the same electronic medical record system. Data pertaining to eyes treated with FAc implant for diabetic macular oedema (DMO) was extracted. Intraocular pressure (IOP)-related adverse events were defined as use of IOP-lowering medication, any rise in IOP>30 mm Hg, or glaucoma surgery. Other measured outcomes included visual acuity, central subfield thickness (CSFT) changes and use of concomitant medications. Results In total, 345 eyes had a mean follow-up of 428 days. Overall, 13.9% of patients required IOP-lowering drops (included initiation, addition and switching of current drops), 7.2% had IOP elevation >30 mm Hg and 0.3% required glaucoma surgery. In patients with prior steroid exposure and no prior IOP-related event, there were no new IOP-related events. In patients without prior steroid use and without prior IOP-related events, 10.3% of eyes required IOP-lowering medication and 4.3% exhibited IOP >30 mm Hg at some point during follow-up. At 24 months, mean best-recorded visual acuity increased from 51.9 to 57.2 letters and 20.8% achieved ≥15-letter improvement. Mean CSFT reduced from 451.2 to 355.5 μm. Conclusions While overall IOP-related emergent events were observed in similar frequency to FAME, no adverse events were seen in the subgroup with prior steroid exposure and no prior IOP events. Efficacy findings confirm that the FAc implant is a useful treatment option for chronic DMO.
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Parrish RK, Campochiaro PA, Pearson PA, Green K, Traverso CE. Characterization of Intraocular Pressure Increases and Management Strategies Following Treatment With Fluocinolone Acetonide Intravitreal Implants in the FAME Trials. Ophthalmic Surg Lasers Imaging Retina 2017; 47:426-35. [PMID: 27183546 DOI: 10.3928/23258160-20160419-05] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 03/21/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE To compare elevated intraocular pressure (IOP) management and outcomes among patients with diabetic macular edema who received fluocinolone acetonide (FAc) implants versus sham-control treatment and explore the prior ocular steroid exposure impact on IOP outcomes. PATIENTS AND METHODS Best-corrected visual acuity (BCVA) was measured using Early Treatment Diabetic Retinopathy Study charts or electronic VA testers. Goldmann applanation tonometry was used to measure IOP. RESULTS Elevated IOP was more common in FAc-versus sham control-treated patients. Medication, and less often trabeculoplasty or surgery, was used to lower IOP without affecting VA outcomes. No patient treated with 0.2 µg/day FAc who received prior ocular steroid required IOP-lowering surgery. CONCLUSION Elevated IOP may occur following FAc implant receipt; however, in the present study, it was manageable and did not impact vision outcomes. Patients previously treated with ocular steroid did not require IOP-lowering surgery following 0.2 µg/day FAc implant administration. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:426-435.].
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Liu E, Craig JE, Burdon K. Diabetic macular oedema: clinical risk factors and emerging genetic influences. Clin Exp Optom 2017; 100:569-576. [PMID: 28556097 DOI: 10.1111/cxo.12552] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 02/20/2017] [Accepted: 03/02/2017] [Indexed: 12/18/2022] Open
Abstract
Diabetic macular oedema is the major cause of visual impairment in type 1 and type 2 diabetes. As type 2 diabetes becomes more prevalent worldwide, the prevalence of diabetic macular oedema is also expected to rise. Current management of diabetic macular oedema is challenging, expensive and not optimal in a subset of patients. Therefore, it is important to increase our understanding of the risk factors involved and develop preventative strategies. While clinical risk factors for diabetic macular oedema have been identified, few studies have addressed potential genetic risk factors. Epidemiology and family studies suggest genetic influences are of importance. In this review, we summarise known clinical risk factors, as well as discuss the small number of genetic studies that have been performed for diabetic macular oedema.
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Affiliation(s)
- Ebony Liu
- Department of Ophthalmology, Flinders Medical Centre, Flinders University, Adelaide, South Australia, Australia
| | - Jamie E Craig
- Department of Ophthalmology, Flinders Medical Centre, Flinders University, Adelaide, South Australia, Australia
| | - Kathryn Burdon
- Cancer, Immunology and Genetics, Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
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Regillo CD, Callanan DG, Do DV, Fine HF, Holekamp NM, Kuppermann BD, Singer MA, Singh RP. Use of Corticosteroids in the Treatment of Patients With Diabetic Macular Edema Who Have a Suboptimal Response to Anti-VEGF: Recommendations of an Expert Panel. Ophthalmic Surg Lasers Imaging Retina 2017; 48:291-301. [PMID: 28419394 DOI: 10.3928/23258160-20170329-03] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 03/20/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND OBJECTIVE Guidance on the use of corticosteroids in the treatment of diabetic macular edema (DME) is lacking. This study aimed to develop a clinically recommended treatment paradigm for DME with emphasis on the role of corticosteroids. PATIENTS AND METHODS An expert panel of nine retinal specialists in the United States developed consensus recommendations for DME treatment through a modified Delphi process. RESULTS The panelists typically use intravitreal injections of vascular endothelial growth factor (VEGF) antagonists as first-line treatment of DME and switch patients with an inadequate response to anti-VEGF therapy (failure of best-corrected visual acuity to improve to 20/40 or better because of edema after three to six monthly injections, or a less-than-50% reduction in excess macular thickness after three to four monthly injections) to intravitreal corticosteroid treatment. CONCLUSION Intravitreal corticosteroids have a potentially useful role in the treatment of patients with DME who have an inadequate response to intravitreal anti-VEGF therapy. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:291-301.].
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SUBTHRESHOLD MICROPULSE DIODE LASER VERSUS CONVENTIONAL LASER PHOTOCOAGULATION FOR DIABETIC MACULAR EDEMA: A Meta-Analysis of Randomized Controlled Trials. Retina 2017; 36:2059-2065. [PMID: 27096529 DOI: 10.1097/iae.0000000000001053] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To evaluate the relative efficacy of subthreshold micropulse diode laser versus conventional laser photocoagulation for the treatment of diabetic macular edema. METHODS A comprehensive literature search was conducted to find relevant randomized controlled trials (RCTs). Efficacy estimates were determined by comparing weighted mean differences of the mean change of best-corrected visual acuity and central macular thickness from baseline. RESULTS Six RCTs were selected for this meta-analysis, including 398 eyes (203 eyes in the subthreshold micropulse diode laser group and 195 eyes in the conventional laser group). Subthreshold micropulse diode laser was superior to conventional laser in terms of mean change of logMAR best-corrected visual acuity at 3, 9, and 12 months after treatment (P = 0.02; P = 0.04, and P = 0.03, respectively), and it showed a similar trend at 6 months (P = 0.05). Although, there was no significant difference in terms of mean change in central macular thickness from baseline to 3, 6, 9, or 12 months (P = 0.80; P = 0.20; P = 0.88, and P = 0.86, respectively). CONCLUSION Subthreshold micropulse diode laser treatment resulted in better visual acuity compared with conventional laser, although the differences before 12 months are likely to be too small to be of clinical relevance and may be dependent on baseline best-corrected visual acuity. The two types of treatment seem to have similar anatomical outcome.
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Rezzola S, Corsini M, Chiodelli P, Cancarini A, Nawaz IM, Coltrini D, Mitola S, Ronca R, Belleri M, Lista L, Rusciano D, De Rosa M, Pavone V, Semeraro F, Presta M. Inflammation and N-formyl peptide receptors mediate the angiogenic activity of human vitreous humour in proliferative diabetic retinopathy. Diabetologia 2017; 60:719-728. [PMID: 28083635 DOI: 10.1007/s00125-016-4204-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 12/13/2016] [Indexed: 12/31/2022]
Abstract
AIMS/HYPOTHESIS Angiogenesis and inflammation characterise proliferative diabetic retinopathy (PDR), a major complication of diabetes mellitus. However, the impact of inflammation on the pathogenesis of PDR neovascularisation has not been elucidated. Here, we assessed the capacity of PDR vitreous fluid to induce pro-angiogenic/proinflammatory responses in endothelium and the contribution of the inflammation-related pattern recognition N-formyl peptide receptors (FPRs) in mediating these responses. METHODS Pooled and individual pars plana vitrectomy-derived PDR vitreous fluid ('PDR vitreous') samples were assessed in endothelial cell proliferation, motility, sprouting and morphogenesis assays, and for the capacity to induce proinflammatory transcription factor activation, reactive oxygen species production, intercellular junction disruption and leucocyte-adhesion molecule upregulation in these cells. In vivo, the pro-angiogenic/proinflammatory activity of PDR vitreous was tested in murine Matrigel plug and chick embryo chorioallantoic membrane (CAM) assays. Finally, the FPR inhibitors Boc-Phe-Leu-Phe-Leu-Phe (Boc-FLFLF) and Ac-L-Arg-Aib-L-Arg-L-Cα(Me)Phe-NH2 tetrapeptide (UPARANT) were evaluated for their capacity to affect the biological responses elicited by PDR vitreous. RESULTS PDR vitreous activates a pro-angiogenic/proinflammatory phenotype in endothelial cells. Accordingly, PDR vitreous triggers a potent angiogenic/inflammatory response in vivo. Notably, the different capacity of individual PDR vitreous samples to induce neovessel formation in the CAM correlates with their ability to recruit infiltrating CD45+ cells. Finally, the FPR inhibitor Boc-FLFLF and the novel FPR antagonist UPARANT inhibit neovessel formation and inflammatory responses triggered by PDR vitreous in the CAM assay. CONCLUSIONS/INTERPRETATION This study provides evidence that inflammation mediates the angiogenic activity of PDR vitreous and paves the way for the development of FPR-targeting anti-inflammatory/anti-angiogenic approaches for PDR therapy.
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Affiliation(s)
- Sara Rezzola
- Department of Molecular and Translational Medicine, University of Brescia, Via Branze 39, Brescia, 25123, Italy.
| | - Michela Corsini
- Department of Molecular and Translational Medicine, University of Brescia, Via Branze 39, Brescia, 25123, Italy
| | - Paola Chiodelli
- Department of Molecular and Translational Medicine, University of Brescia, Via Branze 39, Brescia, 25123, Italy
| | - Anna Cancarini
- Department of Ophthalmology, University of Brescia, Piazzale Spedali Civili 1, Brescia, 25123, Italy
| | - Imtiaz M Nawaz
- Department of Molecular and Translational Medicine, University of Brescia, Via Branze 39, Brescia, 25123, Italy
| | - Daniela Coltrini
- Department of Molecular and Translational Medicine, University of Brescia, Via Branze 39, Brescia, 25123, Italy
| | - Stefania Mitola
- Department of Molecular and Translational Medicine, University of Brescia, Via Branze 39, Brescia, 25123, Italy
| | - Roberto Ronca
- Department of Molecular and Translational Medicine, University of Brescia, Via Branze 39, Brescia, 25123, Italy
| | - Mirella Belleri
- Department of Molecular and Translational Medicine, University of Brescia, Via Branze 39, Brescia, 25123, Italy
| | - Liliana Lista
- Department of Chemical Sciences, 'Federico II' University of Naples, Naples, Italy
| | | | - Mario De Rosa
- Department of Experimental Medicine, Second University of Naples, Naples, Italy
| | - Vincenzo Pavone
- Department of Chemical Sciences, 'Federico II' University of Naples, Naples, Italy
| | - Francesco Semeraro
- Department of Ophthalmology, University of Brescia, Piazzale Spedali Civili 1, Brescia, 25123, Italy.
| | - Marco Presta
- Department of Molecular and Translational Medicine, University of Brescia, Via Branze 39, Brescia, 25123, Italy.
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Intravitreal bevacizumab alone or combined with 1 mg triamcinolone in diabetic macular edema: a randomized clinical trial. Int Ophthalmol 2017; 38:585-598. [PMID: 28349504 DOI: 10.1007/s10792-017-0496-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 03/08/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE To compare the results of intravitreal bevacizumab (IVB) injection alone or in combination with intravitreal 1 mg triamcinolone acetonide (IVT) in center-involved diabetic macular edema. METHODS In this randomized clinical trial study, ninety-two eyes of 46 patients with bilateral center-involved diabetic macular edema and no previous treatment were included in the study. One eye of each patient was randomly assigned to 1.25 mg of IVB injection or combination of 1.25 IVB and 1 mg IVT. Evaluation of best-corrected visual acuity (BCVA), central macular thickness (CMT), intraocular pressure (IOP) and grading of lens opacity was conducted at baseline, and weeks 2, 4, 6, 8, 12 and 24 after treatment. Retreatment was performed at a 6-week interval whenever indicated based on CMT. RESULTS Between the groups, BCVA changes were not statistically different until 24-week follow-up (P > 0.05), but at 24 weeks after treatment, BCVA improvement was significantly better in IVB group (P = 0.049). Significant CMT reduction was observed in each group along the follow-up period (P = 0.001). The mean CMT reduction was more significant in combination (IVB + IVT) group at 2 weeks of follow-up (P < 0.001), but CMT changes were not significant between the groups at weeks 12th and 24th after injection. Overall, retreatment was applied for 59 eyes up to 24 weeks (33 in the IVB group, 26 in the IVB + IVT group). Among patients with 2 or more injections, number of injections was significantly lower in IVB + IVT group (P = 0.043). Three eyes within IVB + IVT group developed IOP rise beyond 21 mmHg, which were controlled with topical anti-glaucoma medications within 1 week. Changes in lens opacity were not significant between two groups. CONCLUSION Eyes treated with IVB plus 1 mg IVT injections had more significant reduction in CMT in early post-injection, but this effect was transient. Although after 24 weeks visual acuity improvement was better in IVB group, combination therapy may decrease the number of injections. Combining 1 mg of intravitreal triamcinolone with bevacizumab was not accompanied with significant side effects.
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Combination of Anti-VEGF and Laser Photocoagulation for Diabetic Macular Edema: A Review. J Ophthalmol 2017; 2017:2407037. [PMID: 28348882 PMCID: PMC5350536 DOI: 10.1155/2017/2407037] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 11/25/2016] [Accepted: 01/18/2017] [Indexed: 02/03/2023] Open
Abstract
Diabetic macular edema (DME) is the most common cause of vision loss in diabetic patients. Thirty years ago, the Early Treatment Diabetic Retinopathy Study (ETDRS) demonstrated that focal/grid laser photocoagulation reduces moderate vision loss from DME by 50% or more; thus, macular photocoagulation became the gold standard treatment for DME. However, with the development of anti-VEGF drugs (bevacizumab, ranibizumab, and aflibercept), better outcomes were obtained in terms of visual acuity gain and decrease in macular thickness in some studies when antiangiogenic drugs were administered in monotherapy. Macular laser therapy may still play an important role as an adjuvant treatment because it is able to improve macular thickness outcomes and reduce the number of injections needed. Here, we review some of the clinical trials that have assessed the efficacy of macular laser treatment, either as part of the treatment protocol or as rescue therapy.
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Report of 12-months efficacy and safety of intravitreal fluocinolone acetonide implant for the treatment of chronic diabetic macular oedema: a real-world result in the United Kingdom. Eye (Lond) 2017; 31:650-656. [PMID: 28106887 PMCID: PMC5396008 DOI: 10.1038/eye.2016.301] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 11/20/2016] [Indexed: 01/06/2023] Open
Abstract
Purpose To report the 12-months visual and anatomical outcomes of chronic diabetic macular oedema (DMO) treated with ILUVIEN in a real-world clinical practice in a single tertiary referral centre. Method Retrospective data collection and analysis of consecutive 28 eyes of 23 diabetic patients received ILUVIEN implant for refractory DMO. Standard assessment included visual acuity (VA), central retinal thickness (CRT), slit-lamp biomicroscopy, and Goldmann tonometry for intraocular pressure (IOP) at 1, 6, and 12 months. Results Baseline mean VA was 47 (SD 18) letters improved to 55 (SD 17) letters (P=0.004) at 12 months. VA was improved in 16 eyes (57%), stabilised in 9 eyes (32%), and decreased in 3 eyes (11%). Seven eyes (25%) gained ≥15 letters, and 10 eyes (36%) gained >10 letters from baseline. The percentage of eyes achieved driving vision (≥70 Early Treatment Diabetic Retinopathy Study letters) was doubled from baseline 18 to 36% at 6 months and 32% at 12 months. Mean CRT decreased by 198 μm from baseline 494 μm (SD 191) to 296 μm (SD 121) at 12 months (P<0.001). Two eyes received additional anti-vascular endothelial growth factor injections after 10 months. Complications: Raised IOP in three eyes (11%) controlled with IOP-lowering drops, vitreous haemorrhage in one eye and one endophthalmitis (1 year vision improved to 6/24). Conclusion Our real-world results show that the visual and the anatomical improvements achieved by a single ILUVIEN implant injection were maintained up to 12 months with minimal adjunctive therapy. IOP monitoring remains essential in ILUVIEN patients, although our study shows a relatively low risk of IOP elevation post ILUVIEN injection, even in existing controlled ocular hypertension. Our results demonstrate that ILUVIEN is an effective long-term option in treating chronic refractory DMO.
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Affiliation(s)
- Rasha Barham
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
| | - Hala El Rami
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
| | - Jennifer K. Sun
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Paolo S. Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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Das T, Aurora A, Chhablani J, Giridhar A, Kumar A, Raman R, Nagpal M, Narayanan R, Natarajan S, Ramasamay K, Tyagi M, Verma L. Evidence-based review of diabetic macular edema management: Consensus statement on Indian treatment guidelines. Indian J Ophthalmol 2016; 64:14-25. [PMID: 26953019 PMCID: PMC4821115 DOI: 10.4103/0301-4738.178142] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The purpose of the study was to review the current evidence and design a diabetic macular edema (DME) management guideline specific for India. The published DME guidelines from different organizations and publications were weighed against the practice trends in India. This included the recently approved drugs. DME management consisted of control of diabetes and other associated systemic conditions, such as hypertension and hyperlipidemia, and specific therapy to reduce macular edema. Quantification of macular edema is precisely made with the optical coherence tomography and treatment options include retinal laser, intravitreal anti-vascular endothelial growth factors (VEGF), and implantable dexamethasone. Specific use of these modalities depends on the presenting vision and extent of macular involvement. Invariable eyes with center-involving macular edema benefit from intravitreal anti-VEGF or dexamethasone implant therapy, and eyes with macular edema not involving the macula center benefit from retinal laser. The results are illustrated with adequate case studies and frequently asked questions. This guideline prepared on the current published evidence is meant as a guideline for the treating physicians.
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Gabriele Schorr S, Hammes HP, Alfons Müller U, Abholz HH, Landgraf R, Bertram B. The Prevention and Treatment of Retinal Complications in Diabetes. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 113:816-823. [PMID: 28073426 PMCID: PMC5241793 DOI: 10.3238/arztebl.2016.0816] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 07/25/2016] [Accepted: 09/05/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Microvascular complications of diabetes mellitus can cause retino pathy and maculopathy, which can irreversibly damage vision and lead to blindness. The prevalence of retinopathy is 9-16% in patients with type 2 diabetes and 24-27% in patients with type 1 diabetes. 0.2-0.5% of diabetics are blind. METHODS The National Disease Management Guideline on the prevention and treatment of retinal complications in diabetes was updated according to recommendations developed by seven scientific medical societies and organizations and by patient representatives and then approved in a formal consensus process. These recommendations are based on international guidelines and systematic reviews of the literature. RESULTS Regular ophthalmological examinations enable the detection of retinopathy in early, better treatable stages. The control intervals should be based on the individual risk profile: 2 years for low-risk patients and 1 year for others, or even shorter depending on the severity of retinopathy. General risk factors for retinopathy include the duration of diabetes, the degree of hyperglycemia, hypertension, and diabetic nephropathy. The general, individually adapted treatment strategies are aimed at improving the risk profile. The most important specifically ophthalmological treatment recommendations are for panretinal laser coagulation in proliferative diabetic retinopathy and, in case of clinically significant diabetic macular edema with foveal involvement, for the intravitreal application of medications (mainly, vascular endothelial growth factor [VEGF] inhibitors), if an improvement of vision with this treatment is thought to be possible. CONCLUSION Regular, risk-adapted ophthalmological examinations, with standardized documentation of the findings for communication between ophthalmologists and the patients' treating primary care physicians/diabetologists, is essential for the prevention of diabetic retinal complications, and for their optimal treatment if they are already present.
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Patrao NV, Antao S, Egan C, Omar A, Hamilton R, Hykin PG, Sivaprasad S, Rajendram R. Real-World Outcomes of Ranibizumab Treatment for Diabetic Macular Edema in a United Kingdom National Health Service Setting. Am J Ophthalmol 2016; 172:51-57. [PMID: 27637784 DOI: 10.1016/j.ajo.2016.09.002] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 09/01/2016] [Accepted: 09/04/2016] [Indexed: 11/27/2022]
Abstract
PURPOSE To determine visual acuity (VA) and spectral-domain optical coherence tomography (OCT) outcomes with intravitreal ranibizumab for diabetic macular edema (DME) in a United Kingdom National Health Service clinical setting. DESIGN Retrospective interventional case series. PARTICIPANTS Consecutive patients with DME, treated with the first ranibizumab injection between August 2013 and March 2014 across 4 sites of Moorfields Eye Hospital, London. METHODS Two hundred eyes of 164 consecutive patients with center-involving DME and VA ≤79 ETDRS letters, central subfield macular thickness (CST) ≥350 μm on Topcon 3D OCT 2000, initiated on a loading phase of 3 intravitreal ranibizumab injections and who had at least 6 months follow-up were reviewed. Subsequent retreatment was guided by VA and OCT with the aim of treating to stability. VA, OCT CST, and macular volume (MV) were recorded at baseline and monthly to 12 months. RESULTS The mean VA, mean CST, and mean MV at baseline were 54.4 (± 15.26) letters, 490.16 (± 116.54) μm, and 10.46 (± 2.28) mm3. The mean VA change at 12 months was +6.6 (± 13.35) letters (P = .0003). A total of 40.3% of patients (n = 77) gained ≥10 letters and 25.1% (n = 48) gained ≥15 letters; 8.9% (n = 17) lost ≥10 letters and 6.3% (n = 12) lost ≥15 letters. At 12 months, the mean change in CST and MV were -133.9 (± 160.12) μm (P = .0001) and -1.5 (± 1.96) mm3 (P = .0001), respectively. An average of 7.2 (± 2.3) injections were given over 12 months. CONCLUSIONS Outcomes with 3 loading injections of 0.5 mg ranibizumab given monthly followed by pro re nata retreatment in a clinical setting are comparable with outcomes from clinical trials.
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Alvi R, Memon MS, Shera S, Mumtaz SN, Shaikh SA, Fahim MF. Visual outcome of laser treatment in diabetic macular edema: Study from an Urban Diabetes Care Center. Pak J Med Sci 2016; 32:1229-1233. [PMID: 27882027 PMCID: PMC5103139 DOI: 10.12669/pjms.325.10597] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the visual outcome of laser treatment in clinically significant macular edema. METHODS This interventional and qausi experimental study was carried out at Diabetic Association of Pakistan (DAP) during January 2011 and December 2012. Approval was taken from Research Ethical Committee of Isra Postgraduate Institute of Ophthalmology. Records of 925 eyes of 464 patients with "Clinical Significant macular edema" (CSME), treated with laser photocoagulation were analyzed. Best-corrected visual acuity (BCVA) at the time of presentation and at the last follow up, minimum of one year and maximum of 45 months was recorded and compared. SPSS version 20.0 was used to analyze the data. RESULTS Diabetic retinopathy was found in 20.3% (1777) of 8742 diabetic attending DAP Hospital" amongst whom 39.6% (705) had Sight threatening diabetic retinopathy. Laser was advised in 96.4% (680) individuals, accepted by 70.5% (480) individuals. Amongst 960 eyes of 480 patients who accepted laser, 925 eyes had clinically significant macular edema and 35 eyes had PDR who are not included in this study. Amongst 925 eyes with CSME, Grid laser was done in 913 eyes (99%) and focal laser was done in 12 eyes (1%). After a follow up of 12 to 45 months, it was found that best corrected visual acuity had declined in 2.4% (22) eyes, stabilized in 67% (619) eyes and improved in 30.7% (284) eyes. One line improvement on Snellen's chart was fond in 21.3% (197) eyes, 2 lines in 8% (74) eyes, 3 lines in 1.2% (12) eyes and 4 lines in one (0.1%) eye with p-value of 0.000. CONCLUSION Laser therapy is an effective treatment in stabilizing/improving the vision in diabetic macular edema particularly at those centers where only Argon Laser is available and OCF, FFA facilities do not exist.
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Affiliation(s)
- Rashid Alvi
- Rashid Alvi, Department of Ophthalmology, Diabetic Association of Pakistan (DAP), WHO Collaborating Center, Karachi, Pakistan
| | - Muhammad Saleh Memon
- Muhammad Saleh Memon, Isra Ophthalmic Research & Development Center, Al-Ibrahim Eye Hospital, Isra postgraduate Institute of Ophthalmology, Karachi, Pakistan
| | - Samad Shera
- Samad Shera, Department of Ophthalmology, Diabetic Association of Pakistan (DAP), WHO Collaborating Center, Karachi, Pakistan
| | - Seema N Mumtaz
- Seema N. Mumtaz, Isra Ophthalmic Research & Development Center, Al-Ibrahim Eye Hospital, Isra postgraduate Institute of Ophthalmology, Karachi, Pakistan
| | - Sikander Ali Shaikh
- Sikander Ali Shaikh, Isra Ophthalmic Research & Development Center, Al-Ibrahim Eye Hospital, Isra postgraduate Institute of Ophthalmology, Karachi, Pakistan
| | - Muhammad Faisal Fahim
- Muhammad Faisal Fahim, Isra Ophthalmic Research & Development Center, Al-Ibrahim Eye Hospital, Isra postgraduate Institute of Ophthalmology, Karachi, Pakistan
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Adjunct Intravitreous Triamcinolone Acetonide in the Treatment of Diabetic Macular Edema with Anti-VEGF Agents. J Ophthalmol 2016; 2016:5282470. [PMID: 27980863 PMCID: PMC5131249 DOI: 10.1155/2016/5282470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 10/10/2016] [Accepted: 10/30/2016] [Indexed: 12/18/2022] Open
Abstract
Aims. To compare visual and anatomic outcomes of adjunct intravitreous (IVT) triamcinolone acetonide to antivascular endothelial growth factor (VEGF) injections to IVT anti-VEGF injections alone for center-involving diabetic macular edema (DME) in treatment-naïve eyes. Methods. Retrospective study of treatment-naïve eyes with center-involving DME. The primary outcome was the change in best corrected visual acuity (BCVA) in eyes receiving only IVT anti-VEGF (group 1) and eyes receiving IVT anti-VEGF and adjunct IVT-TA (group 2). Results. Included were 192 eyes. The mean change in BCVA was +3.5 letters in group 1 compared to −3.5 letters in group 2 (p = 0.048). Final macular thickness improved by −94 μm in group 1 versus −68 μm in group 2 (p = 0.26). In group 1, 5/150 eyes compared to 9/42 eyes in group 2 (3.3% versus 21%, p = 0.0005) had a IOP >10 mmHg increase. Six of 126 phakic eyes in group 1 versus 12/33 phakic eyes in group 2 underwent cataract surgery (4.7% versus 36.3%, p = 0.00009). Conclusions. IVT-TA results in no additional benefit in eyes treated with anti-VEGF agents for DME.
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Effect of leaking perifoveal microaneurysms on resolution of diabetic macular edema treated by combination therapy using anti-vascular endothelial growth factor and short pulse focal/grid laser photocoagulation. Jpn J Ophthalmol 2016; 61:51-60. [PMID: 27730425 DOI: 10.1007/s10384-016-0483-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 08/30/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE The effect of combination therapy using intravitreal ranibizumab (IVR) injections and short pulse focal/grid laser photocoagulation was evaluated for the treatment of diabetic macular edema (DME). METHODS The current investigation was a preliminary single-arm, open-label, prospective clinical study conducted on 21 eyes at 4 sites in Japan. Treatment protocol consisted of two phases. The induction IVR phase included two monthly IVRs followed by PRN IVR phase in which additional IVR was administered if the central macular thickness (CMT) exceeded 300 μm. One week after each IVR in both phases, short pulse focal/grid laser was delivered to treat residual leakage outside of the fovea (>500 μm) and reduce edema fluid influx. At the 6-month endpoint, the effects of treatment were examined in terms of best corrected visual acuity (BCVA), CMT, and required number of IVR injections in eyes with or without perifoveal leaking microaneurysms (MAs). RESULTS In eyes with initial BCVA ≤70 letters, mean BCVA was significantly ameliorated by 7.0 ± 7.4 letters (P = 0.0324) and mean CMT improved significantly by 174.8 ± 105.0 µm (P = 0.0005). Both BCVA improvement (P = 0.8693) and CMT reduction (P = 0.9336) were comparable between MA(-) and MA(+) groups. The MA(-) group required significantly fewer PRN-IVR injections than did the MA(+) group over the 6-month study period (mean 3.4 ± 1.6 vs. 5.3 ± 0.9, median 3.0 vs. 5.5; P = 0.0229). CONCLUSIONS Short pulse focal/grid laser photocoagulation could reduce the number of IVR injections required to resolve macular edema and increase BCVA in a possible mechanism of reduced influx of edema fluid into the foveal area in eyes without apparent perifoveal microaneurysms.
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Abstract
Diabetic retinopathy, a common and sight-threatening microvascular complication of diabetes mellitus, is a leading cause of blindness among working-aged adults. Medical therapies including intensive control of hyperglycemia and hypertension have been shown to reduce the incidence and progression of diabetic retinopathy. The association of dyslipidemia and treatment with statins with diabetic retinopathy is inconsistent in epidemiologic studies. However, two recent randomized clinical trials have demonstrated beneficial effects of systemic fenofibrate therapy in reducing the progression of diabetic retinopathy independently of serum lipid levels. These findings suggest that fenofibrate may be an effective strategy for reducing the progression of diabetic retinopathy, thus reducing the large and growing public health burden of treating the sight-threatening complications of diabetic retinopathy.
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Affiliation(s)
- Jared E. Knickelbein
- National Eye Institute, National Institutes of Health, 10 Center Dr, 10/10D45, Bethesda, MD 20892, USA
| | - Akshar B. Abbott
- National Eye Institute, National Institutes of Health, 10 Center Dr, 10/10D45, Bethesda, MD 20892, USA
| | - Emily Y. Chew
- National Eye Institute, National Institutes of Health, 10 Center Dr, 10/10D45, Bethesda, MD 20892, USA
- Division of Epidemiology and Clinical Applications, Clinical Trials Branch, National Eye Institute/National Institutes of Health, Bldg 10—Clinical Research Center, Room 3-2531, 10 Center Dr, Mailstop Code 1204, Bethesda, MD 20892, USA
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Rajavi Z, Safi S, Javadi MA, Azarmina M, Moradian S, Entezari M, Nourinia R, Ahmadieh H, Shirvani A, Shahraz S, Ramezani A, Dehghan MH, Shahsavari M, Soheilian M, Nikkhah H, Ziaei H, Behboudi H, Farrahi F, Falavarjani KG, Parvaresh MM, Fesharaki H, Abrishami M, Shoeibi N, Rahimi M, Javadzadeh A, Karkhaneh R, Riazi-Esfahani M, Manaviat MR, Maleki A, Kheiri B, Golbafian F. Diabetic Retinopathy Clinical Practice Guidelines: Customized for Iranian Population. J Ophthalmic Vis Res 2016; 11:394-414. [PMID: 27994809 PMCID: PMC5139552 DOI: 10.4103/2008-322x.194131] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 09/24/2016] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To customize clinical practice guidelines (CPGs) for management of diabetic retinopathy (DR) in the Iranian population. METHODS Three DR CPGs (The Royal College of Ophthalmologists 2013, American Academy of Ophthalmology [Preferred Practice Pattern 2012], and Australian Diabetes Society 2008) were selected from the literature using the AGREE tool. Clinical questions were designed and summarized into four tables by the customization team. The components of the clinical questions along with pertinent recommendations extracted from the above-mentioned CPGs; details of the supporting articles and their levels of evidence; clinical recommendations considering clinical benefits, cost and side effects; and revised recommendations based on customization capability (applicability, acceptability, external validity) were recorded in 4 tables, respectively. Customized recommendations were sent to the faculty members of all universities across the country to score the recommendations from 1 to 9. RESULTS Agreed recommendations were accepted as the final recommendations while the non-agreed ones were approved after revision. Eventually, 29 customized recommendations under three major categories consisting of screening, diagnosis and treatment of DR were developed along with their sources and levels of evidence. CONCLUSION This customized CPGs for management of DR can be used to standardize the referral pathway, diagnosis and treatment of patients with diabetic retinopathy.
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Affiliation(s)
- Zhale Rajavi
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sare Safi
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Javadi
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Azarmina
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Siamak Moradian
- Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Morteza Entezari
- Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ramin Nourinia
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Ahmadieh
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Armin Shirvani
- Standardization and CPG Development Office, Deputy of Curative Affairs, Ministry of Health and Medical Education, Tehran, Iran
| | | | - Alireza Ramezani
- Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Ophthalmology, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Hossein Dehghan
- Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Shahsavari
- Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoud Soheilian
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Homayoun Nikkhah
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Ophthalmology, Torfeh Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hossein Ziaei
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hasan Behboudi
- Department of Ophthalmology, Gilan University of Medical Sciences, Rasht, Iran
| | - Fereydoun Farrahi
- Department of Ophthalmology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | | | - Mohammad Mehdi Parvaresh
- Department of Ophthalmology, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid Fesharaki
- Department of Ophthalmology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Majid Abrishami
- Department of Ophthalmology, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Nasser Shoeibi
- Department of Ophthalmology, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mansour Rahimi
- Department of Ophthalmology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Javadzadeh
- Department of Ophthalmology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reza Karkhaneh
- Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Riazi-Esfahani
- Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Alireza Maleki
- Department of Ophthalmology, Al Zahra Eye Center, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Bahareh Kheiri
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Recent advancements in diabetic retinopathy treatment from the Diabetic Retinopathy Clinical Research Network. Curr Opin Ophthalmol 2016; 27:210-6. [PMID: 26913740 DOI: 10.1097/icu.0000000000000262] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Diabetic retinopathy and diabetic macular edema (DME) are common eye diseases leading to vision loss. The Diabetic Retinopathy Clinical Research Network (DRCRnet), a collaboration of private and academic practices supported by the National Eye Institute and the National Institute of Diabetes, Digestive and Kidney Diseases has studied diabetic eye disease for 13 years. This review will discuss the network's findings over the last year, when some of its most important contributions were reported. RECENT FINDINGS The DRCRnet reported intravitreal bevacizumab, ranibizumab and aflibercept all improve visual acuity in DME. With baseline vision of 20/30 to 20/40, all agents had similar efficacy. With baseline vision of 20/50 or worse, aflibercept resulted in superior visual improvement. Protocol S, which compared panretinal photocoagulation with intravitreal injections of ranibizumab for proliferative diabetic retinopathy (PDR), found vision outcomes and surgery rates were not inferior in the injection group. Secondary outcomes indicate improved functional results with ranibizumab supporting injections as a possible alternative treatment for PDR. SUMMARY The DRCRnet has helped clarify the role of various treatments for both DME and PDR, and will continue to evaluate treatments for these vision-threatening conditions.
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Schwartz SG, Scott IU, Stewart MW, Flynn HW. Update on corticosteroids for diabetic macular edema. Clin Ophthalmol 2016; 10:1723-30. [PMID: 27660409 PMCID: PMC5019446 DOI: 10.2147/opth.s115546] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Diabetic macular edema (DME) remains an important cause of visual loss. Although anti-vascular endothelial growth factor (VEGF) agents are generally used as first-line treatments for patients with center-involving DME, there is an important role for corticosteroids as well. Corticosteroids may be especially useful in pseudophakic patients poorly responsive to anti-VEGF therapies, in patients wishing to reduce the number of required injections, and in pregnant patients. Intravitreal triamcinolone acetonide has been used for many years but is not approved for this indication. An extended-release bioerodable dexamethasone delivery system and an extended-release nonbioerodable fluocinolone acetonide insert have both achieved regulatory approval for the treatment of DME. All intravitreal corticosteroids are associated with risks of cataract progression, elevation of intraocular pressure, and endophthalmitis. There is no current consensus regarding the use of corticosteroids, but they are valuable for selected patients with center-involving DME.
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Affiliation(s)
- Stephen G Schwartz
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
| | - Ingrid U Scott
- Department of Ophthalmology; Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Michael W Stewart
- Department of Ophthalmology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Harry W Flynn
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL
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Taylor SC, Rajagopal R. Modern Strategies to Save Sight in Diabetes. MISSOURI MEDICINE 2016; 113:372-377. [PMID: 30228503 PMCID: PMC6139830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Owing to the global epidemic of obesity, the incidence of diabetes and its complications are rapidly increasing around the world. Yet, visual impairment caused by diabetic retinopathy is paradoxically on the decline. This improvement is due to better understanding of etiologic mechanisms, increased screening, and advent of newer therapies. Here, we discuss salient developments in the comprehension of the root causes of diabetic retinopathy and the molecular mechanisms underlying current treatment approaches.
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Affiliation(s)
- Stanford C Taylor
- Stanford C. Taylor, MD, is a Resident in Ophthalmology, Department of Ophthalmology and Visual Sciences Washington University School of Medicine, St. Louis
| | - Rithwick Rajagopal
- Rithwick Rajagopal, MD, PhD, MSMA member since 2014, is an Assistant Professor, Department of Ophthalmology and Visual Sciences Washington University School of Medicine, St. Louis
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Jansen ME, Hariprasad SM, Singer MA. Treatments for Diabetic Macular Edema: Past, Present, and Future. Ophthalmic Surg Lasers Imaging Retina 2016; 47:794-800. [DOI: 10.3928/23258160-20160901-01] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Demirel S, Argo C, Agarwal A, Parriott J, Sepah YJ, Do DV, Nguyen QD. Updates on the Clinical Trials in Diabetic Macular Edema. Middle East Afr J Ophthalmol 2016; 23:3-12. [PMID: 26957834 PMCID: PMC4759901 DOI: 10.4103/0974-9233.172293] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
In this era of evidence-based medicine, significant progress has been made in the field of pharmacotherapeutics for the management of diabetic macular edema (DME). A. number of landmark clinical trials have provided strong evidence of the safety and efficacy of agents such as anti-vascular endothelial growth factors for the treatment of DME. Decades of clinical research, ranging from the early treatment of diabetic retinopathy study to the present-day randomized clinical trials (RCTs) testing novel agents, have shifted the goal of therapy from preventing vision loss to ensuring a maximum visual gain. Systematic study designs have provided robust data with an attempt to optimize the treatment regimens including the choice of the agent and timing of therapy. However, due to a number of challenges in the management of DME with approved agents, further studies are needed. For the purpose of this review, an extensive database search in English language was performed to identify prospective, RCTs testing pharmacological agents for DME. In order to acquaint the reader with the most relevant data from these clinical trials, this review focuses on pharmacological agents that are currently approved or have widespread applications in the management of DME. An update on clinical trials presently underway for DME has also been provided.
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Affiliation(s)
- Sibel Demirel
- Department of Ophthalmology, Faculty of Medicine, Ankara University, Ankara, Turkey; University of Nebraska Medical Center, Stanley M. Truhlsen Eye Institute, Omaha, Nebraska, USA
| | - Colby Argo
- University of Nebraska Medical Center, Stanley M. Truhlsen Eye Institute, Omaha, Nebraska, USA; College of Medicine, University of Nebraska, Omaha, Nebraska, USA
| | - Aniruddha Agarwal
- University of Nebraska Medical Center, Stanley M. Truhlsen Eye Institute, Omaha, Nebraska, USA
| | - Jacob Parriott
- University of Nebraska Medical Center, Stanley M. Truhlsen Eye Institute, Omaha, Nebraska, USA; College of Medicine, University of Nebraska, Omaha, Nebraska, USA
| | - Yasir Jamal Sepah
- University of Nebraska Medical Center, Stanley M. Truhlsen Eye Institute, Omaha, Nebraska, USA
| | - Diana V Do
- University of Nebraska Medical Center, Stanley M. Truhlsen Eye Institute, Omaha, Nebraska, USA
| | - Quan Dong Nguyen
- University of Nebraska Medical Center, Stanley M. Truhlsen Eye Institute, Omaha, Nebraska, USA
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Guillard M, Dupas B, El Sanharawi M, Erginay A, Tadayoni R, Massin P. Symmetry in early response to intravitreal ranibizumab in bilateral diabetic macular oedema. Acta Ophthalmol 2016; 94:e356-60. [PMID: 26564668 DOI: 10.1111/aos.12905] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 09/23/2015] [Indexed: 01/15/2023]
Abstract
PURPOSE To study the symmetry in response to bilateral diabetic macular oedema (DME) treated with bilateral intravitreal injections of ranibizumab (IVR). METHODS The charts of 36 eyes of 18 patients treated with a loading dose of three monthly IVR in both eyes were retrospectively reviewed. Favourable anatomical response was defined as a decrease by more than 10% in baseline central macular thickness (CMT), and favourable functional response was defined as an increase in visual acuity (VA) ≥5 letters. A symmetric response was defined as a similar anatomical and/or functional response in the first (FE) and second (SE) treated eyes. RESULTS The VA improved significantly after ranibizumab treatment in both eyes (p < 0.01). A statistically significant positive correlation was found for the functional response to ranibizumab between the FE and the SE (R(2) = 0.26, p = 0.03). The mean CMT decreased significantly in both eyes (p < 0.01). A strong positive correlation was observed between the anatomical response to ranibizumab in the FE and the SE (R(2) = 0.37, p = 0.01). Symmetric favourable anatomical and functional responses were observed in 13 patients (72%). In two additional patients, an asymmetric functional response was observed despite a decrease in retinal thickness in both eyes. CONCLUSION Symmetric anatomical and functional responses were observed in 72% of patients with DME after three initial IVR in each eye. This finding could be of clinical interest in the decision to treat the fellow eye, in a disease where a bilateral involvement is frequent.
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Affiliation(s)
- Margaux Guillard
- AP-HP; Lariboisiere Hospital; Department of Ophthalmology; Paris-Diderot University; Sorbonne Paris Cité Paris France
| | - Bénédicte Dupas
- AP-HP; Lariboisiere Hospital; Department of Ophthalmology; Paris-Diderot University; Sorbonne Paris Cité Paris France
| | - Mohamed El Sanharawi
- AP-HP; Lariboisiere Hospital; Department of Ophthalmology; Paris-Diderot University; Sorbonne Paris Cité Paris France
| | - Ali Erginay
- AP-HP; Lariboisiere Hospital; Department of Ophthalmology; Paris-Diderot University; Sorbonne Paris Cité Paris France
| | - Ramin Tadayoni
- AP-HP; Lariboisiere Hospital; Department of Ophthalmology; Paris-Diderot University; Sorbonne Paris Cité Paris France
| | - Pascale Massin
- AP-HP; Lariboisiere Hospital; Department of Ophthalmology; Paris-Diderot University; Sorbonne Paris Cité Paris France
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Singer MA, Kermany DS, Waters J, Jansen ME, Tyler L. Diabetic macular edema: it is more than just VEGF. F1000Res 2016; 5. [PMID: 27303642 PMCID: PMC4890310 DOI: 10.12688/f1000research.8265.1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2016] [Indexed: 01/18/2023] Open
Abstract
Diabetic macular edema is a serious visual complication of diabetic retinopathy. This article reviews the history of previous and current therapies, including laser therapy, anti-vascular endothelial growth factor agents, and corticosteroids, that have been used to treat this condition. In addition, it proposes new ways to use them in combination in order to decrease treatment burden and potentially address other causes besides vascular endothelial growth factor for diabetic macular edema.
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Affiliation(s)
| | | | - Jana Waters
- University of Texas Health Science Center, Austin, TX, USA
| | | | - Lyndon Tyler
- University of Texas Health Science Center, Austin, TX, USA
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Abstract
PURPOSE To describe the optical coherence tomography angiography features of diabetic retinopathy. METHODS Using a 70 kHz optical coherence tomography and the split-spectrum amplitude decorrelation angiography algorithm, 6 mm × 6 mm 3-dimensional angiograms of the macula of 4 patients with diabetic retinopathy were obtained and compared with fluorescein angiography for features cataloged by the Early Treatment of Diabetic Retinopathy Study. RESULTS Optical coherence tomography angiography detected enlargement and distortion of the foveal avascular zone, retinal capillary dropout, and pruning of arteriolar branches. Areas of capillary loss obscured by fluorescein leakage on fluorescein angiography were more clearly defined on optical coherence tomography angiography. Some areas of focal leakage on fluorescein angiography that were thought to be microaneurysms were found to be small tufts of neovascularization that extended above the inner limiting membrane. CONCLUSION Optical coherence tomography angiography does not show leakage but can better delineate areas of capillary dropout and detect early retinal neovascularization. This new noninvasive angiography technology may be useful for routine surveillance of proliferative and ischemic changes in diabetic retinopathy.
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Stringham JD, Flynn HW, Schimel AM, Banta JT. Dropless Cataract Surgery: What Are the Potential Downsides? Am J Ophthalmol 2016; 164:viii-x. [PMID: 26895602 DOI: 10.1016/j.ajo.2016.02.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 01/23/2016] [Accepted: 02/01/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Jack D Stringham
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Harry W Flynn
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida.
| | | | - James T Banta
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
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131
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Au A, Singh RP. A multimodal approach to diabetic macular edema. J Diabetes Complications 2016; 30:545-53. [PMID: 26853628 DOI: 10.1016/j.jdiacomp.2015.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 11/07/2015] [Accepted: 11/09/2015] [Indexed: 12/27/2022]
Abstract
Diabetic retinopathy is a common complication of uncontrolled diabetes. A complication is diabetic macular edema, which is the leading cause of blindness in patients with diabetic retinopathy. Historically, management of these conditions was laser photocoagulation with regulation of blood pressure, blood sugar, and cholesterol. The initial studies demonstrated that this treatment regimen prevented further visual deterioration but did not improve visual acuity. Novel studies identifying the presence of vascular endothelial growth factor (VEGF) in the eye with accompanying elucidation of diabetic pathophysiology allowed for the development of alternative therapies, namely antibodies against VEGF and corticosteroids. These two therapies revolutionized the management of diabetic macular edema by not only preventing vision loss, but also improving overall vision. In this review, we outline the major breakthroughs and underlying thought processes of the paradigm shifts that have occurred in management of these conditions. Further, we present how the evolving role of anti-inflammatory and anti-VEGF therapies, in a combinatorial approach, may provide further permutations to optimize treatment.
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Affiliation(s)
- Adrian Au
- Case Western Reserve School of Medicine, 2109 Adelbert Rd. Cleveland, OH 44106
| | - Rishi P Singh
- Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44106.
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132
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Lim LL, Morrison JL, Constantinou M, Rogers S, Sandhu SS, Wickremasinghe SS, Kawasaki R, Al-Qureshi S. Diabetic Macular Edema at the time of Cataract Surgery trial: a prospective, randomized clinical trial of intravitreous bevacizumab versus triamcinolone in patients with diabetic macular oedema at the time of cataract surgery - preliminary 6 month results. Clin Exp Ophthalmol 2016; 44:233-42. [DOI: 10.1111/ceo.12720] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 01/11/2016] [Accepted: 01/16/2016] [Indexed: 01/28/2023]
Affiliation(s)
- Lyndell L Lim
- Centre for Eye Research Australia; Royal Victorian Eye and Ear Hospital; Ophthalmology, University of Melbourne, Department of Surgery; Melbourne Victoria Australia
- Medical Retina Clinic; Royal Victorian Eye and Ear Hospital; Melbourne Victoria Australia
| | - Julie L Morrison
- Centre for Eye Research Australia; Royal Victorian Eye and Ear Hospital; Ophthalmology, University of Melbourne, Department of Surgery; Melbourne Victoria Australia
| | - Marios Constantinou
- Centre for Eye Research Australia; Royal Victorian Eye and Ear Hospital; Ophthalmology, University of Melbourne, Department of Surgery; Melbourne Victoria Australia
| | - Sophie Rogers
- Centre for Eye Research Australia; Royal Victorian Eye and Ear Hospital; Ophthalmology, University of Melbourne, Department of Surgery; Melbourne Victoria Australia
| | - Sukhpal S Sandhu
- Centre for Eye Research Australia; Royal Victorian Eye and Ear Hospital; Ophthalmology, University of Melbourne, Department of Surgery; Melbourne Victoria Australia
- Medical Retina Clinic; Royal Victorian Eye and Ear Hospital; Melbourne Victoria Australia
| | - Sanjeewa S Wickremasinghe
- Centre for Eye Research Australia; Royal Victorian Eye and Ear Hospital; Ophthalmology, University of Melbourne, Department of Surgery; Melbourne Victoria Australia
- Medical Retina Clinic; Royal Victorian Eye and Ear Hospital; Melbourne Victoria Australia
| | - Ryo Kawasaki
- Yamagata University Faculty of Medicine; Yamagata Japan
| | - Salmaan Al-Qureshi
- Centre for Eye Research Australia; Royal Victorian Eye and Ear Hospital; Ophthalmology, University of Melbourne, Department of Surgery; Melbourne Victoria Australia
- Medical Retina Clinic; Royal Victorian Eye and Ear Hospital; Melbourne Victoria Australia
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133
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Trinh HM, Joseph M, Cholkar K, Pal D, Mitra AK. Novel strategies for the treatment of diabetic macular edema. World J Pharmacol 2016; 5:1-14. [DOI: 10.5497/wjp.v5.i1.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 12/19/2015] [Accepted: 01/07/2016] [Indexed: 02/06/2023] Open
Abstract
Macular edema such as diabetic macular edema (DME) and diabetic retinopathy are devastating back-of-the-eye retinal diseases leading to loss of vision. This area is receiving considerable medical attention. Posterior ocular diseases are challenging to treat due to complex ocular physiology and barrier properties. Major ocular barriers are static (corneal epithelium, corneal stroma, and blood-aqueous barrier) and dynamic barriers (blood-retinal barrier, conjunctival blood flow, lymph flow, and tear drainage). Moreover, metabolic barriers impede posterior ocular drug delivery and treatment. To overcome such barriers and treat back-of-the-eye diseases, several strategies have been recently developed which include vitreal drainage, laser photocoagulation and treatment with biologics and/or small molecule drugs. In this article, we have provided an overview of several emerging novel strategies including nanotechnology based drug delivery approach for posterior ocular drug delivery and treatment with an emphasis on DME.
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134
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Lim LT, Chia SN, Ah-Kee EY, Chew N, Gupta M. Advances in the management of diabetic macular oedema based on evidence from the Diabetic Retinopathy Clinical Research Network. Singapore Med J 2016; 56:237-47. [PMID: 26034315 DOI: 10.11622/smedj.2015071] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The Diabetic Retinopathy Clinical Research Network (DRCR.net) performs studies on new treatments for diabetic retinopathy. This review aims to summarise recent findings from DRCR.net studies on the treatment of diabetic macular oedema. We performed a PubMed search of articles from the DRCR.net, which included all studies pertaining to the treatment of diabetic maculopathy. The main outcome measures were retinal thickening as assessed by central subfield thickness on optical coherence tomography and improvement of visual acuity on the Early Treatment Diabetic Retinopathy Study (ETDRS) chart. Findings from each study were divided into modalities of treatment, namely photocoagulation, bevacizumab, triamcinolone, ranibizumab and vitrectomy. While modified ETDRS focal/grid laser remains the standard of care, intravitreal corticosteroids or anti-vascular endothelial growth factor agents have also proven to be effective, although they come with associated side effects. The choice of treatment modality for diabetic macular oedema is a clinical judgement call, and depends on the patient's clinical history and assessment.
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Affiliation(s)
- Lik Thai Lim
- Tennent Institute of Ophthalmology, Gartnavel General Hospital, Glasgow, Scotland, United Kingdom
| | - Seen Nee Chia
- Tennent Institute of Ophthalmology, Gartnavel General Hospital, Glasgow, Scotland, United Kingdom
| | | | - Nejia Chew
- Eye Department, Royal Victoria Infirmary, Newcastle upon Tyne, Tyne and Wear, England, United Kingdom
| | - Manish Gupta
- Tennent Institute of Ophthalmology, Gartnavel General Hospital, Glasgow, Scotland, United Kingdom
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135
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Kim MW, Moon H, Yang SJ, Joe SG. Effect of Posterior Subtenon Triamcinolone Acetonide Injection on Diabetic Macular Edema Refractory to Intravitreal Bevacizumab Injection. KOREAN JOURNAL OF OPHTHALMOLOGY 2016; 30:25-31. [PMID: 26865800 PMCID: PMC4742642 DOI: 10.3341/kjo.2016.30.1.25] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 10/27/2015] [Indexed: 12/26/2022] Open
Abstract
Purpose To evaluate the effects of posterior subtenon triamcinolone acetonide injection on refractory diabetic macular edema (DME) after intravitreal bevacizumab (IVB) injection failure. Methods Patients with DME and central subfield thickness (CST) >300 µm who did not respond to IVB injections were retrospectively included. Specifically, we enrolled patients who were diagnosed with refractory DME and who experienced an increase in CST after 1 to 2 IVB injections or no decrease after ≥3 consecutive IVB injections. One clinician injected 20 mg of triamcinolone acetonide into the posterior subtenon space. All patients received ophthalmic examinations at baseline and at 2, 4, and 6 months post-baseline. Examinations included Snellen visual acuity, intraocular pressure, and spectral-domain optical coherence tomography. Results Forty eyes of 34 patients were included. The average baseline CST was 476 µm. The average CST decreased to 368 µm at 2 months, 374 µm at 4 months, and 427 µm at 6 months (p < 0.001 for all results, Wilcoxon signed-rank test). The average intraocular pressure increased from 15.50 to 16.92 mmHg at 2 months but decreased to 16.30 mmHg at 4 months and 15.65 mmHg at 6 months. Logarithm of the minimum angle of resolution visual acuity improved from 0.56 to 0.50 at 2 months (p = 0.023), 0.50 at 4 months (p = 0.083), and 0.48 at 6 months (p = 0.133, Wilcoxon signed-rank test). No complications were detected. Conclusions Posterior subtenon triamcinolone acetonide is an effective and safe treatment for reducing CST in DME refractory to IVB.
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Affiliation(s)
- Min Woo Kim
- Department of Ophthalmology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Haein Moon
- Department of Ophthalmology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Jae Yang
- Department of Ophthalmology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Soo Geun Joe
- Department of Ophthalmology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
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136
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Shikari H, Samant P. Intravitreal injections: A review of pharmacological agents and techniques. JOURNAL OF CLINICAL OPHTHALMOLOGY AND RESEARCH 2016. [DOI: 10.4103/2320-3897.174429] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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137
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Ocular dominance, coexistent retinal disease, and refractive errors in patients with cataract surgery. Curr Opin Ophthalmol 2016; 27:38-44. [DOI: 10.1097/icu.0000000000000215] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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138
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Raman R, Santhanam K, Gella L, Pal BP, Sharma T. Morphological and functional outcomes following modified early treatment diabetic retinopathy study laser in diabetic macular edema. Oman J Ophthalmol 2015; 8:92-6. [PMID: 26622135 PMCID: PMC4640048 DOI: 10.4103/0974-620x.159252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Aim: The aim was to report morphological and functional outcomes following modified early treatment diabetic retinopathy study (ETDRS) laser in diabetic macular edema (DME). Materials and Methods: Structural and functional changes using spectral domain optical coherence tomography (OCT) and microperimetry (MP) were studied before and 4 months after laser in 37 eyes with clinically significant macular edema (ME) requiring modified ETDRS laser treatment. Paired t-test was used to compare pre and postlaser outcomes P < 0.05 was considered statistically significant. Results: Central foveal thickness showed a significant reduction after laser P = 0.004. There was a significant reduction in mean retinal thickness (MRT) and retinal volume in all the quadrants of ETDRS except for the temporal and nasal quadrants in outer 6 mm ring. Maximum reduction in MRT was seen in eyes with DME having neurosensory detachment (382.66 μ to 292.61 μ). Retinal sensitivities reduced in all quadrants following laser, however, fixation patterns showed improvements. The change in VA was positively correlated to change in MRT (r = 0.468, P = 0.032). Conclusion: Laser not only causes structural benefits such as reduction of retinal thickness and volume, it also causes improvement of fixation patterns.
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Affiliation(s)
- Rajiv Raman
- Department of Shri Bhagwan Mahavir Vitreoretinal, 18, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Kiruthika Santhanam
- Department of Optometry, Elite School of Optometry, No.8, St. Thomas Mount, Chennai, Tamil Nadu, India
| | - Laxmi Gella
- Department of Optometry, Elite School of Optometry, No.8, St. Thomas Mount, Chennai, Tamil Nadu, India
| | - Bikramjit P Pal
- Department of Shri Bhagwan Mahavir Vitreoretinal, 18, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Tarun Sharma
- Department of Shri Bhagwan Mahavir Vitreoretinal, 18, Sankara Nethralaya, Chennai, Tamil Nadu, India
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139
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Yang Y, Bailey C, Loewenstein A, Massin P. INTRAVITREAL CORTICOSTEROIDS IN DIABETIC MACULAR EDEMA: PHARMACOKINETIC CONSIDERATIONS. Retina 2015; 35:2440-9. [PMID: 26352555 PMCID: PMC4697357 DOI: 10.1097/iae.0000000000000726] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE To review the relationship between kinetics, efficacy, and safety of several corticosteroid formulations for the treatment of diabetic macular edema. METHODS Reports of corticosteroid use for the treatment of diabetic macular edema were identified by a literature search, which focused on the pharmacokinetics, efficacy, and safety of these agents in preclinical animal models and clinical trials. RESULTS Available corticosteroids for diabetic macular edema treatment include intravitreal triamcinolone acetonide, dexamethasone, and fluocinolone acetonide. Because of differences in solubility and bioavailability, various delivery mechanisms are used. Bioerodible delivery systems achieve higher maximum concentrations than nonbioerodible formulations. There is a relationship between visual gains and drug persistence in the intravitreal compartment. Safety effects were more complex; level of intravitreal triamcinolone acetonide exposure is related to development of elevated intraocular pressure and cataract; this does not seem to be the case for dexamethasone, where two different doses showed similar mean intraocular pressure and incidence of cataract surgery. With fluocinolone acetonide, rates of intraocular pressure elevations requiring surgery seem to be dose related; rates of cataract extraction were similar regardless of dose. CONCLUSION Available corticosteroids for diabetic macular edema exhibit different pharmacokinetic profiles that impact efficacy and adverse events and should be taken into account when developing individualized treatment plans.
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Affiliation(s)
- Yit Yang
- Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, United Kingdom
| | - Clare Bailey
- University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Anat Loewenstein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; and
| | - Pascale Massin
- Department of Ophthalmology, Lariboisière Hospital, Paris, France
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140
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Lee R, Wong TY, Sabanayagam C. Epidemiology of diabetic retinopathy, diabetic macular edema and related vision loss. EYE AND VISION 2015. [PMID: 26605370 DOI: 10.1186/s40662-015-0026-2 10.1186/s40662-015-0026-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Diabetic retinopathy (DR) is a leading cause of vision-loss globally. Of an estimated 285 million people with diabetes mellitus worldwide, approximately one third have signs of DR and of these, a further one third of DR is vision-threatening DR, including diabetic macular edema (DME). The identification of established modifiable risk factors for DR such as hyperglycemia and hypertension has provided the basis for risk factor control in preventing onset and progression of DR. Additional research investigating novel risk factors has improved our understanding of multiple biological pathways involved in the pathogenesis of DR and DME, especially those involved in inflammation and oxidative stress. Variations in DR prevalence between populations have also sparked interest in genetic studies to identify loci associated with disease susceptibility. In this review, major trends in the prevalence, incidence, progression and regression of DR and DME are explored, and gaps in literature identified. Established and novel risk factors are also extensively reviewed with a focus on landmark studies and updates from the recent literature.
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Affiliation(s)
- Ryan Lee
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore ; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Tien Y Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore ; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore ; Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Charumathi Sabanayagam
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore ; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore ; Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore, Singapore
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141
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Lee R, Wong TY, Sabanayagam C. Epidemiology of diabetic retinopathy, diabetic macular edema and related vision loss. EYE AND VISION (LONDON, ENGLAND) 2015. [PMID: 26605370 DOI: 10.1186/s40662-015-0026-2+10.1186/s40662-015-0026-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Diabetic retinopathy (DR) is a leading cause of vision-loss globally. Of an estimated 285 million people with diabetes mellitus worldwide, approximately one third have signs of DR and of these, a further one third of DR is vision-threatening DR, including diabetic macular edema (DME). The identification of established modifiable risk factors for DR such as hyperglycemia and hypertension has provided the basis for risk factor control in preventing onset and progression of DR. Additional research investigating novel risk factors has improved our understanding of multiple biological pathways involved in the pathogenesis of DR and DME, especially those involved in inflammation and oxidative stress. Variations in DR prevalence between populations have also sparked interest in genetic studies to identify loci associated with disease susceptibility. In this review, major trends in the prevalence, incidence, progression and regression of DR and DME are explored, and gaps in literature identified. Established and novel risk factors are also extensively reviewed with a focus on landmark studies and updates from the recent literature.
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Affiliation(s)
- Ryan Lee
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore ; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Tien Y Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore ; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore ; Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Charumathi Sabanayagam
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore ; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore ; Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore, Singapore
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142
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Agarwal A, Parriott J, Demirel S, Argo C, Sepah YJ, Do DV, Nguyen QD. Nonbiological pharmacotherapies for the treatment of diabetic macular edema. Expert Opin Pharmacother 2015; 16:2625-35. [PMID: 26523670 DOI: 10.1517/14656566.2015.1100172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION During the past decade, there have been significant advances in the pharmacotherapies for the treatment of diabetic macular edema (DME). Among the presently available treatment options, anti-vascular endothelial growth factors (anti-VEGF) agents are the most favored agents due to their efficacy and safety. The index review focuses on nonbiological therapies that have entered in phase 3 clinical trials for DME. AREAS COVERED An extensive review of the literature was performed to identify various nonbiological immunotherapies i.e., drugs other than '-mAbs' (monoclonal antibodies including anti-VEGF agents), '-mibs' (proteasome inhibitors), '-NAbs' (nanoparticle albumin-bound), and '-nibs' (small molecule inhibitor/tyrosine kinase inhibitors), among others. Extended-release low-dose corticosteroid devices have been recently approved for the treatment of DME. Other compounds such as non-steroidal anti-inflammatory drugs, antibody mimetic proteins, nonbiological growth factor inhibitors, and inhibitors of protein kinase C have been described. EXPERT OPINION A number of therapies are under development for the pharmacological management of DME. Due to the rising healthcare costs associated with anti-VEGF agents, a number of alternate treatment options have been explored recently. Some of these agents have reached phase 3 in clinical trials and appear to have a promising role in the management of DME. As further research is conducted, the role of each individual agent will become more defined, alone or in combination therapy.
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Affiliation(s)
- Aniruddha Agarwal
- a Ocular Imaging Research and Reading Center (OIRRC) , Stanley M. Truhlsen Eye Institute, University of Nebraska Medical Center , Omaha , NE , USA
| | - Jacob Parriott
- b College of Medicine , University of Nebraska , Omaha , NE , USA
| | - Sibel Demirel
- a Ocular Imaging Research and Reading Center (OIRRC) , Stanley M. Truhlsen Eye Institute, University of Nebraska Medical Center , Omaha , NE , USA.,c Department of Ophthalmology , Ankara University Faculty of Medicine , Ankara , Turkey
| | - Colby Argo
- b College of Medicine , University of Nebraska , Omaha , NE , USA
| | - Yasir Jamal Sepah
- a Ocular Imaging Research and Reading Center (OIRRC) , Stanley M. Truhlsen Eye Institute, University of Nebraska Medical Center , Omaha , NE , USA
| | - Diana V Do
- a Ocular Imaging Research and Reading Center (OIRRC) , Stanley M. Truhlsen Eye Institute, University of Nebraska Medical Center , Omaha , NE , USA
| | - Quan Dong Nguyen
- a Ocular Imaging Research and Reading Center (OIRRC) , Stanley M. Truhlsen Eye Institute, University of Nebraska Medical Center , Omaha , NE , USA
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Abstract
Glucocorticoids have been used for decades in the treatment of ocular disorders via topical, periocular, and more recently intravitreal routes. However, their exact mechanisms of action on ocular tissues remain imperfectly understood. Fortunately, two recently approved intravitreal sustained-release drug delivery systems have opened new perspectives for these very potent drugs. To date, among other retinal conditions, their label includes diabetic macular edema, for which a long-lasting therapeutic effect has been demonstrated both morphologically and functionally in several randomized clinical trials. The rate of ocular complications of intravitreal sustained-release steroids, mainly cataract formation and intraocular pressure elevation, is higher than with anti-vascular endothelial growth factor agents. Yet, a better understanding of the mechanisms underlying these adverse effects and the search for the minimal efficient dose should help optimize their therapeutic window.
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Affiliation(s)
- Alejandra Daruich
- Department of Ophthalmology, University of Lausanne, Jules-Gonin Eye Hospital, Fondation Asile des Aveugles, Avenue de France 15, 1004, Lausanne, Switzerland.
| | - Alexandre Matet
- Department of Ophthalmology, University of Lausanne, Jules-Gonin Eye Hospital, Fondation Asile des Aveugles, Avenue de France 15, 1004, Lausanne, Switzerland.
| | - Francine Behar-Cohen
- Department of Ophthalmology, University of Lausanne, Jules-Gonin Eye Hospital, Fondation Asile des Aveugles, Avenue de France 15, 1004, Lausanne, Switzerland.
- Sorbonne Universités, UPMC Université Paris 06, UMR 1138, Centre de Recherche des Cordeliers, 3 rue de l'Ecole de Médecine, 75006, Paris, France.
- INSERM, UMR 1138, Centre de Recherche des Cordeliers, 3 rue de l'Ecole de Médecine, 75006, Paris, France.
- Université Paris Descartes, Sorbonne Paris Cité, UMR 1138, Centre de Recherche des Cordeliers, 3 rue de l'Ecole de Médecine, 75006, Paris, France.
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Augustin AJ, Kuppermann BD, Lanzetta P, Loewenstein A, Li XY, Cui H, Hashad Y, Whitcup SM. Dexamethasone intravitreal implant in previously treated patients with diabetic macular edema: subgroup analysis of the MEAD study. BMC Ophthalmol 2015; 15:150. [PMID: 26519345 PMCID: PMC4628378 DOI: 10.1186/s12886-015-0148-2] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 10/20/2015] [Indexed: 12/23/2022] Open
Abstract
Background Dexamethasone intravitreal implant 0.7 mg (DEX 0.7) was approved for treatment of diabetic macular edema (DME) after demonstration of its efficacy and safety in the MEAD registration trials. We performed subgroup analysis of MEAD study results to evaluate the efficacy and safety of DEX 0.7 treatment in patients with previously treated DME. Methods Three-year, randomized, sham-controlled phase 3 study in patients with DME, best-corrected visual acuity (BCVA) of 34–68 Early Treatment Diabetic Retinopathy Study letters (20/200–20/50 Snellen equivalent), and central retinal thickness (CRT) ≥300 μm measured by time-domain optical coherence tomography. Patients were randomized to 1 of 2 doses of DEX (0.7 mg or 0.35 mg), or to sham procedure, with retreatment no more than every 6 months. The primary endpoint was ≥15-letter gain in BCVA at study end. Average change in BCVA and CRT from baseline during the study (area-under-the-curve approach) and adverse events were also evaluated. The present subgroup analysis evaluated outcomes in patients randomized to DEX 0.7 (marketed dose) or sham based on prior treatment for DME at study entry. Results Baseline characteristics of previously treated DEX 0.7 (n = 247) and sham (n = 261) patients were similar. In the previously treated subgroup, mean number of treatments over 3 years was 4.1 for DEX 0.7 and 3.2 for sham, 21.5 % of DEX 0.7 patients versus 11.1 % of sham had ≥15-letter BCVA gain from baseline at study end (P = 0.002), mean average BCVA change from baseline was +3.2 letters with DEX 0.7 versus +1.5 letters with sham (P = 0.024), and mean average CRT change from baseline was −126.1 μm with DEX 0.7 versus −39.0 μm with sham (P < 0.001). Cataract-related adverse events were reported in 70.3 % of baseline phakic patients in the previously treated DEX 0.7 subgroup; vision gains were restored following cataract surgery. Conclusions DEX 0.7 significantly improved visual and anatomic outcomes in patients with DME previously treated with laser, intravitreal anti-vascular endothelial growth factor, intravitreal triamcinolone acetonide, or a combination of these therapies. The safety profile of DEX 0.7 in previously treated patients was similar to its safety profile in the total study population. Trial registration ClinicalTrials.gov NCT00168337 and NCT00168389, registered 12 September 2005
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Affiliation(s)
- Albert J Augustin
- Department of Ophthalmology, Staedtisches Klinikum Karlsruhe, Moltkestrasse 90, 76133, Karlsruhe, Germany.
| | - Baruch D Kuppermann
- Gavin Herbert Eye Institute, University of California at Irvine, Irvine, CA, USA.
| | - Paolo Lanzetta
- Department of Medical and Biological Sciences - Ophthalmology, University of Udine, Udine, Italy.
| | | | | | - Harry Cui
- Avanir Pharmaceuticals, Inc, Aliso Viejo, CA, USA.
| | | | - Scott M Whitcup
- Jules Stein Eye Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
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145
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Cohen SR, Gardner TW. Diabetic Retinopathy and Diabetic Macular Edema. DEVELOPMENTS IN OPHTHALMOLOGY 2015; 55:137-46. [PMID: 26501152 DOI: 10.1159/000438970] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Diabetic retinopathy and diabetic macular edema result from chronic damage to the neurovascular structures of the retina. The pathophysiology of retinal damage remains uncertain but includes metabolic and neuroinflammatory insults. These mechanisms are addressed by intensive metabolic control of the systemic disease and by the use of ocular anti-inflammatory agents, including vascular endothelial growth factor inhibitors and corticosteroids. Improved understanding of the ocular and systemic mechanisms that underlie diabetic retinopathy will lead to improved means to diagnose and treat retinopathy and better maintain vision.
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Heng LZ, Sivaprasad S, Crosby-Nwaobi R, Saihan Z, Karampelas M, Bunce C, Peto T, Hykin PG. A prospective randomised controlled clinical trial comparing a combination of repeated intravitreal Ozurdex and macular laser therapy versus macular laser only in centre-involving diabetic macular oedema (OZLASE study). Br J Ophthalmol 2015; 100:802-7. [PMID: 26472406 DOI: 10.1136/bjophthalmol-2015-307136] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 09/19/2015] [Indexed: 01/27/2023]
Abstract
BACKGROUND/AIMS To evaluate the clinical efficacy and safety of combined repeated Ozurdex and macular laser therapy (MLT) compared with MLT monotherapy in participants with visual impairment due to centre-involving diabetic macular oedema (DMO). METHODS 80 patients with best corrected visual acuity (BCVA) between 54 and 78 ETDRS letters due to centre-involving DMO were randomised to combination therapy with Ozurdex and MLT or MLT only. The combination arm received mandated Ozurdex injections at baseline and 16 weeks followed by retreatment criteria-guided pro-re-nata therapy at 32 and 48 weeks. Patients randomised to MLT only were treated every 16 weeks if clinically significant macular oedema was present. The primary outcome was the mean change from baseline in BCVA between arms at 56 weeks. RESULTS The mean change in BCVA at 56 weeks was -0.3 (SD 11.4) ETDRS letters in the combination arm versus +0.4 (SD 9.6) ETDRS (Early Treatment Diabetic Retinopathy study) letters in the MLT arm (effect estimate 1.15 (95% CI -3.32 to 5.61)). However, at 56 weeks, a post hoc comparison of central subfield thickness (CST) showed a decrease of -113 μm (IQR -218, -64) (combination) versus -17 μm (-128, 12) (MLT arm) (p<0.001). Elevated intraocular pressure requiring topical therapy was observed in 8 (20%) eyes in the combination versus 1 (2.5%) in the MLT arm. 33% (9/27) of phakic patients in the combination arm underwent cataract surgery. CONCLUSIONS Visual outcome following combination therapy did not differ from MLT alone in the centre-involving DMO despite a significant decrease in CST likely due to an entry visual acuity-related ceiling effect and cataract development. TRIAL REGISTRATION NUMBER EudraCT 2011-003339-74.
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Affiliation(s)
- Ling Zhi Heng
- Moorfields Eye Hospital NHS Foundation Trust, UCL Institute of Ophthalmology, NIHR Moorfields Biomedical Research Centre, London, UK
| | - Sobha Sivaprasad
- Moorfields Eye Hospital NHS Foundation Trust, UCL Institute of Ophthalmology, NIHR Moorfields Biomedical Research Centre, London, UK
| | - Roxanne Crosby-Nwaobi
- Moorfields Eye Hospital NHS Foundation Trust, UCL Institute of Ophthalmology, NIHR Moorfields Biomedical Research Centre, London, UK
| | - Zubin Saihan
- Moorfields Eye Hospital NHS Foundation Trust, UCL Institute of Ophthalmology, NIHR Moorfields Biomedical Research Centre, London, UK
| | - Mike Karampelas
- Moorfields Eye Hospital NHS Foundation Trust, UCL Institute of Ophthalmology, NIHR Moorfields Biomedical Research Centre, London, UK
| | - Catey Bunce
- Moorfields Eye Hospital NHS Foundation Trust, UCL Institute of Ophthalmology, NIHR Moorfields Biomedical Research Centre, London, UK
| | - Tunde Peto
- Moorfields Eye Hospital NHS Foundation Trust, UCL Institute of Ophthalmology, NIHR Moorfields Biomedical Research Centre, London, UK
| | - Philip G Hykin
- Moorfields Eye Hospital NHS Foundation Trust, UCL Institute of Ophthalmology, NIHR Moorfields Biomedical Research Centre, London, UK
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Efficacy of Dexamethasone Intravitreal Implant for the Treatment of Diabetic Macular Edema. Eur J Ophthalmol 2015; 25:448-53. [DOI: 10.5301/ejo.5000581] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2015] [Indexed: 11/20/2022]
Abstract
Purpose To assess the efficacy of a single dexamethasone intravitreal implant (Dex-I) injection for the treatment of diabetic macular edema (DME). Methods This was a retrospective chart review of 39 eyes (34 consecutive patients). Best-corrected visual acuity (BCVA), central macular thickness (CMT), and increase in intraocular pressure (IOP) (>24 mm Hg) were analyzed before treatment and 2 and 4 months after injection. Results Preoperative mean CMT was 559 ± 111 μm and decreased to 338 ± 84 and 477 ± 140 μm 2 and 4 months after injection, respectively. Although all eyes showed a significant decrease in CMT 2 months after injection (p<0.0001), a recurrence of the macular edema was observed 4 months after injection in 79% of eyes. Mean BCVA improvement (logMAR) was 0.13 ± 0.18 (p<0.0001) and 0.07 ± 0.21 (p = 0.049) 2 and 4 months after injection, respectively, without significant difference between vitrectomized and nonvitrectomized eyes. Eight eyes (21%) developed reversible increase in IOP 2 months after injection. Conclusions Thirty percent of DME eyes had gained more than 2 logMAR lines 2 months after Dex-I injection and safety was good. Visual acuity gain was maintained 4 months after injection despite a recurrence of edema in most cases.
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148
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Lee R, Wong TY, Sabanayagam C. Epidemiology of diabetic retinopathy, diabetic macular edema and related vision loss. EYE AND VISION 2015; 2:17. [PMID: 26605370 PMCID: PMC4657234 DOI: 10.1186/s40662-015-0026-2] [Citation(s) in RCA: 823] [Impact Index Per Article: 91.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 09/01/2015] [Indexed: 12/15/2022]
Abstract
Diabetic retinopathy (DR) is a leading cause of vision-loss globally. Of an estimated 285 million people with diabetes mellitus worldwide, approximately one third have signs of DR and of these, a further one third of DR is vision-threatening DR, including diabetic macular edema (DME). The identification of established modifiable risk factors for DR such as hyperglycemia and hypertension has provided the basis for risk factor control in preventing onset and progression of DR. Additional research investigating novel risk factors has improved our understanding of multiple biological pathways involved in the pathogenesis of DR and DME, especially those involved in inflammation and oxidative stress. Variations in DR prevalence between populations have also sparked interest in genetic studies to identify loci associated with disease susceptibility. In this review, major trends in the prevalence, incidence, progression and regression of DR and DME are explored, and gaps in literature identified. Established and novel risk factors are also extensively reviewed with a focus on landmark studies and updates from the recent literature.
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Affiliation(s)
- Ryan Lee
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore ; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Tien Y Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore ; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore ; Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Charumathi Sabanayagam
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore ; Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore ; Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Graduate Medical School, Singapore, Singapore
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149
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Ogura S, Yasukawa T, Kato A, Kuwayama S, Hamada S, Hirano Y, Uemura A, Yoshida M, Ogura Y. Indocyanine Green Angiography-Guided Focal Laser Photocoagulation for Diabetic Macular Edema. Ophthalmologica 2015; 234:139-50. [PMID: 26393771 DOI: 10.1159/000437360] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 06/30/2015] [Indexed: 11/19/2022]
Abstract
PURPOSE To evaluate the usefulness of indocyanine green angiography (ICGA) to detect leaking spots and the effectiveness of ICGA-guided focal laser photocoagulation in eyes with diabetic macular edema (DME). METHODS Ten eyes (8 patients) with diffuse DME diagnosed using fluorescein angiography (FA) and refractory to a sub-Tenon injection of triamcinolone acetonide (STTA), grid laser photocoagulation, or both were enrolled. FA and ICGA were performed using the Heidelberg Retina Angiograph 2. Hyperfluorescent spots on early-phase FA and on early- and late-phase ICGA were superimposed onto the macular thickness map measured by optical coherence tomography (OCT) and counted to calculate the spot density in the area with or without macular edema (ME). ICGA-guided focal laser photocoagulation was carried out. In 7 eyes, STTA was simultaneously performed. The central macular thickness (CRT) and macular volume (MV) were measured by OCT. RESULTS On early-phase FA, 4.8 ± 2.3 and 2.3 ± 1.5 hyperfluorescent spots/disk area were observed inside and outside the ME, respectively. In contrast, the spot density was significantly decreased to 1.8 ± 0.9 inside the ME and was only 0.3 ± 0.4 outside the ME on late-phase ICGA (p < 0.01). The mean follow-up period after ICGA-guided photocoagulation was 19.0 months. The mean best-corrected visual acuity improved significantly from 0.77 ± 0.34 logarithm of the minimum angle of resolution at baseline to 0.52 ± 0.37 at the last visit (p < 0.01). Both CRT and MV significantly decreased (p < 0.01). Recurrence of DME was observed in 4 eyes: 3 eyes were treatable only with STTA and 1 required additional ICGA-guided laser photocoagulation. CONCLUSIONS ICGA may be useful to detect leaking spots responsible for DME, enabling less invasive focal laser photocoagulation even in some of the eyes with diffuse DME.
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Affiliation(s)
- Shuntaro Ogura
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Abstract
The treatment of center-involving diabetic macular edema (DME) has improved because of the proven efficacy of drugs that inhibit the effects of vascular endothelial growth factor (VEGF). The newest anti-VEGF drug, aflibercept, has recently been approved by the United States Food and Drug Administration for the treatment of center-involving DME and for diabetic retinopathy in eyes with DME. In the pivotal Phase III VISTA and VIVID trials, intravitreal aflibercept 2 mg injections every 4 or 8 weeks (after 5 monthly loading doses) produced superior gains in BCVA compared to laser/sham injections. In the Diabetic Retinopathy Clinical Research Network Protocol T trial, which featured monthly anti-VEGF monotherapy for 6 months, followed by monthly pro re nata anti-VEGF injections with laser rescue therapy from months 6 through 12, aflibercept 2 mg monthly was superior to bevacizumab 1.25 mg and ranibizumab 0.5 mg in eyes with BCVA of 20/50 or worse (aflibercept versus bevacizumab: P<0.001; aflibercept versus ranibizumab: P=0.003), but the three regimens were comparable for eyes with VA of 20/40 or better. Only in the 20/50 or worse subgroup did aflibercept achieve clinical superiority (>5 letter difference) to bevacizumab. Each treatment regimen led to significant macular thinning, with aflibercept being superior to bevacizumab in both visual acuity subgroups (P<0.001 for each), but it was not statistically superior to ranibizumab in either group. In diabetic patients, aflibercept has an excellent safety profile that does not appear to differ from laser/sham or other VEGF inhibitory drugs.
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Affiliation(s)
- Michael W Stewart
- Department of Ophthalmology, Mayo School of Medicine, Jacksonville, FL, USA
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