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Mehta H, Gillies M, Fraser-Bell S. Perspective on the role of Ozurdex (dexamethasone intravitreal implant) in the management of diabetic macular oedema. Ther Adv Chronic Dis 2015; 6:234-45. [PMID: 26336592 DOI: 10.1177/2040622315590319] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Diabetic macular oedema (DMO) is the most common cause of visual loss in the working age population. Intravitreal therapy has superseded macular laser as the first-line treatment for the management of centre-involving DMO in most patients. As well as the proven efficacy of intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents, phase II and III clinical trials of Ozurdex intravitreal dexamethasone implants for DMO have also demonstrated a mean increase in visual acuity and corresponding mean reduction in central macular thickness, particularly in pseudophakic eyes. Because of the risk of visual loss from cataract, glaucoma and intraocular infection with the use of intravitreal steroids, Ozurdex tends to be reserved for use in patients unresponsive to anti-VEGF therapy for centre-involving DMO. Situations where Ozurdex may be considered a first-line treatment option for eyes with centre-involving DMO include pseudophakia, impending cataract surgery, or in the context of a recent arterial thromboembolic event. Because of their stable pharmacokinetics, Ozurdex slow-release implants may also be considered in vitrectomized eyes.
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Affiliation(s)
- Hemal Mehta
- The Save Sight Institute, University of Sydney, Australia
| | - Mark Gillies
- The Save Sight Institute, University of Sydney, Australia
| | - Samantha Fraser-Bell
- Macula Research Group, Save Sight and Eye Health Institute, University of Sydney, 8 Macquarie Street, Sydney, NSW 2000, Australia
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152
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Güler E, Yağcı R. Diabetic macular edema: Efficacy and safety of anti-vascular endothelial growth factor therapy. World J Ophthalmol 2015; 5:133-141. [DOI: 10.5318/wjo.v5.i3.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 03/05/2015] [Accepted: 05/28/2015] [Indexed: 02/06/2023] Open
Abstract
Diabetic retinopathy is one of the prominent causes of vision impairment in the working-age population in industrialized countries and is related to 1%-5% of cases of blindness in the world. Among patients with diabetic retinopathy, diabetic macular edema (DME) is the major reason of vision impairment and represents a significant public health problem. Previous studies demonstrated the role of vascular endothelial growth factor (VEGF) in diabetic retinopathy and DME pathogenesis, and also revealed the efficacy of anti-VEGF agents for the management of these disorders. This review summarizes the outcomes of clinical studies that evaluated the anti-VEGF therapy including pegaptanib, ranibizumab, bevacizumab, and aflibercept for the management of DME. A significant number of clinical trials indicated favorable functional and anatomical results of anti-VEGF therapy for DME. Therefore, these agents should be considered an option in the treatment of DME in routine clinical practice.
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153
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Vaziri K, Schwartz SG, Relhan N, Kishor KS, Flynn Jr HW. New Therapeutic Approaches in Diabetic Retinopathy. Rev Diabet Stud 2015; 12:196-210. [PMID: 26676668 PMCID: PMC5397990 DOI: 10.1900/rds.2015.12.196] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 04/30/2015] [Indexed: 12/15/2022] Open
Abstract
Diabetic retinopathy is a common microvascular complication of diabetes mellitus. It affects a substantial proportion of US adults over age 40. The condition is a leading cause of visual loss. Much attention has been given to expanding the role of current treatments along with investigating various novel therapies and drug delivery methods. In the treatment of diabetic macular edema (DME), intravitreal pharmacotherapies, especially anti-vascular endothelial growth factor (anti-VEGF) agents, have gained popularity. Currently, anti-VEGF agents are often used as first-line agents in center-involved DME, with recent data suggesting that among these agents, aflibercept leads to better visual outcomes in patients with worse baseline visual acuities. While photocoagulation remains the standard treatment for proliferative diabetic retinopathy (PDR), recent FDA approvals of ranibizumab and aflibercept in the management of diabetic retinopathy associated with DME may suggest a potential for pharmacologic treatments of PDR as well. Novel therapies, including small interfering RNAs, chemokines, kallikrein-kinin inhibitors, and various anti-angiogenic agents, are currently being evaluated for the management of diabetic retinopathy and DME. In addition to these strategies, novel drug delivery methods such as sustained-release implants and refillable reservoir implants are either under active evaluation or have recently gained FDA approval. This review provides an update on the novel developments in the treatment of diabetic retinopathy.
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Affiliation(s)
| | - Stephen G. Schwartz
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, 900 NW 17th Street, Miami, FL 33136, USA
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154
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Yun SH, Adelman RA. Recent developments in laser treatment of diabetic retinopathy. Middle East Afr J Ophthalmol 2015; 22:157-63. [PMID: 25949072 PMCID: PMC4411611 DOI: 10.4103/0974-9233.150633] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Laser photocoagulation has been the mainstay of diabetic retinopathy treatment since its development in mid-20th century. With the advent of antivascular endothelial growth factor therapy, the role of laser therapy appeared to be diminished, however many advances in laser technology have been developed since. This review will describe recent advances in laser treatment of diabetic retinopathy including pattern scan laser, short-pulse duration and a reduced fluence laser, and navigated laser system for proliferative diabetic retinopathy and macular edema.
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Affiliation(s)
- Samuel H Yun
- Department of Ophthalmology and Visual Sciences, Yale School of Medicine, New Haven, CT 06511, USA
| | - Ron A Adelman
- Department of Ophthalmology and Visual Sciences, Yale School of Medicine, New Haven, CT 06511, USA
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156
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Ozkurt YB, Akkaya S, Aksoy S, Evciman T, Haboğlu M. Posterior Subtenon's Capsule Triamcinolone Acetonide Injection for the Treatment of Diabetic Macular Edema. J Ocul Pharmacol Ther 2015; 31:455-60. [PMID: 26154736 DOI: 10.1089/jop.2014.0130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To evaluate and compare the efficacy of posterior subtenon's triamcinolone injections versus grid laser photocoagulation (GLP) combined with posterior subtenon's triamcinolone injection in eyes with diabetic macular edema (DME). METHODS In this prospective clinical study, 42 eyes with DME that showed a decrease in visual acuity (VA) were included. The first group consisted of 22 eyes that received a posterior subtenon's injection of 40 mg of triamcinolone acetonide under topical anesthesia. The second group of 20 eyes received macular GLP applied 1 month after subtenon's triamcinolone acetonide (STTA) injection. All patients were evaluated at baseline and 1 day; 1, 2, 4, 6, and 8 weeks; and 3 and 6 months after injection. In some patients, injections were repeated after 3 months. The main outcome measures were VA, central macular thickness (CMT), intraocular pressure, cataract progression, and frequency of complications. RESULTS The mean baseline CMT for Group I was 456.85 ± 56.90 μm. The mean baseline CMT for Group II was 455.66 ± 57 μm. In the first group, mean CMTs for second week, 8th week, 12th week, and 6th month were 258.15, 276.50, 280.05, and 433.30 μm, respectively. In the second group, mean CMTs for second week, 8th week, 12th week, and 6th month were 261.42, 272.76, 284.71, and 291.76 μm, respectively. Before treatment, in the first group, the mean best-corrected visual acuity (BCVA) measured using a Snellen chart was 0.19, while the first week, third, and sixth month BCVA means were 0.59, 0.57, and 0.41, respectively. Before treatment, BCVA in the second group was 0.17, while the first week, third, and sixth month means were 0.61, 0.64, and 0.60, respectively. Treatment complications included cataracts in 4 eyes and glaucoma in 1 eye. CONCLUSION There is a temporary therapeutic effect of posterior subtenon's triamcinolone injection without laser photocoagulation. GLP improves VA and reduces the risk of recurrent macular edema after posterior STTA injection.
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Affiliation(s)
- Yelda Buyru Ozkurt
- 1 Department of Ophthalmology, Fatih Sultan Mehmet Training and Research Hospital , Istanbul, Turkey
| | - Sezen Akkaya
- 1 Department of Ophthalmology, Fatih Sultan Mehmet Training and Research Hospital , Istanbul, Turkey
| | - Sibel Aksoy
- 1 Department of Ophthalmology, Fatih Sultan Mehmet Training and Research Hospital , Istanbul, Turkey
| | - Tufan Evciman
- 2 Department of Ophthalmology Clinics, Ersoy Hospital , Istanbul, Turkey
| | - Melih Haboğlu
- 3 Department of Ophthalmology Clinics, Asya Eye Hospital , Istanbul, Turkey
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Tajima N, Noda M, Origasa H, Noto H, Yabe D, Fujita Y, Goto A, Fujimoto K, Sakamoto M, Haneda M. Evidence-based practice guideline for the treatment for diabetes in Japan 2013. Diabetol Int 2015. [DOI: 10.1007/s13340-015-0206-2] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Schauwvlieghe AME, Dijkman G, Hooymans JM, Verbraak FD, Hoyng CB, Dijkgraaf MGW, Van Leeuwen R, Vingerling JR, Moll AC, Schlingemann RO. Comparing the effectiveness and costs of Bevacizumab to Ranibizumab in patients with Diabetic Macular Edema: a randomized clinical trial (the BRDME study). BMC Ophthalmol 2015; 15:71. [PMID: 26149170 PMCID: PMC4491889 DOI: 10.1186/s12886-015-0043-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 05/19/2015] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The effectiveness of ranibizumab in the treatment of diabetic macular edema has been proven with large clinical trials. For bevacizumab only two clinical trials have been published and a head-to-head comparison is lacking to date. However, if proved non-inferior to ranibizumab, use of the off-label bevacizumab could reduce costs enormously without a loss in visual acuity. A cost-effectiveness study has been designed to substantiate this hypothesis. AIM To compare the effectiveness and costs of 1.25 mg of bevacizumab to 0.5 mg ranibizumab given as monthly intravitreal injections during 6 months in patients with diabetic macular edema. It is hypothesized that bevacizumab is non-inferior to ranibizumab regarding its effectiveness. DESIGN This is a randomized, controlled, double masked, clinical trial in 246 patients in seven academic trial centres in The Netherlands. OUTCOMES The primary outcome measure is the change in best-corrected visual acuity (BCVA) in the study eye from baseline to month 6. Secondary outcomes are the proportions of patients with a gain or loss of 15 letters or more or a BCVA of 20/40 or more at 6 months, the change in leakage on fluorescein angiography and the change in foveal thickness by optical coherence tomography at 6 months, the number of adverse events in 6 months, and the costs per quality adjusted life-year of the two treatments.
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Affiliation(s)
- A M E Schauwvlieghe
- Department of Ophthalmology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - G Dijkman
- Department of Ophthalmology, Leiden University Medical Centre, Leiden, The Netherlands.
| | - J M Hooymans
- Department of Ophthalmology, University Medical Center Groningen, Groningen, The Netherlands.
| | - F D Verbraak
- Department of Ophthalmology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
- Ocular Angiogenesis Group, Departments of Ophthalmology and Cell Biology and Histology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - C B Hoyng
- Department of Ophthalmology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
| | - M G W Dijkgraaf
- Clinical Research Unit, Academic Medical Center, Amsterdam, The Netherlands.
| | - R Van Leeuwen
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - J R Vingerling
- Department of Ophthalmology, Erasmus Medical Center, Rotterdam, The Netherlands.
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands.
| | - A C Moll
- Department of Ophthalmology, VU University Medical Centre, Amsterdam, The Netherlands.
| | - Reinier O Schlingemann
- Department of Ophthalmology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
- Ocular Angiogenesis Group, Departments of Ophthalmology and Cell Biology and Histology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
- Netherlands Institute for Neurosciences, Amsterdam, The Netherlands.
- Medical Retina Unit and Ocular Angiogenesis Group, Department Of Ophthalmology, Academic Medical Center, Room A2-122, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
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159
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INTRAVITREAL DEXAMETHASONE IMPLANT IN PATIENTS WITH RANIBIZUMAB PERSISTENT DIABETIC MACULAR EDEMA. Retina 2015; 35:1429-35. [DOI: 10.1097/iae.0000000000000490] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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160
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Yang Y, Bailey C, Holz FG, Eter N, Weber M, Baker C, Kiss S, Menchini U, Ruiz Moreno JM, Dugel P, Lotery A. Long-term outcomes of phakic patients with diabetic macular oedema treated with intravitreal fluocinolone acetonide (FAc) implants. Eye (Lond) 2015; 29:1173-80. [PMID: 26113503 PMCID: PMC4565956 DOI: 10.1038/eye.2015.98] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 05/06/2015] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Diabetic macular oedema (DMO) is a leading cause of blindness in working-age adults. Slow-release, nonbioerodible fluocinolone acetonide (FAc) implants have shown efficacy in the treatment of DMO; however, the National Institute for Health and Care Excellence recommends that FAc should be used in patients with chronic DMO considered insufficiently responsive to other available therapies only if the eye to be treated is pseudophakic. The goal of this analysis was to examine treatment outcomes in phakic patients who received 0.2 μg/day FAc implant. METHODS This analysis of the phase 3 FAME (Fluocinolone Acetonide in Diabetic Macular Edema) data examines the safety and efficacy of FAc implants in patients who underwent cataract extraction before (cataract before implant (CBI) group) or after (cataract after implant (CAI) group) receiving the implant. The data were further examined by DMO duration. RESULTS Best corrected visual acuity (BCVA) after 36 months was comparable in the CAI and CBI groups. Both the percentage of patients gaining ≥ 3 lines of vision and mean change in BCVA letter score were numerically greater in the CAI group. In addition, most patients who underwent cataract surgery experienced a net gain in BCVA from presurgery baseline as well as from original study baseline. CONCLUSIONS These data support the use of 0.2 μg/day FAc implants in phakic as well as in pseudophakic patients. These findings will serve as a pilot for design of future studies to evaluate the potential protective effect of FAc implants before cataract surgery in patients with DMO and cataract.
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Affiliation(s)
- Y Yang
- Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - C Bailey
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - F G Holz
- University of Bonn, Bonn, Germany
| | - N Eter
- University of Muenster Medical Center, Muenster, Germany
| | - M Weber
- University Hospital of Nantes, Nantes, France
| | - C Baker
- Paducah Retinal Center, Paducah, KY, USA
| | - S Kiss
- Weill Cornell Medical College, New York, NY, USA
| | - U Menchini
- Università degli Studi di Firenze, Firenze, Italy
| | | | - P Dugel
- Retinal Consultants of Arizona, Phoenix, AZ, USA
| | - A Lotery
- University of Southampton, Southampton, UK
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161
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A review of therapies for diabetic macular oedema and rationale for combination therapy. Eye (Lond) 2015; 29:1115-30. [PMID: 26113500 DOI: 10.1038/eye.2015.110] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 05/06/2015] [Indexed: 12/23/2022] Open
Abstract
Diabetic macular oedema (DMO) is responsible for significant visual impairment in diabetic patients. The primary cause of DMO is fluid leakage resulting from increased vascular permeability through contributory anatomical and biochemical changes. These include endothelial cell (EC) death or dysfunction, pericyte loss or dysfunction, thickened basement membrane, loss or dysfunction of glial cells, and loss/change of EC Glycocalyx. The molecular changes include increased reactive oxygen species, pro-inflammatory changes: advanced glycation end products, intracellular adhesion molecule-1, Complement 5-9 deposition and cytokines, which result in increased paracellular permeability, tight junction disruption, and increased transcellular permeability. Laser photocoagulation has been the mainstay of treatment until recently when pharmacological treatments were introduced. The current treatments for DMO target reducing vascular leak in the macula once it has occurred, they do not attempt to treat the underlying pathology. These pharmacological treatments are aimed at antagonising vascular endothelial growth factor (VEGF) or non-VEGF inflammatory pathways, and include intravitreal injections of anti-VEGFs (ranibizumab, aflibercept or bevacizumab) or steroids (fluocinolone, dexamethasone or triamcinolone) as single therapies. The available evidence suggests that each individual treatment modality in DMO does not result in a completely dry macula in most cases. The ideal treatment for DMO should improve vision and improve morphological changes in the macular (eg, reduce macular oedema) for a significant duration, reduced adverse events, reduced treatment burden and costs, and be well tolerated by patients. This review evaluates the individual treatments available as monotherapies, and discusses the rationale and potential for combination therapy in DMO. A comprehensive review of clinical trials related to DMO and their outcomes was completed. Where phase III randomised control trials were available, these were referenced, if not available, phase II trials have been included.
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162
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Berger AR, Cruess AF, Altomare F, Chaudhary V, Colleaux K, Greve M, Kherani A, Mandelcorn ED, Parsons H, Rhéaume MA, Tourville E. Optimal Treatment of Retinal Vein Occlusion: Canadian Expert Consensus. Ophthalmologica 2015; 234:6-25. [DOI: 10.1159/000381357] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 02/25/2015] [Indexed: 11/19/2022]
Abstract
Background: The availability of new therapeutic approaches, particularly intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapies, has prompted significant changes to the established treatment paradigms for retinal vein occlusion (RVO). Better visual outcomes and significantly lower rates of adverse events have been noted in multiple large randomized clinical trials and have led to a new standard of care for this sight-threatening condition. Objective: To develop an expert consensus for the management of RVO and associated complications in the context of recent clinical evidence. Methods: The development of a Canadian expert consensus for optimal treatment began with a review of clinical evidence, daily practice, and existing treatment guidelines and algorithms. The expert clinicians (11 Canadian retina specialists) met on February 1, 2014, in Toronto to discuss their findings and to propose strategies for consensus. Results: The result of this expert panel is a consensus proposal for Canadian ophthalmologists and retina specialists treating patients presenting with RVO. Treatment algorithms specific to branch and central RVO (BRVO and CRVO) were also developed. Conclusions: The consensus provides guidelines to aid clinicians in managing RVO and associated complications in their daily practice. In summary, laser remains the therapy of choice when neovascularization secondary to RVO is detected. Adjunctive anti-VEGF could be considered in managing neovascularization secondary to RVO in cases of vitreous hemorrhage. Intravitreal anti-VEGF should be considered for symptomatic visual loss associated with center-involving macular edema on optical coherence tomography. Patients with BRVO and a suboptimal response to anti-VEGF could be treated with grid laser, and those with CRVO and an inadequate response to anti-VEGF may be candidates for intravitreal steroids.
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163
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Colucciello M. Current intravitreal pharmacologic therapies for diabetic macular edema. Postgrad Med 2015; 127:640-53. [PMID: 26036708 DOI: 10.1080/00325481.2015.1052523] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Diabetic retinopathy is the leading cause of vision loss in working-age adults; it is a highly prevalent cause of vision loss overall and has a potent impact on the quality of life in those with diabetes mellitus and public health in general. Diabetic macular edema (DME) is the most common cause of vision loss from diabetic retinopathy. In patients with diabetes mellitus, chronic hyperglycemia leads to activation of the inflammatory cascade and retinal capillary damage that result in microaneurysm formation in the retina. In addition to the possibility of associated ischemia, microaneurysms are hyperpermeable; the resultant loss of the blood-retinal barrier leads to vision loss if consequent edema involves the center of the fovea. The standard of DME therapy for >25 years was focal laser photocoagulation applied to or near the microaneurysms. However, results from clinical trials of intravitreal vascular endothelial growth factor (VEGF) blockers and corticosteroids for the treatment of DME have led to a dramatic paradigm shift away from laser therapy to primary treatment with these pharmacologic agents. METHODS Medline literature search of approaches for treating DME. RESULTS Intravitreal pharmacologic treatments with anti-VEGF agents and corticosteroids have recently been shown to be superior to laser treatment of DME. CONCLUSION The existence of pharmacologic treatment of DME, shown to be superior to laser monotherapy, has created a seismic change in the approach of treatment of these patients. This review provides a summary of the therapies and the rationale regarding the current pharmacologic therapy of DME.
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164
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Ishibashi T, Li X, Koh A, Lai TYY, Lee FL, Lee WK, Ma Z, Ohji M, Tan N, Cha SB, Shamsazar J, Yau CL. The REVEAL Study: Ranibizumab Monotherapy or Combined with Laser versus Laser Monotherapy in Asian Patients with Diabetic Macular Edema. Ophthalmology 2015; 122:1402-15. [PMID: 25983216 DOI: 10.1016/j.ophtha.2015.02.006] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 02/05/2015] [Accepted: 02/05/2015] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE The primary study hypothesis was that ranibizumab 0.5 mg monotherapy or combined with laser is superior to laser monotherapy based on mean average change in best-corrected visual acuity (BCVA) over 12 months in Asian patients with visual impairment resulting from diabetic macular edema (DME). DESIGN A 12-month, randomized, double-masked, multicenter, laser-controlled, phase III study. PARTICIPANTS Three hundred ninety-six patients aged ≥18 years, with type 1 or 2 diabetes mellitus, BCVA of 78-39 Early Treatment Diabetic Retinopathy Study (ETDRS) letters, and visual impairment resulting from DME. METHODS Patients were randomized to ranibizumab + sham laser (n = 133), ranibizumab + active laser (n = 132), or sham injection + active laser (n = 131). Ranibizumab/sham injections were administered on day 1 and continued monthly. As of month 3, monthly injections were continued if stable vision was not reached. Treatment was reinitiated if BCVA decreased because of DME progression. Active/sham laser was administered on day 1 and thereafter according to ETDRS guidelines. MAIN OUTCOME MEASURES Average change in BCVA from baseline to months 1 through 12, central retinal subfield thickness (CRST), and safety over 12 months. RESULTS Ranibizumab monotherapy or combined with laser was superior to laser in improving mean average change in BCVA from baseline to months 1 through 12 (+5.9 and +5.7 vs +1.4 letters). At month 12, greater proportion of patients gained ≥15 letters with ranibizumab and ranibizumab + laser compared with laser (18.8% and 17.8% vs 7.8%). Mean CRST reduced significantly from baseline to month 12 with ranibizumab (-134.6 μm) and ranibizumab + laser (-171.8 μm) versus laser (-57.2 μm). Patients received a mean of 7.8 and 7.0 ranibizumab injections in the ranibizumab and ranibizumab + laser arms, respectively, and 1.5-1.9 active laser across treatment arms over 12 months. Conjunctival hemorrhage was the most common ocular, whereas nasopharyngitis and hypertension were the most common nonocular adverse events. Ranibizumab was not associated with any cases of cerebrovascular hemorrhage and cerebrovascular ischemia. No death related to study treatment was reported. CONCLUSIONS Ranibizumab monotherapy or combined with laser showed superior BCVA improvements over laser treatment alone in Asian patients with visual impairment resulting from DME. No new ocular or nonocular safety findings were observed and treatment was well tolerated over 12 months.
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Affiliation(s)
- Tatsuro Ishibashi
- Department of Ophthalmology, Kyushu University Hospital, Fukuoka, Japan
| | - Xiaoxin Li
- Peking University People's Hospital, Beijing, China.
| | - Adrian Koh
- Department of Ophthalmology, Tan Tock Seng Hospital, Singapore, Republic of Singapore
| | - Timothy Y Y Lai
- Department of Ophthalmology & Visual Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Fenq-Lih Lee
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
| | - Won-Ki Lee
- Department of Ophthalmology, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Republic of Korea
| | - Zhizhong Ma
- Peking University Third Hospital, Beijing, China
| | - Masahito Ohji
- Shiga University of Medical Science Hospital, Ohtsu, Japan
| | - Nikolle Tan
- Department of Ophthalmology, Tan Tock Seng Hospital, Singapore, Republic of Singapore; National Healthcare Group Eye Institute, Singapore, Republic of Singapore
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Abstract
Intravitreal injections for the treatment of retinal disorders and intraocular infection have become a common ophthalmic procedure, and injections of anti-vascular endothelial growth factor agents or steroids are frequently performed for the treatment of diabetic macular edema or other diabetic vascular pathology. Diabetic patients may be at higher risk of adverse events than non-diabetic individuals given frequent systemic co-morbidities, such as cardiovascular and renal disease, susceptibility to infection, and unique ocular pathology that includes fibrovascular proliferation. Fortunately, many associated complications, including endophthalmitis, are related to the injection procedure and can therefore be circumvented by careful attention to injection techniques. This review highlights the safety profile of intravitreal injections in patients with diabetes. Although diabetic patients may theoretically be at higher risk than non-diabetic patients for complications, a comprehensive review of the literature does not demonstrate substantial increased risk of intravitreal injections in patients with diabetes.
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Affiliation(s)
- Hasanain Shikari
- Beetham Eye Institute, Joslin Diabetes Center , Boston, Massachusetts , USA and
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166
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Schmit-Eilenberger VK. A novel intravitreal fluocinolone acetonide implant (Iluvien(®)) in the treatment of patients with chronic diabetic macular edema that is insufficiently responsive to other medical treatment options: a case series. Clin Ophthalmol 2015; 9:801-11. [PMID: 25999689 PMCID: PMC4427264 DOI: 10.2147/opth.s79785] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background Iluvien® is a novel, nonbiodegradable, sustained-release drug delivery system (0.2 μg/d fluocinolone acetonide [FAc]) indicated in Europe for the treatment of vision impairment associated with chronic diabetic macular edema (DME), considered insufficiently responsive to available therapies. Objective To evaluate the safety and efficacy of 190-μg FAc implant in patients with chronic DME refractory to other medical treatment options in a clinical setting. Methods Retrospective registry data were collected by using standard case report forms (CRFs). Prior to intravitreal injection of the FAc implant, all patients were treated either with a vascular endothelial growth factor (VEGF) antagonist and/or a steroid (triamcinolone, dexamethasone implant). Patients were excluded from receiving FAc if they had a known history of elevated intraocular pressure (IOP) following corticosteroid therapy, glaucoma, ocular hypertension, or any contraindications cited in the summary of product characteristics. Best-corrected visual acuity (BCVA) was the main study parameter. Central fovea thickness (CFT) and IOP were measured concurrently. These parameters were recorded prior to and after the injection of the 190-μg FAc implant (between 1 week and 9 months). Injections were performed between May 2013 and March 2014. Results Fifteen eyes from ten patients were treated. Thirteen eyes (nine patients) were pseudophakic, and seven eyes (five patients) were vitrectomized prior to receiving therapy. BCVA improved in eleven eyes (73.3%), remained unchanged in two eyes (13.3%), and decreased slightly in two eyes (13.3%) at the last follow-up visit versus baseline levels. IOP increased in two patients and was controlled using fixed-combination of IOP-lowering eyedrops or sectorial cyclocryotherapy (n=1). Conclusion The 190-μg FAc implant was efficacious and showed a favorable benefit-to-risk profile in the patient population with chronic DME of this case series that were refractory to other therapies. The longer-term efficacy and safety in a real-life setting is still being assessed in this center. FAc may offer an important treatment option for patients with chronic DME refractory to other treatment options.
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Abstract
Diabetic retinopathy (DR) is one of today's main causes of blindness in numerous developed countries worldwide. The underlying pathogenesis of DR is complex and not well understood, thus impeding development of specific, effective treatment modalities. Consequently, the use of animal models of DR is of critical importance for investigating the pathogenesis of and treatment for DR. While rats and mice are the most commonly used animal models of DR, the zebrafish now appears to be a promising model. Nonhuman primates and humans have similar eye structures, and both can develop spontaneous diabetes mellitus (DM). Although various traditionally used animal models of DR undergo a number of pathological changes similar to those of human DR, several human variations, e.g. retinal neovascularization, cannot yet be fully mimicked in any existing animal model of DM. Since both the animal models and the methods chosen for inducing DR have great influence on experimental results, a clear understanding of available animal models is vital for planning an experimental design. In this review, we summarize the mechanisms, methodologies and pros and cons of the most commonly used animal models of DR.
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Affiliation(s)
- Xiaoyan Jiang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University , Guangzhou , P.R. China
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168
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Bucolo C, Grosso G, Drago V, Gagliano C. Intravitreal triamcinolone acetonide in the treatment of ophthalmic inflammatory diseases with macular edema: a meta-analysis study. J Ocul Pharmacol Ther 2015; 31:228-40. [PMID: 25825799 DOI: 10.1089/jop.2014.0094] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE To perform a meta-analysis of randomized controlled trials (RCTs) that compared the effects of treatment with intravitreal injections of triamcinolone acetonide (TA) with the standard of care for ocular inflammatory diseases. METHODS Medline database was searched for causes of macular edema terms in association with intravitreal triamcinolone. The primary outcome of interest included changes in best corrected visual acuity (BCVA) and central macular thickness (CMT). Pooled summary estimates for primary outcomes were calculated as weighted mean differences (WMD) either on a fixed- or random-effect model. RESULTS A total of 8 studies were included for quantitative analysis. Treatment with intravitreal TA showed improvement in BCVA compared with standard of care at 1 month (WMD, -0.09; 95% confidence interval [CI], -0.17 to -0.02), at 4 months (WMD, -0.09; 95% CI, -0.15 to -0.03), at 6 months (WMD, -0.13; 95% CI, -0.21 to -0.05), and in CMT at 1 month (WMD, -88.14; 95% CI, -105.86 to -70.43). Increased intraocular pressure (IOP) among patients treated with intravitreal TA was found at 4 months (WMD, 2.83; 95% CI, 1.96 to 3.70), persisting also at 12 months (WMD, 3.78; 95% CI, 2.97 to 4.59), compared with those receiving the standard of care. All outcomes are mostly equivalent at further follow-up times. CONCLUSIONS Intravitreal injections of TA may offer certain advantages over the standard of care for ocular inflammatory diseases, especially in the early stage of follow-up. However, it is necessary to take into account risks and benefits of TA treatment for ocular inflammatory diseases due to possible ocular hypertension elicited, in general, by intravitreal injection of corticosteroids.
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Affiliation(s)
- Claudio Bucolo
- 1 Section of Pharmacology and Biochemistry, Department of Biomedical and Biotechnological Sciences, University of Catania , Catania, Italy
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169
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Yaseri M, Zeraati H, Mohammad K, Soheilian M, Ramezani A, Eslani M, Peyman GA. Intravitreal bevacizumab injection alone or combined with triamcinolone versus macular photocoagulation in bilateral diabetic macular edema; application of bivariate generalized linear mixed model with asymmetric random effects in a subgroup of a clinical trial. J Ophthalmic Vis Res 2015; 9:453-60. [PMID: 25709771 PMCID: PMC4329706 DOI: 10.4103/2008-322x.150818] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 05/17/2014] [Indexed: 11/04/2022] Open
Abstract
PURPOSE To compare the efficacy of intravitreal bevacizumab (IVB) injection alone or with intravitreal triamcinolone acetonide (IVB/IVT) versus macular photocoagulation (MPC) in bilateral diabetic macular edema (DME). METHODS In this study we revisited data from a subset of subjects previously enrolled in a randomized clinical trial. The original study included 150 eyes randomized to three treatment arms: 1.25 mg IVB alone, combined injection of 1.25 mg IVB and 2 mg IVT, and focal or modified grid MPC. To eliminate the possible effects of systemic confounders, we selected fellow eyes of bilaterally treated subjects who had undergone different treatments; eventually 30 eyes of 15 patients were re-evaluated at baseline, 6, 12, 18, and 24 months. Using mixed model analysis, we compared the treatment protocols regarding visual acuity (VA) and central macular thickness (CMT). RESULTS Improvement in VA in the IVB group was significantly greater compared to MPC at months 6 and 12 (P = 0.037 and P = 0.035, respectively) but this difference did not persist thereafter up to 24 months. Other levels of VA were comparable at different follow-up intervals (all P > 0.05). The only significant difference in CMT was observed in favor of the IVB group as compared to IVB/IVT group at 24 months (P = 0.048). CONCLUSION Overall VA was superior in IVB group as compared to MPC up to 12 months. Although the IVB group showed superiority regarding CMT reduction over 24 months as compared to IVB/IVT group, it was comparable to the MPC group through the same period of follow up.
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Affiliation(s)
- Mehdi Yaseri
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Hojjat Zeraati
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Kazem Mohammad
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoud Soheilian
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Ramezani
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran ; Department of Ophthalmology, Imam Hossein Medical Center, Tehran, Iran
| | - Medi Eslani
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Gholam A Peyman
- Department of Ophthalmology, University of Arizona Health Science Center, Tucson, Arizona, USA
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Micro-implant d’acétonide de fluocinolone (ILUVIEN®) pour l’œdème maculaire diabétique chronique. J Fr Ophtalmol 2015; 38:159-67. [DOI: 10.1016/j.jfo.2014.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 08/08/2014] [Accepted: 09/11/2014] [Indexed: 11/19/2022]
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Totan Y, Güler E, Gürağaç FB. Dexamethasone Intravitreal Implant for Chronic Diabetic Macular Edema Resistant to Intravitreal Bevacizumab Treatment. Curr Eye Res 2015; 41:107-13. [DOI: 10.3109/02713683.2014.1002048] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Domalpally A, Ip MS, Ehrlich JS. Effects of intravitreal ranibizumab on retinal hard exudate in diabetic macular edema: findings from the RIDE and RISE phase III clinical trials. Ophthalmology 2015; 122:779-86. [PMID: 25601535 DOI: 10.1016/j.ophtha.2014.10.028] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 10/11/2014] [Accepted: 10/31/2014] [Indexed: 02/02/2023] Open
Abstract
PURPOSE To evaluate the effect of monthly intravitreal ranibizumab on hard exudate (HE) area and the impact of HE on visual acuity (VA) outcomes in diabetic macular edema (DME) patients using data from 2 phase III clinical trials. DESIGN Exploratory analyses of phase III, randomized, double-masked, sham-controlled, multicenter clinical trials. PARTICIPANTS Adults with DME, baseline best-corrected VA 20/40 to 20/320 Snellen equivalent, and central foveal thickness of ≥275 μm. METHODS Between the 2 studies, 759 patients with DME were randomized to receive monthly 0.3 or 0.5 mg intravitreal ranibizumab (Lucentis; Genentech, Inc., South San Francisco, CA) or sham injections. MAIN OUTCOME MEASURES Hard exudate area was assessed from color fundus stereophotographs both on an ordinal scale and using continuous estimates of areas within the Early Treatment Diabetic Retinopathy Study grid. RESULTS Data from 739 eyes were available for analysis. Mean baseline HE area was similar across treatment groups, ranging from 0.65 to 0.82 mm(2). Through month 24, the percentage of eyes without HE increased from 20.9% to 36.3% in the sham group and from 22.1% to 61.3% and 23.6% to 62.0% in the ranibizumab 0.3-mg and 0.5-mg groups, respectively. Resolution of HE became apparent sometime after month 6 in ranibizumab-treated eyes. At baseline, there was no meaningful correlation between VA and presence or absence of HE. After baseline, there also was no consistent correlation between presence or absence of HE and change in VA over time. CONCLUSIONS In this exploratory analysis, monthly intravitreal ranibizumab resulted in significantly greater reduction of HE area compared with sham (P < 0.0001). In contrast to the rapid effects of ranibizumab on macular edema, changes in HE area were more gradual. Contrary to prior expectations, the presence and area of HE did not increase as DME resolved (either in the ranibizumab or sham groups). Importantly, baseline VA was not correlated with presence of HE, nor was the therapeutic benefit of ranibizumab on VA affected negatively by the presence of HE. These data suggest that in the context of intravitreal anti-vascular endothelial growth factor therapy, the presence of HE is not a prognostic indicator of poor visual outcomes.
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Affiliation(s)
- Amitha Domalpally
- Department of Ophthalmology and Visual Sciences, University of Wisconsin Medical School, Madison, Wisconsin
| | - Michael S Ip
- Department of Ophthalmology and Visual Sciences, University of Wisconsin Medical School, Madison, Wisconsin.
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Cebeci Z, Kir N. Role of implants in the treatment of diabetic macular edema: focus on the dexamethasone intravitreal implant. Diabetes Metab Syndr Obes 2015; 8:555-66. [PMID: 26604809 PMCID: PMC4655951 DOI: 10.2147/dmso.s73540] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Diabetic macular edema (DME) is the leading cause of sight-threatening complication in diabetic patients, and several treatment modalities have been developed and evaluated to treat this pathology. Intravitreal agents, such as anti-vascular endothelial growth factors (anti-VEGF) or corticosteroids, have become more popular in recent years and are widely used for treating DME. Sustained release drugs appear to be mentioned more often nowadays for extending the period of intravitreal activity, and corticosteroids play a key role in inhibiting the inflammatory process in DME. A potent corticosteroid, dexamethasone (Ozurdex(®)), in the form of an intravitreal implant, has been approved for various ocular etiologies among which DME is also one. This review evaluates the role of implants in the treatment of DME, mainly focusing on the dexamethasone intravitreal implant.
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Affiliation(s)
- Zafer Cebeci
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Capa, Istanbul, Turkey
- Correspondence: Zafer Cebeci, Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Capa 34390, Istanbul, Turkey, Tel +90 212 414 2000, Fax +90 212 414 2026, Email
| | - Nur Kir
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Capa, Istanbul, Turkey
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174
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Mathew C, Yunirakasiwi A, Sanjay S. Updates in the management of diabetic macular edema. J Diabetes Res 2015; 2015:794036. [PMID: 25984537 PMCID: PMC4423013 DOI: 10.1155/2015/794036] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 03/26/2015] [Accepted: 03/26/2015] [Indexed: 02/06/2023] Open
Abstract
Diabetes mellitus is a chronic disease which has multiple effects on different end-organs, including the retina. In this paper, we discuss updates on diabetic macular edema (DME) and the management options. The underlying pathology of DME is the leakage of exudates from retinal microaneurysms, which trigger subsequent inflammatory reactions. Both clinical and imaging techniques are useful in diagnosing, classifying, and gauging the severity of DME. We performed a comprehensive literature search using the keywords "diabetes," "macula edema," "epidemiology," "pathogenesis," "optical coherence tomography," "intravitreal injections," "systemic treatment," "hypertension," "hyperlipidemia," "anemia," and "renal disease" and collated a total of 47 relevant articles published in English language. The main modalities of treatment currently in use comprise laser photocoagulation, intravitreal pharmacological and selected systemic pharmacological options. In addition, we mention some novel therapies that show promise in treating DME. We also review systemic factors associated with exacerbation or improvement in DME.
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Affiliation(s)
- Christopher Mathew
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597
| | | | - Srinivasan Sanjay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117597
- Department of Ophthalmology and Visual Sciences, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828
- *Srinivasan Sanjay:
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175
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Effect of intravitreal triamcinolone in diabetic macular edema unresponsive to intravitreal bevacizumab. Retina 2014; 34:1606-11. [PMID: 24553409 DOI: 10.1097/iae.0000000000000109] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE To evaluate the efficacy of intravitreal triamcinolone injection in diabetic macular edema unresponsive to intravitreal bevacizumab. METHODS Patients with diabetic macular edema unresponsive to at least three monthly intravitreal bevacizumabs were included. At least 2 months after the last intravitreal bevacizumab, intravitreal triamcinolone was performed after obtaining an aqueous humor sample. Multiplex cytokine array was used to assay vascular endothelial growth factor, interleukin (IL)-2, IL-6, IL-8, tumor necrosis factor-α, and transforming growth factor-β2. Best-corrected visual acuity and central subfield thickness were evaluated from Month 0 to 3. RESULTS Twenty eyes were enrolled. The mean best-corrected visual acuity was 47.1 ± 18.9 letters at baseline, and significantly increased to 53.3 ± 19.7 letters at 1 month (P = 0.002) and 52.4 ± 19.1 letters at 2 months (P = 0.041). These visual gains were not sustained at 3 months (50.9 ± 18.6; P = 0.204). A decrease in central subfield thickness more than 11% of baseline occurred in 12 eyes at 1 month. Multivariate analysis showed that intraocular levels of IL-8 (β = 0.538 P = 0.006) was an independent factor for anatomic response at 1 month. CONCLUSION Intravitreal triamcinolone has a role in patients who are unresponsive to intravitreal bevacizumab over the short-term. Elevated intraocular IL-8 levels were related to the efficacy.
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176
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Abstract
For the past several decades, tremendous efforts have been made to decrease the complications of diabetes, including diabetic retinopathy. New diagnostic modalities like ultrawide field fundus fluorescein angiography and spectral domain optical coherence tomography has allowed more accurate diagnosis of early diabetic retinopathy and diabetic macular edema. Antivascular endothelial growth factors are now extensively used to treat diabetic retinopathy and macular edema with promising results. There remains uncertainty over the long term effects and the socioeconomic costs of these agents.
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Affiliation(s)
- Su Jeong Song
- Department of Ophthalmology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tien Yin Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Duke-NUS Graduate Medical School, National University of Singapore, Singapore
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177
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Corticosteroids for the Treatment of Diabetic Macular Edema. CURRENT OPHTHALMOLOGY REPORTS 2014. [DOI: 10.1007/s40135-014-0051-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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178
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O'Day RF, Barthelmes D, Zhu M, Wong TY, McAllister IL, Arnold JJ, Gillies MC. Intraocular pressure rise is predictive of vision improvement after intravitreal triamcinolone acetonide for diabetic macular oedema: a retrospective analysis of data from a randomised controlled trial. BMC Ophthalmol 2014; 14:123. [PMID: 25335434 PMCID: PMC4223852 DOI: 10.1186/1471-2415-14-123] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Accepted: 09/25/2014] [Indexed: 01/27/2023] Open
Abstract
Background Intravitreal triamcinolone acetonide (IVTA) is an effective treatment for recalcitrant diabetic macular oedema (DMO). It has been shown to improve vision with benefits persisting up to five years. The most common initial side effect of IVTA treatment is rise in intraocular pressure, occurring in approximately 50% of patients within the first 6 months of treatment. We evaluated whether there is a correlation between the development of intraocular pressure rise and improvement in vision. Methods Analysis of individual data from 33 eyes of 33 participants treated with IVTA for DMO from a prospective, randomised, double-masked, placebo controlled trial. The degree of intraocular pressure (IOP) rise was correlated with improvement in best-corrected visual acuity (BCVA) at 1 and 6 months. Results The proportion of eyes gaining 5 or more logMAR letters was higher in eyes with greater IOP rise (p = 0.044). Better absolute improvement in BCVA at 6 months (p = 0.045) was also found in eyes with greater IOP rise. Regression analyses revealed a correlation between IOP rise of 10 or more mmHg and absolute BCVA improvement at 6 months (odds ratio 1.22, 95% confidence interval 1.01-1.48, p = 0.039), but not at 1 month. Conclusions IOP rise and vision improvement appear to be correlated following IVTA for DMO, suggesting that the mechanisms that cause both may be linked. Trial Registration Clinical trials.gov NCT00167518, September 5, 2005.
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Affiliation(s)
- Roderick F O'Day
- Clinical Ophthalmology & Eye Health, The University of Sydney, Sydney, Australia.
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Boyer DS, Yoon YH, Belfort R, Bandello F, Maturi RK, Augustin AJ, Li XY, Cui H, Hashad Y, Whitcup SM. Three-Year, Randomized, Sham-Controlled Trial of Dexamethasone Intravitreal Implant in Patients with Diabetic Macular Edema. Ophthalmology 2014; 121:1904-14. [DOI: 10.1016/j.ophtha.2014.04.024] [Citation(s) in RCA: 546] [Impact Index Per Article: 54.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Revised: 02/21/2014] [Accepted: 04/21/2014] [Indexed: 02/08/2023] Open
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Cunha-Vaz J, Ashton P, Iezzi R, Campochiaro P, Dugel PU, Holz FG, Weber M, Danis RP, Kuppermann BD, Bailey C, Billman K, Kapik B, Kane F, Green K. Sustained Delivery Fluocinolone Acetonide Vitreous Implants. Ophthalmology 2014; 121:1892-903. [DOI: 10.1016/j.ophtha.2014.04.019] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 12/30/2013] [Accepted: 04/18/2014] [Indexed: 01/27/2023] Open
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Laser-based strategies to treat diabetic macular edema: history and new promising therapies. J Ophthalmol 2014; 2014:769213. [PMID: 25332833 PMCID: PMC4190043 DOI: 10.1155/2014/769213] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 07/30/2014] [Accepted: 09/04/2014] [Indexed: 02/08/2023] Open
Abstract
Diabetic macular edema (DME) is the main cause of visual impairment in diabetic patients. The management of DME is complex and often various treatment approaches are needed. At the present time, despite the enthusiasm for evaluating several new treatments for DME, including the intravitreal pharmacologic therapies (e.g., corticosteroids and anti-VEGF drugs), laser photocoagulation still remains the current standard in DME. The purpose of this review is to update our knowledge on laser photocoagulation for DME and describe the developments in laser systems. And we will also discuss the new laser techniques and review the latest results including benefits of combined therapy. In this paper, we briefly summarize the major laser therapeutics for the treatment of diabetic macular edema and allude to some future promising laser therapies.
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Treatment of anti-vascular endothelial growth factor-resistant diabetic macular edema with dexamethasone intravitreal implant. Retina 2014; 34:719-24. [PMID: 23975006 DOI: 10.1097/iae.0b013e3182a48958] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE To investigate the efficiency of intravitreal dexamethasone implant in patients with chronic diabetic macular edema nonresponsive to three consecutive monthly intravitreal injections of anti-vascular endothelial growth factor administered previously. METHODS Fifteen patients (16 eyes) were included in this 4-month prospective clinical trial. Main observed outcomes were the changes between initial and monthly visits in best-corrected visual acuity, central foveal thickness, and intraocular pressure (IOP). Patients included had central foveal thickness of >225 μm (measured by optical coherence tomography) and were nonresponsive to previously administered 3 consecutive monthly intravitreal injections of 1.25-mg bevacizumab. Administration of intravitreal dexamethasone implant was performed at baseline, and patients were followed-up monthly. RESULTS Statistically significant changes from baseline were observed in best-corrected visual acuity (at 2 months), central foveal thickness (at 1, 2, and 3 months), and IOP (at Months 1, 2, and 3) as follows: mean best-corrected visual acuity significantly increased from 0.29 Snellen lines at baseline to 0.39 lines after 2 months (P = 0.0381). At Months 1, 2, and 3, the mean central foveal thickness significantly decreased, from 462 μm at baseline, to 366 μm (P = 0.0343), 346 μm (P = 0.0288), and 355 μm (P = 0.0370), respectively. When compared with baseline IOP of 15.38 mmHg (12-19 mmHg), IOP increased significantly at Months 1, 2, and 3: 18.93 mmHg (range, 16-24 mmHg; P = 0.0003), 19.5 mmHg (range, 16-27 mmHg; P = 0.0003), and 17.5 mmHg (range, 15-21 mmHg; P = 0.0048), respectively. CONCLUSION Dexamethasone intravitreal implant may present an alternative option in the treatment of chronic diabetic macular edema nonresponsive to three consecutive monthly bevacizumab injections administered previously. However, IOP measures were only slightly increased. It seems that the effect of dexamethasone may last till 4 months after initial injection.
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183
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Towler HMA. New technologies and drugs in the management of diabetic retinopathy. PRACTICAL DIABETES 2014. [DOI: 10.1002/pdi.1884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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184
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Bandello F, Preziosa C, Querques G, Lattanzio R. Update of Intravitreal Steroids for the Treatment of Diabetic Macular Edema. Ophthalmic Res 2014; 52:89-96. [DOI: 10.1159/000362764] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 04/04/2014] [Indexed: 11/19/2022]
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185
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Douvali M, Chatziralli IP, Theodossiadis PG, Chatzistefanou KI, Giannakaki E, Rouvas AA. Effect of Macular Ischemia on Intravitreal Ranibizumab Treatment for Diabetic Macular Edema. Ophthalmologica 2014; 232:136-43. [DOI: 10.1159/000360909] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Accepted: 02/23/2014] [Indexed: 11/19/2022]
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186
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Intravitreal diclofenac versus intravitreal bevacizumab in naive diabetic macular edema: a randomized double-masked clinical trial. Int Ophthalmol 2014; 35:421-8. [DOI: 10.1007/s10792-014-9967-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Accepted: 06/22/2014] [Indexed: 10/25/2022]
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Kuppermann BD, Zacharias LC, Kenney MC. Steroid differentiation: the safety profile of various steroids on retinal cells in vitro and their implications for clinical use (an American Ophthalmological Society thesis). TRANSACTIONS OF THE AMERICAN OPHTHALMOLOGICAL SOCIETY 2014; 112:116-41. [PMID: 25646032 PMCID: PMC4311675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
PURPOSE To determine if potentially viable alternatives to the clinical use of intravitreal triamcinolone acetonide should be considered based on a comparative assessment of the in vitro effects of five commercially available corticosteroids. We hypothesized that dexamethasone, betamethasone, methylprednisolone, loteprednol etabonate, and fluocinolone acetonide, at clinically relevant doses, may show different levels of in vitro cytotoxicity to retinal cells. METHODS Cultures of human retinal pigment epithelial cells (ARPE-19) and rat embryonal neurosensory precursor retinal cells (R28) were treated with dexamethasone, betamethasone, methylprednisolone, loteprednol, or fluocinolone acetonide. Cell viability as a measure of cell death was determined by trypan blue dye exclusion assay. The mechanical effect of drug crystals was evaluated by solubilizing the steroid formulations. Mitochondrial dehydrogenase and membrane potential were assessed to measure cell damage. RESULTS Betamethasone, loteprednol, and methylprednisolone, in commercially available forms, caused significant cytotoxic changes to retinal cells in vitro at clinically relevant doses. This effect was less pronounced with solubilized betamethasone. Dexamethasone at concentrations up to 5 times the clinical dose of free drug injections and 1000 times greater than a drug implant did not cause decreased cell viability. Fluocinolone acetonide at doses 1000 times higher than observed with drug delivery systems showed no cytotoxic effect. CONCLUSIONS Betamethasone, loteprednol, and methylprednisolone exhibited cytotoxicity at clinically relevant doses and do not appear to be good therapeutic options for intravitreal use. In comparison, dexamethasone and fluocinolone acetonide, which exhibited fewer cytotoxic effects than other steroids, may be potentially viable alternatives to triamcinolone acetonide for clinical use.
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Affiliation(s)
- Baruch D Kuppermann
- Gavin Herbert Eye Institute, Department of Ophthalmology, University of California Irvine, Irvine, California
| | | | - M Cristina Kenney
- Gavin Herbert Eye Institute, Department of Ophthalmology, University of California Irvine, Irvine, California
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188
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Zhang X, Zeng H, Bao S, Wang N, Gillies MC. Diabetic macular edema: new concepts in patho-physiology and treatment. Cell Biosci 2014; 4:27. [PMID: 24955234 PMCID: PMC4046142 DOI: 10.1186/2045-3701-4-27] [Citation(s) in RCA: 132] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 04/22/2014] [Indexed: 12/22/2022] Open
Abstract
Diabetic macular edema (DME), a serious eye complication caused primarily by hyperglycemia, is one of the major causes of blindness. DME, which is characterized by cystic retinal thickening or lipid deposition, is prone to relapse after successful treatment. DME is a complex pathological process caused by multiple factors, including breakdown of the inner and outer blood-retinal barriers, oxidative stress, and elevated levels of vascular endothelial growth factor which have been demonstrated in both preclinical and clinical studies. Starling's law theory explains many of the features of DME. Early detection and treatment of DME can prevent vision loss. Current effective interventions for DME include treatment of systemic risk factors, such as elevated blood glucose, blood pressure and dyslipidemia. Ophthalmic treatments include laser photocoagulation, surgery and intraocular pharmacotherapy. New drugs, which are given by intraocular injection, have emerged in recent years to become first line treatment for DME that affects the central macula with loss of vision. Laser photocoagulation is still the gold standard of treatment for DME which does not involve the central macular. This review outlines these new treatments with particular emphasis on the optimal timing of how they are given.
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Affiliation(s)
- Xinyuan Zhang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University; Beijing Ophthalmology & Visual Sciences Key Lab, Beijing 100730 PR China ; Macula Research Group, Save Sight Institute, The University of Sydney, Sydney, NSW, Australia
| | - Huan Zeng
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University; Beijing Ophthalmology & Visual Sciences Key Lab, Beijing 100730 PR China
| | - Shian Bao
- Discipline of Pathology, School of Medical Sciences and Bosch Institute, The University of Sydney, Sydney, NSW 2006, Australia
| | - Ningli Wang
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University; Beijing Ophthalmology & Visual Sciences Key Lab, Beijing 100730 PR China
| | - Mark C Gillies
- Macula Research Group, Save Sight Institute, The University of Sydney, Sydney, NSW, Australia
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189
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Spectral-domain optical coherence tomography for macular edema. ScientificWorldJournal 2014; 2014:191847. [PMID: 24963500 PMCID: PMC4053271 DOI: 10.1155/2014/191847] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 04/19/2014] [Indexed: 11/19/2022] Open
Abstract
Optical coherence tomography (OCT) is a rapid noncontact method that allows in vivo imaging of the retina and it has become an important component in clinical practice. OCT is a useful ancillary tool for assessing retinal diseases because of its ability to provide cross-sectional retinal images and quantitatively analyze retinal morphology. The introduction of spectral-domain OCT provided major improvements in image acquisition speed and image resolution. Future studies will address how these major technologic advances will impact the use of OCT in research and clinical practice.
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190
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Carle MV, Chu TG, Boyer DS. Fluocinolone acetonide (Iluvien) extended-release intravitreal implant for diabetic macular edema. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/17469899.2014.902310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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191
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Mitchell P, Wong TY. Management paradigms for diabetic macular edema. Am J Ophthalmol 2014; 157:505-13.e1-8. [PMID: 24269850 DOI: 10.1016/j.ajo.2013.11.012] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Revised: 11/10/2013] [Accepted: 11/12/2013] [Indexed: 01/18/2023]
Abstract
PURPOSE To provide evidence-based recommendations for diabetic macular edema (DME) management based on updated information from publications on DME treatment modalities. DESIGN Perspective. METHODS A literature search for "diabetic macular edema" or "diabetic maculopathy" was performed using the PubMed, Cochrane Library, and ClinicalTrials.gov databases to identify studies from January 1, 1985 to July 31, 2013. Meta-analyses, systematic reviews, and randomized controlled trials with at least 1 year of follow-up published in the past 5 years were preferred sources. RESULTS Although laser photocoagulation has been the standard treatment for DME for nearly 3 decades, there is increasing evidence that superior outcomes can be achieved with anti-vascular endothelial growth factor (anti-VEGF) therapy. Data providing the most robust evidence from large phase II and phase III clinical trials for ranibizumab demonstrated visual improvement and favorable safety profile for up to 3 years. Average best-corrected visual acuity change from baseline ranged from 6.1-10.6 Early Treatment Diabetic Retinopathy Study (ETDRS) letters for ranibizumab, compared to 1.4-5.9 ETDRS letters with laser. The proportion of patients gaining ≥ 10 or ≥ 15 letters with ranibizumab was at least 2 times higher than that of patients treated with laser. Patients were also more likely to experience visual loss with laser than with ranibizumab treatment. Ranibizumab was generally well tolerated in all studies. Studies for bevacizumab, aflibercept, and pegaptanib in DME were limited but also in favor of anti-VEGF therapy over laser. CONCLUSIONS Anti-VEGF therapy is superior to laser photocoagulation for treatment of moderate to severe visual impairment caused by DME.
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Romero-Aroca P, Reyes-Torres J, Baget-Bernaldiz M, Blasco-Suñe C. Laser treatment for diabetic macular edema in the 21st century. Curr Diabetes Rev 2014; 10:100-12. [PMID: 24852439 PMCID: PMC4051253 DOI: 10.2174/1573399810666140402123026] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 03/28/2014] [Accepted: 04/02/2014] [Indexed: 11/22/2022]
Abstract
Diabetic macular edema (DME) is the leading cause of blindness in the diabetic population. The diabetes Control and Complications Trial reported that 27% of patients affected by type 1 diabetes develop DME within 9 years of onset. Other studies have shown that in patients with type 2 diabetes, the prevalence increased from 3% to 28% within 5 years of diagnosis to twenty years after the onset. At the present time, despite the enthusiasm for evaluating several new treatments for DME, including the intravitreal therapies for DME (e.g., corticosteroids, and anti-VEGF drugs), laser photocoagulation remains the current gold standard and the only treatment with proven efficacy in a wide range of clinical trials for this condition. Despite being the standard technique for comparison and evaluation of the emerging treatments, we have generally poor understanding of the ETDRS recommendations, and we often forget about the results of laser in DME. The purpose of this review is to update our knowledge on laser photocoagulation for DME with an extensive review of the ETDRS results and discuss the laser techniques. Furthermore, we will describe the new developments in laser systems and review the current indications and results. Finally, we will discuss the results of laser treatments versus the current pharmacological therapies. We conclude by trying to provide a general overview that which laser treatment must be indicated and what types of lasers are currently recommended.
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Affiliation(s)
| | | | | | - Cristina Blasco-Suñe
- Department of Ophthalmology, University Hospital Sant Joan, University Rovira i Virgili, Institut de Investigació Sanitaria Pere Virgili (IISPV), Reus, Spain, Avda. Josep Laporte 1, 43204 Reus, Spain.
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193
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Abu El-Asrar AM. Evolving strategies in the management of diabetic retinopathy. Middle East Afr J Ophthalmol 2014; 20:273-82. [PMID: 24339676 PMCID: PMC3841944 DOI: 10.4103/0974-9233.119993] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Diabetic retinopathy (DR), the most common long-term complication of diabetes mellitus, remains one of the leading causes of blindness worldwide. Tight glycemic and blood pressure control has been shown to significantly decrease the risk of development as well as the progression of retinopathy and represents the cornerstone of medical management of DR. The two most threatening complications of DR are diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR). Focal/grid photocoagulation and panretinal photocoagulation are standard treatments for both DME and PDR, respectively. Focal/grid photocoagulation is a better treatment than intravitreal triamcinolone acetonide in eyes with DME. Currently, most experts consider combination focal/grid laser therapy and pharmacotherapy with intravitreal antivascular endothelial growth factor agents in patients with center-involving DME. Combination therapy reduces the frequency of injections needed to control edema. Vitrectomy with removal of the posterior hyaloid seems to be effective in eyes with persistent diffuse DME, particularly in eyes with associated vitreomacular traction. Emerging therapies include fenofibrate, ruboxistaurin, renin-angiotensin system blockers, peroxisome proliferator-activated receptor gamma agonists, pharmacologic vitreolysis, and islet cell transplantation.
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Affiliation(s)
- Ahmed M Abu El-Asrar
- Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Anti-VEGF for the management of diabetic macular edema. J Immunol Res 2014; 2014:632307. [PMID: 24741610 PMCID: PMC3987934 DOI: 10.1155/2014/632307] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 12/22/2013] [Indexed: 12/18/2022] Open
Abstract
Diabetic retinopathy (DR) is an important cause of vision loss around the world, being the leading cause in the population between 20 and 60 years old. Among patients with DR, diabetic macular edema (DME) is the most frequent cause of vision impairment and represents a significant public health issue. Macular photocoagulation has been the standard treatment for this condition reducing the risk of moderate visual loss by approximately 50%. The role of vascular endothelial growth factor (VEGF) in DR and DME pathogenesis has been demonstrated in recent studies. This review addresses and summarizes data from the clinical trials that investigated anti-VEGF for the management of DME and evaluates their impact on clinical practice. The literature searches were conducted between August and October 2013 in PubMed and Cochrane Library with no date restrictions and went through the most relevant studies on pegaptanib, ranibizumab, bevacizumab, and aflibercept for the management of DME. The efficacy and safety of intravitreal anti-VEGF as therapy for DME have recently been proved by various clinical trials providing significantly positive visual and anatomical results. Regarding clinical practice, those outcomes have placed intravitreal injection of anti-VEGF as an option that must be considered for the treatment of DME.
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196
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Kuppermann BD. Sustained-release dexamethasone intravitreal implant for treatment of diabetic macular edema. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/eop.10.82] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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197
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Abu El-Asrar AM, Al-Mezaine HS, Ola MS. Pathophysiology and management of diabetic retinopathy. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/eop.09.52] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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198
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Intravitreal steroids for the treatment of retinal diseases. ScientificWorldJournal 2014; 2014:989501. [PMID: 24526927 PMCID: PMC3910383 DOI: 10.1155/2014/989501] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 10/10/2013] [Indexed: 11/22/2022] Open
Abstract
Diabetic macular edema (DME), pseudophakic cystoid macular edema (CME), age-related macular degeneration (AMD), retinal vascular occlusion (RVO), and uveitis are ocular conditions related to severe visual impairment worldwide. Corticosteroids have been widely used in the treatment of these retinal diseases, due to their well-known antiangiogenic, antiedematous, and anti-inflammatory properties. Intravitreal steroids have emerged as novel and essential tools in the ophthalmologist's armamentarium, allowing for maximization of drug efficacy and limited risk of systemic side effects. Recent advances in ocular drug delivery methods led to the development of intraocular implants, which help to provide prolonged treatment with controlled drug release. Moreover, they may add some potential advantages over traditional intraocular injections by delivering certain rates of drug directly to the site of action, amplifying the drug's half-life, contributing in the minimization of peak plasma levels of the drug, and avoiding the side effects associated with repeated intravitreal injections. The purpose of this review is to provide an update on the use of intravitreal steroids as a treatment option for a variety of retinal diseases and to review the current literature considering their properties, safety, and adverse events.
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199
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Pershing S, Enns EA, Matesic B, Owens DK, Goldhaber-Fiebert JD. Cost-effectiveness of treatment of diabetic macular edema. Ann Intern Med 2014; 160:18-29. [PMID: 24573663 PMCID: PMC4020006 DOI: 10.7326/m13-0768] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Macular edema is the most common cause of vision loss among patients with diabetes. OBJECTIVE To determine the cost-effectiveness of different treatments of diabetic macular edema (DME). DESIGN Markov model. DATA SOURCES Published literature and expert opinion. TARGET POPULATION Patients with clinically significant DME. TIME HORIZON Lifetime. PERSPECTIVE Societal. INTERVENTION Laser treatment, intraocular injections of triamcinolone or a vascular endothelial growth factor (VEGF) inhibitor, or a combination of both. OUTCOME MEASURES Discounted costs, gains in quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). RESULTS OF BASE-CASE ANALYSIS All treatments except laser monotherapy substantially reduced costs, and all treatments except triamcinolone monotherapy increased QALYs. Laser treatment plus a VEGF inhibitor achieved the greatest benefit, gaining 0.56 QALYs at a cost of $6975 for an ICER of $12 410 per QALY compared with laser treatment plus triamcinolone. Monotherapy with a VEGF inhibitor achieved similar outcomes to combination therapy with laser treatment plus a VEGF inhibitor. Laser monotherapy and triamcinolone monotherapy were less effective and more costly than combination therapy. RESULTS OF SENSITIVITY ANALYSIS VEGF inhibitor monotherapy was sometimes preferred over laser treatment plus a VEGF inhibitor, depending on the reduction in quality of life with loss of visual acuity. When the VEGF inhibitor bevacizumab was as effective as ranibizumab, it was preferable because of its lower cost. LIMITATION Long-term outcome data for treated and untreated diseases are limited. CONCLUSION The most effective treatment of DME is VEGF inhibitor injections with or without laser treatment. This therapy compares favorably with cost-effective interventions for other conditions. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.
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Bhat M, Pouliot M, Couture R, Vaucher E. The kallikrein-kinin system in diabetic retinopathy. PROGRESS IN DRUG RESEARCH. FORTSCHRITTE DER ARZNEIMITTELFORSCHUNG. PROGRES DES RECHERCHES PHARMACEUTIQUES 2014; 69:111-43. [PMID: 25130041 DOI: 10.1007/978-3-319-06683-7_5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Diabetic retinopathy (DR) is a major microvascular complication associated with type 1 and type 2 diabetes mellitus, which can lead to visual impairment and blindness. Current treatment strategies for DR are mostly limited to laser therapies, steroids, and anti-VEGF agents, which are often associated with unwanted side effects leading to further complications. Recent evidence suggests that kinins play a primary role in the development of DR through enhanced vascular permeability, leukocytes infiltration, and other inflammatory mechanisms. These deleterious effects are mediated by kinin B1 and B2 receptors, which are expressed in diabetic human and rodent retina. Importantly, kinin B1 receptor is virtually absent in sane tissue, yet it is induced and upregulated in diabetic retina. These peptides belong to the kallikrein-kinin system (KKS), which contains two separate and independent pathways of regulated serine proteases, namely plasma kallikrein (PK) and tissue kallikrein (TK) that are involved in the biosynthesis of bradykinin (BK) and kallidin (Lys-BK), respectively. Hence, ocular inhibition of kallikreins or antagonism of kinin receptors offers new therapeutic avenues in the treatment and management of DR. Herein, we present an overview of the principal features and known inflammatory mechanisms associated with DR along with the current therapeutic approaches and put special emphasis on the KKS as a new and promising therapeutic target due to its link with key pathways directly associated with the development of DR.
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