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Kim YC, Shin JP, Pak KY, Kim HW, Sagong M, Lee SJ, Chung IY, Park SW, Lee JE. Two-year outcomes of the treat-and-extend regimen using aflibercept for treating diabetic macular oedema. Sci Rep 2020; 10:22030. [PMID: 33328488 PMCID: PMC7745011 DOI: 10.1038/s41598-020-78954-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 11/18/2020] [Indexed: 11/21/2022] Open
Abstract
This study was performed to investigate the efficacy of the treat-and-extend regimen using aflibercept for treating diabetic macular oedema (DME). This prospective, multicentre, interventional, single-arm, 104-week clinical trial included 48 patients with DME visual impairment. The patients’ eyes received five consecutive intravitreal injections (2 mg aflibercept) every four weeks with two-week adjustments based on central subfield macular thickness (CSMT) changes. Injections were deferred when CSMT was stable. The number of injections, best-corrected visual acuity (BCVA), CSMT, and diabetic retinopathy severity scale scores were analysed. Compared to baseline, BCVA improved by + 9.1 letters at 52 weeks and was maintained with + 9.4-letter gain at 104 weeks (P < 0.001). Between baseline and 104 weeks, CSMT decreased from 489 to 298 μm (P < 0.001) and eyes with vision ≥ 20/40 increased from 17.4 to 43.5% (P = 0.007). The mean number of injections decreased from 8.5 in year one to 3.9 in year two. The injection interval was extended to ≥ 12 weeks in 56.5% of patients. The treat-and-extend regimen of aflibercept in DME showed 2-year efficacy comparable to that of fixed dosing regimens. The flexible dosing of this regimen reduced the number of injections in year two while maintaining efficacy.
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Affiliation(s)
- Yu Cheol Kim
- Department of Ophthalmology, Keimyung University School of Medicine, Daegu, Korea
| | - Jae Pil Shin
- Department of Ophthalmology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Kang Yeun Pak
- Department of Ophthalmology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hyun Woong Kim
- Department of Ophthalmology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Min Sagong
- Department of Ophthalmology, Yeungnam University College of Medicine, Daegu, Korea
| | - Sang Joon Lee
- Department of Ophthalmology, Kosin University College of Medicine, Busan, Korea
| | - In Young Chung
- Department of Ophthalmology, Gyeongsang National University School of Medicine, Jinju, Korea
| | - Sung Who Park
- Department of Ophthalmology, Pusan National University, School of Medicine, 49, Busandaehak-ro, Mulgeum-eup, Yangsan, Gyeongsangnam-do, 50612, Korea.,Biomedical Institute, Pusan National University Hospital, Busan, Korea
| | - Ji Eun Lee
- Department of Ophthalmology, Pusan National University, School of Medicine, 49, Busandaehak-ro, Mulgeum-eup, Yangsan, Gyeongsangnam-do, 50612, Korea. .,Biomedical Institute, Pusan National University Hospital, Busan, Korea.
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202
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Lee YJ, Kang KD. Short-term Results of Intravitreal Dexamethasone Implant Combined with Bevacizumab versus Intravitreal Bevacizumab for Treatment-naive Diabetic Macular Edema. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2020. [DOI: 10.3341/jkos.2020.61.12.1485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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203
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Gabrielle P, Massin P, Arnould L, Couturier A, Bouché‐Pillon J, Maupin E, Aho‐Glele S, Bron AM, Kodjikian L, Creuzot‐Garcher C. Development of a 1-year risk-prediction nomogram for good functional response with anti-VEGF agents in naive diabetic macular oedema. Acta Ophthalmol 2020; 98:e975-e982. [PMID: 32268017 DOI: 10.1111/aos.14428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 03/12/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE To develop a risk-prediction nomogram based on baseline variables for good functional response during the 1st year of treatment with anti-VEGF agents in naive diabetic macular oedema (DME). METHODS This retrospective study included patients presenting naive-DME treated with anti-VEGF therapy at Dijon University Hospital (France) between 1 February 2012 and 31 March 2015 (derivation cohort). We studied baseline variables that had significant associations with a good functional response to anti-VEGF agents during the 1st year of treatment. We used a program to generate a nomogram based on a binary logistic regression predictive model. Then, this nomogram was tested on data from a separate cohort of naive-DME patients from a multicenter study involving 20 French ophthalmologic centres between January 2014 and June 2015 (validation cohort). RESULTS Age, baseline BCVA and ellipsoid zone integrity on spectral-domain optical coherence tomography (SD-OCT) are functional prognostic factors and were used to build a nomogram. The nomogram showed excellent discrimination for good functional responders (area under the curve (AUC) = 0.906, 95% confidence interval (95% CI) = [0.849-0.964], p = 0.004). The discriminative power of this nomogram was tested on the validation cohort data, demonstrating good discrimination of good functional responders (AUC = 0.942, 95% CI = [0.898-0.986], p < 0.001). CONCLUSION This nomogram provides a useful estimation of a good functional response in naive-DME patients treated with anti-VEGF agents.
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Affiliation(s)
- Pierre‐Henry Gabrielle
- Ophthalmology Department University Hospital Dijon France
- Eye and Nutrition Research Group Centre des Sciences du Goût et de l’Alimentation UMR1324 INRA 6265 CNRS University of Bourgogne Franche‐Comté Dijon France
| | - Pascale Massin
- Ophthalmology Department Lariboisière Hospital Assistance Publique des Hôpitaux de Paris Université Paris Diderot Paris France
| | - Louis Arnould
- Ophthalmology Department University Hospital Dijon France
| | - Aude Couturier
- Ophthalmology Department Lariboisière Hospital Assistance Publique des Hôpitaux de Paris Université Paris Diderot Paris France
| | | | - Edouard Maupin
- Ophthalmology Department University Hospital Dijon France
| | | | - Alain M. Bron
- Ophthalmology Department University Hospital Dijon France
- Eye and Nutrition Research Group Centre des Sciences du Goût et de l’Alimentation UMR1324 INRA 6265 CNRS University of Bourgogne Franche‐Comté Dijon France
| | - Laurent Kodjikian
- Ophthalmology Department Lyon la Croix‐Rousse Hospices civils de Lyon Lyon France
| | - Catherine Creuzot‐Garcher
- Ophthalmology Department University Hospital Dijon France
- Eye and Nutrition Research Group Centre des Sciences du Goût et de l’Alimentation UMR1324 INRA 6265 CNRS University of Bourgogne Franche‐Comté Dijon France
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204
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Hwang DK, Yu WK, Lin TC, Chou SJ, Yarmishyn A, Kao ZK, Kao CL, Yang YP, Chen SJ, Hsu CC, Jheng YC. Smartphone-based diabetic macula edema screening with an offline artificial intelligence. J Chin Med Assoc 2020; 83:1102-1106. [PMID: 33210900 DOI: 10.1097/jcma.0000000000000355] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Diabetic macular edema (DME) is a sight-threatening condition that needs regular examinations and remedies. Optical coherence tomography (OCT) is the most common used examination to evaluate the structure and thickness of the macula, but the software in the OCT machine does not tell the clinicians whether DME exists directly. Recently, artificial intelligence (AI) is expected to aid in diagnosis generation and therapy selection. We thus develop a smartphone-based offline AI system that provides diagnostic suggestions and medical strategies through analyzing OCT images from diabetic patients at the risk of developing DME. METHODS DME patients receiving treatments in 2017 at Taipei Veterans General Hospital were included in this study. We retrospectively collected the OCT images of these patients from January 2008 to July 2018. We established the AI model based on MobileNet architecture to classify the OCT images conditions. The confusion matrix has been applied to present the performance of the trained AI model. RESULTS Based on the convolutional neural network with the MobileNet model, our AI system achieved a high DME diagnostic accuracy of 90.02%, which is comparable to other AI systems such as InceptionV3 and VGG16. We further developed a mobile-application based on this AI model available at https://aicl.ddns.net/DME.apk. CONCLUSION We successful integrated an AI model into the mobile device to provide an offline method to provide the diagnosis for quickly screening the risk of developing DME. With the offline property, our model could help those nonophthalmological healthcare providers in offshore islands or underdeveloped countries.
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Affiliation(s)
- De-Kuang Hwang
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Wei-Kuang Yu
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Tai-Chi Lin
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Shih-Jie Chou
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Aliaksandr Yarmishyn
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Zih-Kai Kao
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chung-Lan Kao
- Department of Physical Medicine & Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Physical Medicine and Rehabilitation, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Yi-Ping Yang
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Pharmacology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Shih-Jen Chen
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Chih-Chien Hsu
- Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Ying-Chun Jheng
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Physical Medicine & Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Physical Medicine and Rehabilitation, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
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Framme C, Greb O, Bayer S, Buley P, Pielen A, Hufendiek K, Junker B, Volkmann I. Development of a Patient-Oriented Organizational Management System for Intravitreal Injection Therapy in a Standardized "Treat-and-Extend" Regime at a University Eye Clinic. Klin Monbl Augenheilkd 2020; 238:1312-1324. [PMID: 33242883 DOI: 10.1055/a-1266-3546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The treatment of macular edema with intravitreal injections has revolutionized the treatment of associated diseases in ophthalmology. However, with a few exceptions, this is a chronic treatment where patients require many injections and usually need to stay in treatment for years. Patient adherence and control of patient flow are critical to treatment success. In this manuscript, we describe the development of a patient-oriented organization management for intravitreal injections in a university hospital. MATERIAL AND METHODS In 2015, the intravitreal treatment in our clinic was switched to the treat-and-extend regime. At the same time, the optimization of the previous organizational processes in perioperative management was evaluated. For the period 2015 to 2018, we analyzed and gradually optimized the procedures of our intravitreal injection therapy in a survey with a specialized service provider. RESULTS Through the analysis of the original processes, the patient appointment was optimized, work processes were summarized, spatially reorganized and there was only a slight increase in the number of staff involved compared with the significant increase in the number of injections. Through these measures, the total in-hospital-time of the patients could be drastically reduced and at the same time the number of patients on one operation day could be multiplied. CONCLUSION In the context of chronic treatment with intravitreal injections, the care of an increased number of patients is a logistical challenge. By optimizing processes, existing resources can be better used to meet the increased demands. An optimized system offers the patient greater adherence and a better visual outcome largely independent of the medication used.
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Affiliation(s)
- Carsten Framme
- Universitätsklinik für Augenheilkunde, Medizinische Hochschule Hannover, Deutschland
| | - Oliver Greb
- Universitätsklinik für Augenheilkunde, Medizinische Hochschule Hannover, Deutschland
| | - Sascha Bayer
- Niederlassung Schweiz, Q_PERIOR, Zürich, Schweiz
| | - Pascal Buley
- Universitätsklinik für Augenheilkunde, Medizinische Hochschule Hannover, Deutschland
| | - Amelie Pielen
- Universitätsklinik für Augenheilkunde, Medizinische Hochschule Hannover, Deutschland
| | - Katerina Hufendiek
- Universitätsklinik für Augenheilkunde, Medizinische Hochschule Hannover, Deutschland
| | - Bernd Junker
- Universitätsklinik für Augenheilkunde, Medizinische Hochschule Hannover, Deutschland
| | - Ingo Volkmann
- Universitätsklinik für Augenheilkunde, Medizinische Hochschule Hannover, Deutschland
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206
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Campochiaro PA, Akhlaq A. Sustained suppression of VEGF for treatment of retinal/choroidal vascular diseases. Prog Retin Eye Res 2020; 83:100921. [PMID: 33248215 DOI: 10.1016/j.preteyeres.2020.100921] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/15/2020] [Accepted: 11/18/2020] [Indexed: 12/27/2022]
Abstract
Neovascular age-related macular degeneration (NVAMD) is the most prevalent choroidal vascular disease, and diabetic retinopathy (DR) and retinal vein occlusion (RVO) are the most prevalent retinal vascular diseases. In each of these, hypoxia plays a central role by stabilizing hypoxia-inducible factor-1 which increases production of vascular endothelial growth factor (VEGF) and other hypoxia-regulated gene products. High VEGF causes excessive vascular permeability, neovascularization, and in DR and RVO, promotes closure of retinal vessels exacerbating hypoxia and creating a positive feedback loop. Hence once VEGF expression is elevated it tends to remain elevated and drives disease progression. While other hypoxia-regulated gene products also contribute to pathology in these disease processes, it is remarkable how much pathology is reversed by selective inhibition of VEGF. Clinical trials have demonstrated outstanding visual outcomes in patients with NVAMD, DR, or RVO from frequent intraocular injections of VEGF-neutralizing proteins, but for a variety of reasons injection frequency has been substantially less in clinical practice and visual outcomes are disappointing. Herein we discuss the rationale, preclinical, and early clinical results of new approaches that provide sustained suppression of VEGF. These approaches will revolutionize the management of these prevalent retinal/choroidal vascular diseases.
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Affiliation(s)
- Peter A Campochiaro
- The Departments of Ophthalmology and Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Anam Akhlaq
- The Departments of Ophthalmology and Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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207
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Wroblewski JJ, McChancy C, Pickel K, Buterbaugh H, Wieland T, Gonzalez A. Reproducibility of Fixed-luminance and Multi-luminance Flicker Electroretinography in Patients With Diabetic Retinopathy Using an Office-based Testing Paradigm. J Diabetes Sci Technol 2020; 14:1095-1103. [PMID: 31640411 PMCID: PMC7645135 DOI: 10.1177/1932296819882719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND We evaluated the reproducibility of office-based flicker electroretinography (ERG) in patients with nonproliferative diabetic retinopathy (NPDR). METHODS An observational study was conducted in which ultra-widefield fluorescein angiography (UWF-FA) was performed on 20 patients with mild-to-moderate NPDR; images were graded by the Fundus Photography Reading Center (Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, WI, USA). Fixed- and multi-luminance flicker ERG was repeated four times (greater than or equal to seven days apart). Recording consistency was assessed using intra-class correlation coefficients (ICCs), coefficients of variation, and Pearson correlations. RESULTS 82.5% and 17.5% of eyes had mild and moderate NPDR using UWF-FA; 90% of the angiograms were given a high confidence grade. Fixed-luminance phase values were highly reproducible (ICC: 0.949; P < .001). There was a significant negative correlation between fixed-luminance phase and log-corrected ischemic index values (-0.426; P = .015). CONCLUSIONS Office-based, fixed-luminance phase values are highly reproducible and negatively correlate with retinal ischemia in NPDR, suggesting that global retinal dysfunction may be reliably quantified early in patients with diabetes.
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Affiliation(s)
- John J. Wroblewski
- Cumberland Valley Retina Consultants, Hagerstown, MD, USA
- John J. Wroblewski, MD, Cumberland Valley Retina Consultants, 1150 Opal Court, Hagerstown, MD 21740, USA.
| | | | | | | | - Tyler Wieland
- Cumberland Valley Retina Consultants, Hagerstown, MD, USA
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The Short-term Effect of a Single Lapse in Anti-Vascular Endothelial Growth Factor Treatment for Diabetic Macular Edema Within Routine Clinical Practice. Am J Ophthalmol 2020; 219:215-221. [PMID: 32640254 PMCID: PMC7335491 DOI: 10.1016/j.ajo.2020.06.040] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/26/2020] [Accepted: 06/30/2020] [Indexed: 11/26/2022]
Abstract
Purpose Diabetic macular edema (DME) is a leading cause of vision loss in diabetics. Anti–vascular endothelial growth factor (VEGF) therapy has been shown to be an effective treatment option for DME, although the injections are costly and require frequent visits, which increases the risk for unintended treatment lapses. The aim of this study is to characterize the effects of an unintended treatment lapse in patients with DME undergoing anti-VEGF therapy. Design Retrospective, comparative case series. Methods This retrospective chart review compared patients seen in a multicenter institutional practice with DME exhibiting an unintended minimum 3-month lapse in anti-VEGF treatment, with a control group of DME patients receiving regular anti-VEGF treatment without lapses. The primary outcome was difference in central subfield thickness (CST) between the control group and the treatment lapse group at 6 months following treatment lapse. Results A total of 164 patients were evaluated, 82 patients in the treatment lapse group and 82 patients in the control group. The average age was 65 years, and the average lapse in treatment was 6.2 ± 3.5 months (range 3-24 months). Comparison of data between the lapse and control groups revealed no significant differences in CST (359.9 ± 108.3 μm and 335.4±94.6 μm, respectively, P = .066) or in visual acuity (66.5 ± 14.3 and 68.9 ± 14.5, respectively, P = .136). Limitations included a relatively small sample size, retrospective nature, and only a single lapse being evaluated. Conclusions An unintended, single, relatively short-term lapse in anti-VEGF treatment in patients with DME did not appear to result in significant anatomic or visual compromise upon resumption of regular follow-up and treatment.
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209
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EFFECT OF REIMBURSEMENT POLICY ON VISUAL OUTCOMES IN PATIENTS WITH DIABETIC MACULAR EDEMA TREATED WITH RANIBIZUMAB. Retina 2020; 40:2191-2197. [DOI: 10.1097/iae.0000000000002716] [Citation(s) in RCA: 2] [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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210
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Evaluation of a New Model of Care for People with Complications of Diabetic Retinopathy: The EMERALD Study. Ophthalmology 2020; 128:561-573. [PMID: 33130144 PMCID: PMC7980088 DOI: 10.1016/j.ophtha.2020.10.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/29/2020] [Accepted: 10/16/2020] [Indexed: 01/21/2023] Open
Abstract
Purpose The increasing diabetes prevalence and advent of new treatments for its major visual-threatening complications (diabetic macular edema [DME] and proliferative diabetic retinopathy [PDR]), which require frequent life-long follow-up, have increased hospital demands markedly. Subsequent delays in patient's evaluation and treatment are causing sight loss. Strategies to increase capacity are needed urgently. The retinopathy (EMERALD) study tested diagnostic accuracy, acceptability, and costs of a new health care pathway for people with previously treated DME or PDR. Design Prospective, multicenter, case-referent, cross-sectional, diagnostic accuracy study undertaken in 13 hospitals in the United Kingdom. Participants Adults with type 1 or 2 diabetes previously successfully treated DME or PDR who, at the time of enrollment, had active or inactive disease. Methods A new health care pathway entailing multimodal imaging (spectral-domain OCT for DME, and 7-field Early Treatment Diabetic Retinopathy Study [ETDRS] and ultra-widefield [UWF] fundus images for PDR) interpreted by trained nonmedical staff (ophthalmic graders) to detect reactivation of disease was compared with the current standard care (face-to-face examination by ophthalmologists). Main Outcome Measures Primary outcome: sensitivity of the new pathway. Secondary outcomes: specificity; agreement between pathways; costs; acceptability; proportions requiring subsequent ophthalmologist assessment, unable to undergo imaging, and with inadequate images or indeterminate findings. Results The new pathway showed sensitivity of 97% (95% confidence interval [CI], 92%–99%) and specificity of 31% (95% CI, 23%–40%) to detect DME. For PDR, sensitivity and specificity using 7-field ETDRS images (85% [95% CI, 77%–91%] and 48% [95% CI, 41%–56%], respectively) or UWF images (83% [95% CI, 75%–89%] and 54% [95% CI, 46%–61%], respectively) were comparable. For detection of high-risk PDR, sensitivity and specificity were higher when using UWF images (87% [95% CI, 78%–93%] and 49% [95% CI, 42%–56%], respectively, for UWF versus 80% [95% CI, 69–88%] and 40% [95% CI, 34%–47%], respectively, for 7-field ETDRS images). Participants preferred ophthalmologists’ assessments; in their absence, they preferred immediate feedback by graders, maintaining periodic ophthalmologist evaluations. When compared with the current standard of care, the new pathway could save £1390 per 100 DME visits and between £461 and £1189 per 100 PDR visits. Conclusions The new pathway has acceptable sensitivity and would release resources. Users’ suggestions should guide implementation.
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211
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Ciulla T, Pollack JS, Williams DF. Visual acuity outcomes and anti-VEGF therapy intensity in macular oedema due to retinal vein occlusion: a real-world analysis of 15 613 patient eyes. Br J Ophthalmol 2020; 105:1696-1704. [PMID: 33055088 PMCID: PMC8639936 DOI: 10.1136/bjophthalmol-2020-317337] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/25/2020] [Accepted: 09/13/2020] [Indexed: 02/03/2023]
Abstract
Background/Aims To assess visual acuity (VA) outcomes and antivascular endothelial growth factor (anti-VEGF) therapy intensity in retinal vein occlusion (RVO)-related macular oedema (ME). Methods A retrospective study was completed in treatment-naïve patients with RVO-related ME from 2013 to 2019, using the Vestrum Health Retina Database. Results Mean baseline age was 72.4 years and 54% were women. In 6 months, in 8876 eyes with branch retinal vein occlusion (BRVO)-related ME, after a mean of 4.5 anti-VEGF injections, VA increased by 9.4 letters (95% confidence interval (CI) for change in VA +8.94 to +9.78, p<0.001) from a baseline of 55.1 letters. In 6737 eyes with central retinal vein occlusion (CRVO)-related ME, after a mean of 4.6 anti-VEGF injections over 6 months, VA improved by 9.2 letters (95% CI +8.50 to +9.87, p<0.001) from a baseline of 37.2 letters. In 1 year, VA gain was similar (BRVO: 7.4 injections, +8.1 letters, 95% CI +7.55 to +8.57, p<0.001; CRVO: 7.6 injections, +7.1 letters, 95% CI +6.31 to +7.95, p<0.001). In 6 months and 1 year, mean letters gain increased with number of anti-VEGF injections. Patient eyes with baseline VA of 20/40 or better tended to lose VA in 1 year. Conclusion Mean change in VA correlates with treatment intensity, but patients with better VA at presentation are susceptible to vision loss, reflecting a ceiling effect. Assessed with the same database, VA gains compare favourably with 1-year VA gains in neovascular age-related macular degeneration and diabetic ME, but exhibit a larger gap when compared with corresponding randomised controlled trials.
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Affiliation(s)
- Thomas Ciulla
- Retina Service, Midwest Eye Institute, Indianapolis, Indiana, USA .,Indiana University School of Medicine, Indianapolis, Indiana, USA
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Choovuthayakorn J, Phinyo P, Tantraworasin A, Kunavisarut P, Patikulsila D, Chaikitmongkol V, Watanachai N, Pathanapitoon K. Intravitreal Anti-Vascular Endothelial Growth Factor Therapy for Diabetic Macular Edema in Clinical Practice of Single Center: Three-Year Outcomes. Ophthalmic Res 2020; 64:483-493. [PMID: 33053556 DOI: 10.1159/000512300] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/10/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The objective of this study was to explore visual and anatomical outcomes in patients who underwent intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection for visual impairment from center-involved diabetic macular edema (CI-DME) in clinical practice. METHODS Medical records of consecutive CI-DME patients who initiated treatment with intravitreal bevacizumab injection between January 2012 and December 2016 and were followed for at least 12 months were retrospectively reviewed. Visual and anatomical changes after treatment over a 36-month period were evaluated. RESULTS There were 286 patients (423 eyes) with a mean (standard deviation, SD) age of 56.8 (8.5) years included in this study. One hundred and forty-six (51%) patients were female, and 137 (47.9%) patients received bilateral eye treatment. Mean (SD) presenting visual acuity (VA) of overall eyes was 50.2 (19.6) letter scores. Stratified by baseline vision, eyes with initial VA worse than 20/40 achieved a statistically significant VA improvement, compared to baseline, by +8.4, +6.9, and +5.4 letters at 12, 24, and 36 months, respectively, with all p values <0.001. However, when initial VA was 20/40 and better, a non-statistically significant change in mean VA by +2.0, -3.5, and -3.6 letters were noted at the same time point (p value between 0.078 and 0.273). Unlike visual changes, a statistically significant decline in central subfield thickness compared to baseline was noted at the end of months 12, 24, and 36 in both initial VA subgroups (all p values <0.001). Nevertheless, even though the median number of given injections considerably decreased from 6 in the first 12 months to 2 in the second 12-month period and 1 in the final 12-month interval, required ophthalmic clinic visits decreased in frequency with median numbers of 10, 7, and 6 appointments in each consecutive 12-month duration. CONCLUSION This study supports the benefits of practical intravitreal anti-VEGF utilization to manage CI-DME in real-world settings. The improvement of vision in eyes presenting with poor baseline VA and maintenance of vision in eyes with better baseline VA were demonstrated through the 3-year review of each case. However, the burden of frequent monitoring warrants further evaluation of long-term compliance and efficacy.
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Affiliation(s)
- Janejit Choovuthayakorn
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Phichayut Phinyo
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Clinical Epidemiology and Clinical Statistics Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Apichat Tantraworasin
- Clinical Epidemiology and Clinical Statistics Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Paradee Kunavisarut
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Direk Patikulsila
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Voraporn Chaikitmongkol
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nawat Watanachai
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kessara Pathanapitoon
- Department of Ophthalmology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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213
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Vilà González M, Eleftheriadou M, Kelaini S, Naderi-Meshkin H, Flanagan S, Stewart S, Virgili G, Grieve DJ, Stitt AW, Lois N, Margariti A. Endothelial Cells Derived From Patients With Diabetic Macular Edema Recapitulate Clinical Evaluations of Anti-VEGF Responsiveness Through the Neuronal Pentraxin 2 Pathway. Diabetes 2020; 69:2170-2185. [PMID: 32796081 DOI: 10.2337/db19-1068] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 07/29/2020] [Indexed: 11/13/2022]
Abstract
Diabetic macular edema (DME) remains a leading cause of vision loss worldwide. DME is commonly treated with intravitreal injections of vascular endothelial growth factor (VEGF)-neutralizing antibodies. VEGF inhibitors (anti-VEGFs) are effective, but not all patients fully respond to them. Given the potential side effects, inconvenience, and high cost of anti-VEGFs, identifying who may not respond appropriately to them and why is essential. Herein we determine first the response to anti-VEGFs, using spectral-domain optical coherence tomography scans obtained from a cohort of patients with DME throughout the 1st year of treatment. We found that fluid fully cleared at some time during the 1st year in 28% of eyes ("full responders"); fluid cleared only partly in 66% ("partial responders"); and fluid remained unchanged in 6% ("nonresponders"). To understand this differential response, we generated induced pluripotent stem cells (iPSCs) from full responders and nonresponders, from subjects with diabetes but no DME, and from age-matched volunteers without diabetes. We differentiated these iPSCs into endothelial cells (iPSC-ECs). Monolayers of iPSC-ECs derived from patients with diabetes showed a marked and prolonged increase in permeability upon exposure to VEGF; the response was significantly exaggerated in iPSC-ECs from nonresponders. Moreover, phosphorylation of key cellular proteins in response to VEGF, including VEGFR2, and gene expression profiles, such as that of neuronal pentraxin 2, differed between full responders and nonresponders. In this study, iPSCs were used in order to predict patients' responses to anti-VEGFs and to identify key mechanisms that underpin the differential outcomes observed in the clinic. This approach identified NPTX2 as playing a significant role in patient-linked responses and as having potential as a new therapeutic target for DME.
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Affiliation(s)
| | | | - Sophia Kelaini
- Wellcome-Wolfson Institute for Experimental Medicine, Belfast, U.K
| | | | - Shonagh Flanagan
- Wellcome-Wolfson Institute for Experimental Medicine, Belfast, U.K
| | | | | | - David J Grieve
- Wellcome-Wolfson Institute for Experimental Medicine, Belfast, U.K
| | - Alan W Stitt
- Wellcome-Wolfson Institute for Experimental Medicine, Belfast, U.K
| | - Noemi Lois
- Wellcome-Wolfson Institute for Experimental Medicine, Belfast, U.K.
- The Belfast Health and Social Care Trust, Belfast, U.K
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214
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Golshani C, Conti TF, Conti FF, Silva FQ, Rachitskaya A, Yuan A, Schachat A, Kaiser PK, Singh RP, Babiuch A. Diabetic Macular Edema Treated With Intravitreal Aflibercept Injection After Treatment With Other Anti-VEGF Agents (SWAP-TWO Study)—12-Month Analysis. JOURNAL OF VITREORETINAL DISEASES 2020; 4:364-371. [PMID: 37008295 PMCID: PMC9979021 DOI: 10.1177/2474126420916074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: This article reports 12-month outcomes of patients with diabetic macular edema previously treated with other antivascular endothelial growth factor agents and transitioned to fixed dosing of intravitreal aflibercept (IAI). Methods: This prospective, single-arm study enrolled patients to receive IAI 2 mg (0.05 mL) every 4 weeks until optical coherence tomography demonstrated no fluid. Patients then received fixed dosing of IAI 2 mg once every 8 weeks through 12 months. Primary outcome was mean absolute change from baseline central subfield thickness (CST) at 12 months measured by optical coherence tomography. Results: Twenty eyes were enrolled. At baseline, best-corrected visual acuity was 70.0 letters, mean CST was 419.7 µm ± 92.0, superficial capillary perfusion density (CPD) was 46.0 ± 4.2%, and deep CPD was 50.8 ± 4.3%. At 12 months, the mean CST improved to 287.2 µm ± 80.2 ( P < .001), superficial CPD decreased to 43.6 ± 4.8% ( P = .04), and deep CPD decreased to 47.6 ± 4.8% ( P = .05). Conclusions: Patients who switched to fixed dosing of IAI demonstrated significant anatomic improvements in CST at 12 months. CPD values decreased significantly both in superficial and deep layers without significant changes in vision.
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Affiliation(s)
- Cyrus Golshani
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Thais F. Conti
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA
- Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Felipe F. Conti
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA
- Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA
- Federal University of São Paulo, São Paulo, Brazil
| | | | | | - Alex Yuan
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Rishi P. Singh
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA
- Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amy Babiuch
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA
- Center for Ophthalmic Bioinformatics, Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA
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215
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Yoshida S, Murakami T, Nozaki M, Suzuma K, Baba T, Hirano T, Sawada O, Sugimoto M, Takamura Y, Tsuiki E. Review of clinical studies and recommendation for a therapeutic flow chart for diabetic macular edema. Graefes Arch Clin Exp Ophthalmol 2020; 259:815-836. [PMID: 32997288 DOI: 10.1007/s00417-020-04936-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 09/03/2020] [Accepted: 09/10/2020] [Indexed: 12/25/2022] Open
Abstract
Diabetic macular edema (DME), characterized by exudative fluid accumulation in the macula, is the most common form of sight-threatening retinopathy in patients with diabetes. The management of DME has changed considerably in recent years, especially following the development of intravitreal anti-vascular endothelial growth factor therapy which has emerged as a first-line therapy for center-involved DME. Laser treatment, intravitreal steroid therapy, and vitrectomy are also important treatment options for DME. We believe that it is important to choose the most appropriate treatment option for DME based on the clinical evidences, in addition to the careful consideration of individual patients' general or ocular condition, DME characteristics, patients' motivation, and compliance to the treatment in real-world clinical practice. In this review, we have summarized important clinical evidences for the main treatments for DME, presented an expert review for these evidences, and proposed a recommended therapeutic flow chart for DME. We hope that our review of the clinical evidences and the recommended therapeutic flow chart for DME will contribute to better treatment outcome for DME.
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Affiliation(s)
- Shigeo Yoshida
- Department of Ophthalmology, Kurume University School of Medicine, 67 Asahi-machi, Kurume-shi, Fukuoka, 830-0011, Japan.
| | - Tomoaki Murakami
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, 54 Shogoin-Kawaharacho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Miho Nozaki
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, 1-Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya-Shi, Aichi, 467-8601, Japan
| | - Kiyoshi Suzuma
- Department of Ophthalmology, Kagawa University Faculty of Medicine, 1750-1 Ikenobe, Miki-cho, Kagawa, Kita-gun, 761-0793, Japan
| | - Takayuki Baba
- Department of Ophthalmology and Visual Science, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8677, Japan
| | - Takao Hirano
- Department of Ophthalmology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto-shi, Nagano, 390-8621, Japan
| | - Osamu Sawada
- Department of Ophthalmology, Shiga University of Medical Science, Seta Tsukinowa-cho, Otsu-shi, Shiga, 520-2192, Japan
| | - Masahiko Sugimoto
- Department of Ophthalmology, Mie University Graduate School of Medicine, 2-174, Edobashi, Tsu-shi, Mie, 514-8507, Japan
| | - Yoshihiro Takamura
- Department of Ophthalmology, Faculty of Medical Sciences, University of Fukui, 23-3, Matsuokashimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
| | - Eiko Tsuiki
- Department of Ophthalmology and Visual Sciences, Graduate School of Biomedical Sciences, Nagasaki University, Sakamoto 1-7-1, Nagasaki-shi, Nagasaki, 852-8523, Japan
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Li AS, Veerappan M, Mittal V, Do DV. Anti-VEGF agents in the management of diabetic macular edema. EXPERT REVIEW OF OPHTHALMOLOGY 2020. [DOI: 10.1080/17469899.2020.1806713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Angela S. Li
- Stanford University School of Medicine, Stanford University, Palo Alto, CA, USA
- Department of Ophthalmology, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Malini Veerappan
- Stanford University School of Medicine, Stanford University, Palo Alto, CA, USA
- Department of Ophthalmology, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Vaishali Mittal
- Stanford University School of Medicine, Stanford University, Palo Alto, CA, USA
- Department of Ophthalmology, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Diana V. Do
- Stanford University School of Medicine, Stanford University, Palo Alto, CA, USA
- Department of Ophthalmology, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
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217
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Petrachkov DV, Budzinskaya MV, Arzhukhanov DD. [The role of internal limiting membrane peeling in the treatment of diabetic macular edema]. Vestn Oftalmol 2020; 136:359-366. [PMID: 32880162 DOI: 10.17116/oftalma2020136042359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Analysis of the current understanding of the role of internal limiting membrane in the pathogenesis of diabetic macular edema and the feasibility of its surgical removal is based on data from domestic and international literature on pathogenesis, clinical manifestations, outcomes of multicenter studies of treatment and prognosis of this disease. The advantages and disadvantages of both peeling and preservation of the inner limiting membrane are described. The limitations and inconsistencies of data provided by the authors of each theory requires more complete functional studies in the pre- and postoperative periods, increasing the selection of patients, modifying the criteria for inclusion in groups, and microscopic examination of removed membranes. Thus, this issue requires further study due to the ambiguity of the conclusions and the lack of comparative data on the long-term prospects of each of the methods.
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218
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Tiosano L, Ayalon A, Banin E, Averbukh E, Jaouni T, Chowers I. Correlation of Response between Both Eyes to First- and Second-Line Anti-VEGF Therapy in Diabetic Macular Edema. Curr Eye Res 2020; 46:539-545. [PMID: 32804540 DOI: 10.1080/02713683.2020.1812085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE To evaluate the anatomical correlation between fellow eyes for bilateral second-line anti-VEGF treatment in eyes with bilateral diabetic macular edema (DME) with incomplete response to first-line bevacizumab therapy. METHODS Seventy-four eyes (n = 37 patients) with bilateral-DME having incomplete response to first-line bevacizumab therapy that were switched for bilateral treatment with ranibizumab were retrospectively evaluated. Data collected included demographics, visual acuity and macular thickness. We evaluate the correlation for the response of both eyes in terms of macular thickness and visual acuity. RESULTS The mean±SD age was 76 ± 8 years. The mean±SD number of bevacizumab injections prior the switch was 11.03 ± 5.1 in the first eye (FE) and 10.9 ± 5.2 in the second eye (SE). The central subfield thickness (CST) reduced from 472 ± 171 microns at baseline to 418 ± 161 after the last bevacizumab injection and 365 ± 74 after 3 ranibizumab injections in the FE (p = .016, p = .004, respectively), and from 463 ± 145 microns to 446 ± 123, and 421 ± 103 in the SE (p = .112, p = .001, respectively). There was strong positive correlation between the eyes for the CST reduction under bevacizumab and ranibizumab treatments in each visit. BCVA± SD at baseline was 0.41 ± 0.30 LogMAR in the FE, and 0.42 ± 0.29 in the SE (p = .44). After 3 injections of bevacizumab, the BCVA was 0.37 ± 0.26 and 0.42 ± 0.23 in FE and SE respectively (p = .013, p = .132, respectively). CONCLUSIONS This study demonstrated a strong anatomical correlation responses between the eyes in patients with bilateral DME for both first-line bevacizumab therapy and second-line ranibizumab therapy. Response to second-line therapy was favorable and correlated among eyes regardless they were from the same or different individuals.
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Affiliation(s)
- Liran Tiosano
- Department of Ophthalmology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Anfisa Ayalon
- Department of Ophthalmology, Meir Medical Center, Kfar Saba, and the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Banin
- Department of Ophthalmology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Edward Averbukh
- Department of Ophthalmology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Tareq Jaouni
- Department of Ophthalmology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Itay Chowers
- Department of Ophthalmology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Abdelghany AA, Toraih EA, Mohamed AA, Lashine RM, Mohammad MHS, Nafie MS, Fawzy MS. Association of VEGF Gene Family Variants with Central Macular Thickness and Visual Acuity after Aflibercept Short-Term Treatment in Diabetic Patients: A Pilot Study. Ophthalmic Res 2020; 64:261-272. [PMID: 32836220 DOI: 10.1159/000511087] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 08/20/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Diabetic retinopathy (DR) is one of the major vision-threatening causes worldwide. Searching for an individualized therapeutic strategy to prevent its progress is challenging. OBJECTIVE This work aimed to investigate the association of angiogenesis-inducer vascular endothelial growth factor (VEGF) gene family and related receptor variants (rs833069, rs12366035, rs7664413, rs7993418, and rs2305948) with susceptibility of DR and the response to 1 dose of aflibercept treatment in type 2 diabetes mellitus (T2DM). METHODS Consecutive eligible patients with T2DM (n = 125) and 110 unrelated controls were enrolled in this preliminary prospective case-controlled study. Genotyping was identified using TaqMan real-time PCR. Adjusted odds ratio (OR) with 95% confidence interval (CI) was applied to assess the strength of the association with the clinical/ophthalmological characteristics and early response to intravitreal aflibercept treatment in terms of improved visual acuity (BCVA) and central macular thickness (CMT). RESULTS We found that both VEGFB rs12366035 and VEGFC rs7664413 conferred higher risk for DR progression under allelic (OR [95% CI]: 1.71 [1.07-2.74]), homozygote comparison (3.55 [1.32-9.57]), and recessive (3.77 [1.43-9.93]) models for the former and under allelic (2.09 [1.25-3.490, homozygote comparison (2.76 [1.02-7.45]), and recessive (2.62 [0.98-6.98] models for the latter. In contrast, VEGFR1 rs7993418 conferred protection against DR under heterozygote comparison and dominant models. The rs12366035*T/T genotype showed the worst pretreatment BCVA score (0.35 ± 0.24) compared to other corresponding genotypes (0.66 ± 0.26 in C/T and 0.54 ± 0.25 in C/C carriers) (p = 0.008). Meanwhile, patients with rs7993418*G/G of VEGFR1 exhibited a significant reduction in CMT after aflibercept injection (12.26 ± 35.43 µ in G/G vs. 3.57 ± 8.74 µ in A/A) (p = 0.037). CONCLUSIONS Polymorphisms of the studied VEGF/receptors could be considered as genetic risk factors of DM/DR development and could play an important role in aflibercept early response for DR patients in the study population.
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Affiliation(s)
- Ahmed A Abdelghany
- Department of Ophthalmology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Eman A Toraih
- Department of Surgery, Tulane University, School of Medicine, New Orleans, Louisiana, USA.,Department of Histology and Cell Biology (Genetics Unit), Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Ahmed A Mohamed
- Department of Ophthalmology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Rehab M Lashine
- Department of Clinical Pharmacology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Mai H S Mohammad
- Department of Clinical Pathology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Mohamed S Nafie
- Department of Chemistry, Faculty of Science, Suez Canal University, Ismailia, Egypt
| | - Manal S Fawzy
- Department of Medical Biochemistry and Molecular Biology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt, .,Department of Biochemistry, Faculty of Medicine, Northern Border University, Arar, Saudi Arabia,
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220
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Mukai R, Matsumoto H, Akiyama H. Surgical outcomes of vitrectomy for intractable diabetic macular edema. Graefes Arch Clin Exp Ophthalmol 2020; 259:363-368. [PMID: 32816100 DOI: 10.1007/s00417-020-04898-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/06/2020] [Accepted: 08/16/2020] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To investigate clinical outcomes of vitrectomy for intractable diabetic macular edema (DME) in which anti-vascular endothelial growth factor (anti-VEGF) agents or periocular steroid were not effective. METHODS This retrospective study examined 27 eyes of 25 cases. The main measurements included changes in visual acuity (VA) and retinal morphology. Vitrectomies were performed using the Constellation System 25G. RESULTS Prior to undergoing vitrectomy, patients were treated with anti-VEGF agents or periocular injection of triamcinolone acetonide. The average number of anti-VEGF agent injections was 3.1 ± 2.8. Triamcinolone was used in 15 eyes. There was no significant change in the mean logMAR best-corrected visual acuity (BCVA) between baseline and posttreatment, with values of 0.49 ± 0.29 and 0.55 ± 0.33, respectively (P = 0.31). Compared with preoperative BCVA, postoperative BCVA improved by more than two lines in 4 eyes (14%), remained the same in 17 eyes (63%), and decreased in 6 eyes (23%). Morphologically, retinal thickness improved by more than 50 μm in 16 eyes (59%), remained unchanged in 7 eyes (26%), and increased in 5 eyes (18%). Retinal edema resolved in all of the cases in which macular epiretinal membrane (ERM) or vitreomacular traction (VMT) was detected by optical coherence tomography during pretreatment. CONCLUSIONS Vitrectomy can potentially stabilize the retinal morphology in intractable DME and is likely more effective in DME cases accompanied by ERM or VMT.
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Affiliation(s)
- Ryo Mukai
- Department of Ophthalmology, Gunma University Graduate School of Medicine, 3-35-15 Showa-cho, Maebashi, Gunma, 371-8511, Japan.
| | - Hidetaka Matsumoto
- Department of Ophthalmology, Gunma University Graduate School of Medicine, 3-35-15 Showa-cho, Maebashi, Gunma, 371-8511, Japan
| | - Hideo Akiyama
- Department of Ophthalmology, Gunma University Graduate School of Medicine, 3-35-15 Showa-cho, Maebashi, Gunma, 371-8511, Japan
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221
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Keles A, Sonmez K, Erol YO, Ayyıldız SN, Ogus E. Vitreous levels of vascular endothelial growth factor, stromal cell-derived factor-1α, and angiopoietin-like protein 2 in patients with active proliferative diabetic retinopathy. Graefes Arch Clin Exp Ophthalmol 2020; 259:53-60. [PMID: 32813109 DOI: 10.1007/s00417-020-04889-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/04/2020] [Accepted: 08/06/2020] [Indexed: 12/31/2022] Open
Abstract
PURPOSE To determine the vitreous levels of vascular endothelial growth factor (VEGF), stromal cell-derived factor-1α (SDF-1α) and angiopoietin-like protein 2 (ANGPTL2) in patients with active proliferative diabetic retinopathy (PDR), and to ascertain their contribution on different clinical presentation of active PDR. METHODS This case-control study included 31 eyes with active PDR and 10 eyes with idiopathic macular hole (MH) (control group). Eyes with active PDR were divided into three subgroups: vitreous hemorrhage (VH), tractional retinal detachment (TRD) caused by active fibrovascular membrane (FVM), and coexistence of VH and TRD with FVM. Vitreous samples obtained during vitrectomy were analyzed for concentrations of VEGF, SDF-1α, and ANGPTL2. RESULTS Vitreous level of VEGF (2021 (168-6550) pg/ml vs 110.1 (74.5-236) pg/ml), SDF-1α (517 (194-1044) pg/ml vs 388 (320-535) pg/ml), and ANGPTL2 (725 (131-1590) ng/ml vs 196 (75.9-437) ng/ml) were significantly higher in eyes with active PDR than in control group (p < 0.001, p = 0.002, and p < 0.001, respectively). The concentrations of these meaditors in each active PDR subgroups were also significantly higher than control group (p < 0.05). The vitreous level of ANGPTL2 was significantly higher in eyes with TRD caused by FVM (1033 ± 401 ng/ml) than in eyes with VH (561 ± 237 ng/ml; p = 0.008). CONCLUSION High levels of SDF-1α, ANGPTL2 and particularly VEGF seem to be associated with PDR. Since the vitreous levels of ANGPTL2 tend to be higher in eyes with active fibrovascular tractional detachment, vitreous levels of this chemokine seem to be affected by the clinical presentation of vascularly active PDR eyes.
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Affiliation(s)
- Ali Keles
- Department of Ophthalmology, Cizre State Hospital, Sırnak, Turkey
| | - Kenan Sonmez
- Ulucanlar Eye Training and Research Hospital, University of Health Sciences, Kale Mh. Ulucanlar Cd. No:59, 06250, Altındag, Ankara, Turkey.
| | - Yasemin Ozdamar Erol
- Ulucanlar Eye Training and Research Hospital, University of Health Sciences, Kale Mh. Ulucanlar Cd. No:59, 06250, Altındag, Ankara, Turkey
| | - Sema Nur Ayyıldız
- Department of Medical Biochemistry, Ankara Training and Research Hospital, Ankara, Turkey
| | - Elmas Ogus
- Department of Medical Biochemistry, Ankara Training and Research Hospital, Ankara, Turkey
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Barakat MR, Wykoff CC, Gonzalez V, Hu A, Marcus D, Zavaleta E, Ciulla TA. Suprachoroidal CLS-TA plus Intravitreal Aflibercept for Diabetic Macular Edema: A Randomized, Double-Masked, Parallel-Design, Controlled Study. Ophthalmol Retina 2020; 5:60-70. [PMID: 32829027 DOI: 10.1016/j.oret.2020.08.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 07/21/2020] [Accepted: 08/14/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE This study evaluated the potential safety, efficacy, and durability advantages of investigational triamcinolone acetonide suspension (CLS-TA; Clearside Biomedical, Alpharetta, GA) administered suprachoroidally in conjunction with intravitreal aflibercept compared with aflibercept monotherapy for treatment of diabetic macular edema (DME). DESIGN TYBEE was a prospective, controlled, double-masked study. Patients were randomized 1:1 to CLS-TA and aflibercept (active) or aflibercept monotherapy (control), and assessed over 24 weeks. PARTICIPANTS Treatment-naive DME patients with best-corrected visual acuity (BCVA) of 20 to 70 letters and central subfield retinal thickness (CST) of more than 300 μm. METHODS Patients in the active group (n = 36) received CLS-TA and aflibercept at baseline and week 12. Patients in the control group (n = 35) received aflibercept at baseline, week 4, week 8, and week 12. To mask both groups, sham suprachoroidal and intravitreal injections were utilized. All patients were eligible to receive aflibercept as needed at weeks 4, 8, 16, and 20 per prespecified criteria. MAIN OUTCOME MEASURE Mean change in BCVA from baseline. Treatment differences were assessed with a 2-sided significance level of 0.10. RESULTS Mean BCVA changes from baseline to week 24 were not statistically different in the active and control groups (intention-to-treat [ITT] population: +11.4 letters and +13.8 letters [P = 0.288]; per protocol [PP] population: +12.3 letters and +13.5 letters [P = 0.664]; respectively). Greater improvement in CST was seen in the active versus control group (ITT population: -212.1 μm and -178.6 μm [P = 0.089]; PP population: -226.5 μm and -176.1 μm [P = 0.035]; respectively). Compared with the control group, eyes in the active group received fewer treatments (scheduled plus as-needed treatments averaging 4.6 versus 2.6, respectively). No treatment-related serious adverse events were observed. Ocular adverse events were low for both arms. Cataract events, all assessed as unrelated to treatment, and events of elevated intraocular pressure trended higher in the active group. CONCLUSIONS CLS-TA administered suprachoroidally in conjunction with intravitreal aflibercept for treatment of DME provides simliar visual benefit at 24 weeks' follow-up compared with aflibercept monotherapy, is well tolerated and shows modest anatomic benefit with potential to reduce treatment burden.
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Affiliation(s)
| | - Charles C Wykoff
- Retina Consultants of Houston, Houston, Texas; Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas
| | | | - Allen Hu
- Cumberland Valley Retina Consultants, Hagerstown, Maryland
| | | | - Eric Zavaleta
- West Texas Retina Consultants, LLC, Abilene, Texas; Retina Research Institute of Texas, Abilene, Texas
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Di Y, Li Z, Ye J, Li L, Li B, Yu R. The fellow eye effect of unilateral intravitreal conbercept injections in eyes with diabetic macular edema. Acta Diabetol 2020; 57:1001-1007. [PMID: 32215730 DOI: 10.1007/s00592-020-01511-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 02/29/2020] [Indexed: 12/14/2022]
Abstract
AIMS To investigate whether intravitreal conbercept injection affects contralateral untreated eyes in bilateral diabetic macular edema (DME) patients. METHODS In this retrospective study, 15 patients (30 eyes) with type 2 diabetes were followed after bilateral DME diagnosis in the Department of Ophthalmology, Peking Union Medical College Hospital from 2015 to 2018. Patients underwent examinations including best corrected visual acuity (BCVA), slit-lamp microscopy, indirect ophthalmoscope, color fundus photography, fundus fluorescein angiography, optical coherence tomography, and glycated hemoglobin (HbA1c). Each patient received conbercept (0.5 mg) intravitreally in the severe eye. Nonparametric Wilcoxon signed-rank tests and Pearson's correlation coefficient were used to assess changes in BCVA and central retinal thickness (CRT) and relations between BCVA changes in treated and untreated eyes, respectively. RESULTS The mean follow-up time was 10.60 ± 2.29 months, and the mean injection number of 15 treated eyes was 9.13 ± 0.68. HbA1c remained below 10% during treatment with no significant changes between the initial and final visits (7.81 ± 1.17 vs 7.62 ± 1.19%) (P = 0.576). In untreated eyes, CRT significantly decreased from the initial to final visits (368.93 ± 125.45 vs 306.27 ± 89.70 μm) (P = 0.028). In untreated eyes, BCVA showed no significant difference between the initial and final visits (0.38 ± 0.30 vs 0.40 ± 0.30 logMAR) (P = 0.937), but BCVA changes in treated and untreated eyes were positively correlated (r = 0.527, P = 0.044). CONCLUSIONS Intravitreal conbercept injection results in decreased CRT and increased BCVA in untreated eyes, which is consistent with the changes in treated eyes for patients with bilateral DME.
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Affiliation(s)
- Yu Di
- Department of Ophthalmology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Zhiqing Li
- Tianjin Medical University Eye Hospital, Tianjin, 300384, China
| | - Junjie Ye
- Department of Ophthalmology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China.
| | - Lue Li
- Department of Ophthalmology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Bing Li
- Department of Ophthalmology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Rongguo Yu
- Tianjin Medical University Eye Hospital, Tianjin, 300384, China
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Chatzirallis A, Theodossiadis P, Droutsas K, Koutsandrea C, Ladas I, Moschos MM. Ranibizumab versus aflibercept for diabetic macular edema: 18-month results of a comparative, prospective, randomized study and multivariate analysis of visual outcome predictors. Cutan Ocul Toxicol 2020; 39:317-322. [PMID: 32722955 DOI: 10.1080/15569527.2020.1802741] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE The purpose of this study was to compare the anatomical and functional outcomes of ranibizumab versus aflibercept for the treatment of diabetic macular edema (DME) in a long-term follow-up. METHODS Participants in this prospective study were 112 treatment naïve patients with DME, who received treatment with either intravitreal ranibizumab (n = 54) or aflibercept (n = 58). The demographic data, the best-corrected visual acuity (BCVA) and spectral-domain optical coherence tomography (SD-OCT) characteristics were evaluated at baseline and at month 1, 2, 3, 6, 12, and 18 post treatment, while factors affecting visual outcome were determined using multivariate analysis. RESULTS At month 18, the mean BCVA of ranibizumab-treated eyes increased 7.9 letters compared to 6.9 letters for eyes receiving aflibercept, with greater number of injections in ranibizumab group (9.2 ± 2.3 vs. 7.6 ± 2.1 injections in the ranibizumab and aflibercept group respectively, p = 0.0002). The difference in letters between the two groups was not statistically significant, nor the difference in central subfield thickness at month 18. Factors associated with poorer BCVA were found to be increasing age, HbA1c ≥7.5%, increasing central retinal thickness and disrupted ellipsoid zone. CONCLUSIONS Ranibizumab and aflibercept presented similar anatomical and functional outcomes in 18-month follow-up in patients with DME. It is important to determine factors, affecting VA, so as to provide individualized treatment.
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Affiliation(s)
| | | | - Konstantinos Droutsas
- 1st Department of Ophthalmology, National and Kapodistrian University of Athens, Athens, Greece
| | - Chryssanthi Koutsandrea
- 1st Department of Ophthalmology, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Ladas
- 1st Department of Ophthalmology, National and Kapodistrian University of Athens, Athens, Greece
| | - Marilita M Moschos
- 1st Department of Ophthalmology, National and Kapodistrian University of Athens, Athens, Greece
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Özsaygili C, Küçük B, Yildirim Y. The effect of posterior vitreous detachment on aflibercept response in diabetic macular oedema. Br J Ophthalmol 2020; 105:800-805. [PMID: 32727727 DOI: 10.1136/bjophthalmol-2020-316155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 03/23/2020] [Indexed: 01/12/2023]
Abstract
PURPOSE To investigate the effect of posterior vitreous detachment (PVD) on aflibercept response in treatment-naïve diabetic macular oedema (DME). DESIGN A retrospective cohort study. METHODS One hundred and fifty eyes of 150 treatment-naïve patients with DME were enrolled. The patients were divided into three groups according to their PVD status: group 1 (no PVD during injections), group 2 (PVD during injections) and group 3 (PVD already present initially). Three consecutive aflibercept injections at intervals of 1 month were applied to all patients. The efficacy of the aflibercept treatment on DME was assessed by comparing changes in central retinal thickness (CRT) and best-corrected visual acuity (BCVA) values after three loading dose injections. RESULTS After three consecutive injections, the mean reduction of CRT in groups 1, 2 and 3 were -199.6±106.9, -224.9±124.1 and -210.7±126.3, respectively. The decrease in CRT was significant in all groups (p<0.001 in all groups, paired-samples t-test); however, mean changes in CRT were similar among groups (all p>0.05, one-way analysis of variance (ANOVA)). The mean improvement in BCVA in groups 1, 2 and 3 was 6.6±0.9, 6.5±0.8 and 6.1±0.4 ETDRS letters, respectively. The improvement of BCVA was significant in all groups (p<0.001 in all groups, paired-samples t-test) and mean changes were similar between groups (p>0.05, one-way ANOVA). There was no significant relationship between the presence or development of PVD and the mean decrease of CRT and improvement of BCVA (for CRT r=-0.052, p=0.531 and for BCVA r=-0.078, p=0.342). CONCLUSION In the present study, it was observed that the efficacy of aflibercept treatment in patients with DME did not depend on PVD status.
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Affiliation(s)
- Cemal Özsaygili
- Kayseri City Training and Research Hospital, Kayseri, Turkey
| | - Bekir Küçük
- Kayseri City Training and Research Hospital, Kayseri, Turkey
| | - Yener Yildirim
- Kayseri City Training and Research Hospital, Kayseri, Turkey
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226
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Dhoot DS, Hill LF, Ghanekar A, Tarnowski KW, Ali FS. Baseline Factors Associated with Diabetic Retinopathy Improvement in RIDE/RISE. Ophthalmol Retina 2020; 5:101-103. [PMID: 32688084 DOI: 10.1016/j.oret.2020.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/13/2020] [Indexed: 11/25/2022]
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227
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Shiono A, Sasaki H, Sekine R, Abe Y, Matsumura Y, Inagaki T, Tanaka T, Kodama T, Aburatani H, Sakai J, Takagi H. PPARα activation directly upregulates thrombomodulin in the diabetic retina. Sci Rep 2020; 10:10837. [PMID: 32616724 PMCID: PMC7331602 DOI: 10.1038/s41598-020-67579-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 06/08/2020] [Indexed: 12/19/2022] Open
Abstract
Two large clinical studies showed that fenofibrate, a commonly used peroxisome proliferator-activated receptor α (PPARα) agonist, has protective effects against diabetic retinopathy. However, the underlying mechanism has not been clarified. We performed genome-wide analyses of gene expression and PPARα binding sites in vascular endothelial cells treated with the selective PPARα modulator pemafibrate and identified 221 target genes of PPARα including THBD, which encodes thrombomodulin (TM). ChIP-qPCR and luciferase reporter analyses showed that PPARα directly regulated THBD expression via binding to the promoter. In the rat diabetic retina, treatment with pemafibrate inhibited the expression of inflammatory molecules such as VCAM-1 and MCP1, and these effects were attenuated by intravitreal injection of small interfering RNA targeted to THBD. Furthermore, pemafibrate treatment inhibited diabetes-induced vascular leukostasis and leakage through the upregulation of THBD. Our results indicate that PPARα activation inhibits inflammatory and vasopermeable responses in the diabetic retina through the upregulation of TM.
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Affiliation(s)
- Akira Shiono
- Department of Ophthalmology, St. Marianna University of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, Japan
| | - Hiroki Sasaki
- Department of Ophthalmology, St. Marianna University of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, Japan
| | - Reio Sekine
- Department of Ophthalmology, St. Marianna University of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, Japan
| | - Yohei Abe
- Division of Metabolic Medicine, The University of Tokyo, RCAST, 4-6-1 Komaba, Meguro-ku, Tokyo, Japan
| | - Yoshihiro Matsumura
- Division of Metabolic Medicine, The University of Tokyo, RCAST, 4-6-1 Komaba, Meguro-ku, Tokyo, Japan
| | - Takeshi Inagaki
- Laboratory of Epigenetics and Metabolism, IMCR, Gunma University, 3-39-15 Showa-cho, Maebashi, Gunma, Japan
| | - Toshiya Tanaka
- Research Center for Advanced Science and Technology, The University of Tokyo, 4-6-1 Komaba, Meguro-ku, Tokyo, Japan
| | - Tatsuhiko Kodama
- Research Center for Advanced Science and Technology, The University of Tokyo, 4-6-1 Komaba, Meguro-ku, Tokyo, Japan
| | - Hiroyuki Aburatani
- Genome Science Division, The University of Tokyo, 4-6-1 Komaba, Meguro-ku, Tokyo, Japan
| | - Juro Sakai
- Division of Metabolic Medicine, The University of Tokyo, RCAST, 4-6-1 Komaba, Meguro-ku, Tokyo, Japan.,Molecular Physiology and Metabolism Division, Tohoku University Graduate School of Medicine, 2-1 Seiryo-cho, Aoba, Sendai, Miyagi, Japan
| | - Hitoshi Takagi
- Department of Ophthalmology, St. Marianna University of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, Japan.
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An open-source data set of anti-VEGF therapy in diabetic macular oedema patients over 4 years and their visual acuity outcomes. Eye (Lond) 2020; 35:1354-1364. [PMID: 32591734 DOI: 10.1038/s41433-020-1048-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 06/10/2020] [Accepted: 06/16/2020] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVES The objective of this paper is to evaluate visual acuity (VA) outcomes of intravitreal anti-vascular endothelial growth factor (VEGF) in diabetic macular oedema (DMO). METHODS In this retrospective cohort study, electronic medical records for all patients undergoing intravitreal injections in a tertiary referral centre between March 2013 and October 2018 were analysed. Treatment response in terms of VA outcomes was reported for all eyes over a 4-year observation period. RESULTS Our cohort includes 2614 DMO eyes of 1964 patients over 48 months. Cox proportional-hazards modelling identified injection number (hazard ratio (HR) = 1.18), male gender (HR = 1.13) and baseline VA (HR = 1.09) as independent predictors to reach a favourable visual outcome of more than 70 Early Treatment Diabetic Retinopathy Study letters. Half of our cohort reached 70 letters 1.9 months after starting anti-VEGF therapy. Of those that reached 70 letters, 50% fell below 70 letters by 14.7 months. CONCLUSION To date, this is the largest single centre cohort study and over the longest observation period reporting on real-life outcomes of anti-VEGF in DMO. We have made an anonymised version of our data set available on an open-source data repository as a resource for clinical researchers globally.
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Blindbæk SL, Peto T, Grauslund J. Aflibercept and navigated versus conventional laser in diabetic macular oedema: a 12-month randomized clinical trial. Acta Ophthalmol 2020; 98:347-352. [PMID: 31602811 DOI: 10.1111/aos.14266] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/14/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE To examine the efficacy of intravitreal aflibercept and navigated laser as compared to intravitreal aflibercept and conventional laser in diabetic macular oedema (DME) treatment. METHODS In 12-month randomized clinical trial, 48 eyes of 37 patients with centre-involved DME at Odense University Hospital were randomized 1:1 to receive three monthly injections of aflibercept followed by navigated (group A) or conventional (group B) focal/grid laser. From month four through twelve, patients were examined monthly, and additional injections were given pro re nata (PRN) (central retinal thickness [CRT]>20% from lowest measurement or loss in visual acuity [VA]>5 Early Treatment Diabetic Retinopathy Study [ETDRS] letters compared with baseline). Outcome measures; (1) percentage of eyes that needed additional injections after laser in group A and B, (2) mean number of injections in group A and B, and (3) mean change in VA and CRT in group A and B. RESULTS In the PRN phase, 60.5% of patients needed additional injections without differences between groups A and B (58.3 versus 63.2%, p > 0.99). The mean number of injections between baseline and month 12 was 4.4 (4.2 versus 4.6, p = 0.41). From baseline to month 12, VA improved by 8.4 ETDRS letters, and CRT was reduced by 97.4 μm (+9.4 versus +7.1 letters, p = 0.17, and -83.2 versus -115.4 μm, p = 0.21). CONCLUSION No difference in need for retreatment was detected between treatment arms of aflibercept and navigated versus conventional laser.
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Affiliation(s)
- Søren L. Blindbæk
- Department of Ophthalmology Odense University Hospital Odense Denmark
- Department of Clinical Research University of Southern Denmark Odense Denmark
- OPEN, Odense Patient Data Explorative Network Odense University Hospital Odense Denmark
| | - Tunde Peto
- Department of Clinical Research University of Southern Denmark Odense Denmark
- Centre for Public Health Queen's University Belfast Belfast UK
| | - Jakob Grauslund
- Department of Ophthalmology Odense University Hospital Odense Denmark
- Department of Clinical Research University of Southern Denmark Odense Denmark
- Steno Diabetes Center Odense Odense Denmark
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231
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Relationships among Retinal Nonperfusion, Neovascularization, and Vascular Endothelial Growth Factor Levels in Quiescent Proliferative Diabetic Retinopathy. J Clin Med 2020; 9:jcm9051462. [PMID: 32414164 PMCID: PMC7290947 DOI: 10.3390/jcm9051462] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/09/2020] [Accepted: 05/11/2020] [Indexed: 01/18/2023] Open
Abstract
Purpose: To investigate the relationships among the retinal nonperfusion (NP) area, neovascularization (NV) area, and aqueous humor vascular endothelial growth factor (VEGF) levels in quiescent proliferative diabetic retinopathy (PDR). Methods: Forty-seven eyes from 47 patients with treatment-naïve PDR that did not show macular edema or vitreous hemorrhage were enrolled. NP area, NV number, and NV area were quantitatively measured using ultra-widefield fluorescein angiography in an automated manner. Aqueous humor VEGF level was measured using a bead assay. Results: The NP areas of the total, posterior pole, peripheral retinae, and NV area positively correlated with each other (all p < 0.034). NV number correlated with total NP area, peripheral NP area, and NV area (all p ≤ 0.001). VEGF levels were significantly positively correlated with total, posterior polar, and peripheral NP areas and NV area (r = 0.575, 0.422, 0.558, and 0.362, respectively; all p ≤ 0.012). In eyes with NV in the disc area, the VEGF level was higher compare to eyes without NV in the disc area (208.89 ± 192.77 pg/mL vs. 103.34 ± 132.66, p = 0.010). A multiple linear regression model using NP area, NV area, and NVD demonstrated good prediction for VEGF level (R2 = 0.417, p < 0.001) and revealed a significant contribution of the peripheral NP area in predicting the VEGF level (β = 0.497, p = 0.002). Conclusions: Aqueous humor VEGF levels in quiescent PDR eyes were associated with NP and NV areas, which had positive correlations with each other. In addition, the NP area of the peripheral retina was the most important predictor of VEGF level.
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Biechl AC, Bhandari S, Nguyen V, Arnold JJ, Young S, Fraser-Bell S, Mehta H, Gillies M, Barthelmes D. Changes in real-world treatment patterns for diabetic macular oedema from 2009 to 2019 and 5-year outcomes: Data from the Fight Retinal Blindness! Registry. Clin Exp Ophthalmol 2020; 48:802-812. [PMID: 32383527 DOI: 10.1111/ceo.13781] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/30/2020] [Accepted: 05/03/2020] [Indexed: 12/22/2022]
Abstract
IMPORTANCE Evaluating the treatment outcomes of diabetic macular oedema (DMO) in routine clinical practice provides data for comparison with those of clinical trials. BACKGROUND Phase 3 clinical trials of vascular endothelial growth factor (VEGF) inhibitors for DMO have reported significant improvements in visual acuity (VA) not previously reported with laser and steroid treatments. DESIGN Retrospective analysis of observational data from routine clinical practice. PARTICIPANTS Eyes receiving treatments for DMO tracked in the Fight Retinal Blindness! Registry. METHODS We analysed 510 eyes (347 patients) that started DMO treatment between 2009 and 2014. MAIN OUTCOME MEASURES Changes in DMO treatment patterns and mean change in VA (letters logMAR) and central subfield thickness (CST) 5 years after starting treatment. RESULTS Treatment choice for DMO changed to predominantly VEGF inhibitors from 2009 to 2014. A total of 238 eyes (47%) were followed for at least 5 years. The mean VA at the start of treatment improved from 2009 (58 letters) to 2014 (68 letters) while mean VA change at 5 years were + 4.5 and + 5.3 letters for eyes starting treatment in 2009 and 2014, respectively. The mean CST dropped from 401 μm at baseline to 314 μm at 5 years. Eyes received a median of four injections in the first, two in the second, third and fourth and three in the fifth years. CONCLUSIONS AND RELEVANCE Changing the treatment of DMO from macular laser and intravitreal triamcinolone to VEGF inhibitors from 2011 onwards was associated with better VA outcomes, part of which were due to better VA at the start of treatment. The outcomes of treatment in eyes in real-world practice were, however, worse than those reported by clinical trials, likely because they were undertreated.
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Affiliation(s)
- Anne C Biechl
- Department of Ophthalmology, University of Zurich, Zurich, Switzerland
| | - Sanjeeb Bhandari
- Sydney Medical School, Discipline of Ophthalmology and Eye Health, Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Vuong Nguyen
- Sydney Medical School, Discipline of Ophthalmology and Eye Health, Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Stephanie Young
- Gladesville Eye Specialists, Gladesville, New South Wales, Australia
| | - Samantha Fraser-Bell
- Sydney Medical School, Discipline of Ophthalmology and Eye Health, Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Hemal Mehta
- Sydney Medical School, Discipline of Ophthalmology and Eye Health, Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia.,Ophthalmology Department, Royal Free London NHS Foundation Trust, London, UK
| | - Mark Gillies
- Sydney Medical School, Discipline of Ophthalmology and Eye Health, Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
| | - Daniel Barthelmes
- Department of Ophthalmology, University of Zurich, Zurich, Switzerland.,Sydney Medical School, Discipline of Ophthalmology and Eye Health, Save Sight Institute, The University of Sydney, Sydney, New South Wales, Australia
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Kristiansen IS, Haugli Bråten R, Jørstad ØK, Moe MC, Sæther EM. Intravitreal therapy for retinal diseases in Norway 2011-2015. Acta Ophthalmol 2020; 98:279-285. [PMID: 31587508 DOI: 10.1111/aos.14262] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 09/06/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE During the past decade, intravitreally administered biologic drugs have advanced the treatment of retinal diseases, such as wet age-related macular degeneration (AMD), diabetic macular oedema and retinal venous occlusions. The drugs as well as the necessary disease management imply considerable economic burden on healthcare systems. This Norwegian study documents the rates of use of intravitreal therapies and intercounty variation over a 5-year period. METHODS We collected data from the Norwegian Patient Register for all episodes of care encompassing intravitreal therapy during the period 2011-2015. For each episode, we received information on patient age, sex, county of residence, diagnosis and name of drug injected. RESULTS During the study period, 21 277 patients had in total 236 857 episodes of care. The number of intravitreal injections doubled from 2011 to 2015, reaching 63 601 injections in 2015, of which 77% were for diagnosed wet AMD. In 2015, the age-adjusted number of episodes varied from 19 to 55 per 1000 population aged 50+ across Norway's 19 counties. The age-adjusted number of patients treated per 1000 population aged 50+ varied from 5.22 to 8.35. CONCLUSION The use of intravitreal injections increased rapidly with wet AMD as the most frequent diagnosis and with varying utilization across Norway's 19 counties. The causes of the varying use of intravitreal therapies could not be established but may reflect variation in disease prevalence, treatment capacity, travel distance to the nearest ophthalmic service and lack of national treatment guidelines. The geographic variation in utilization may challenge policy goals of equitable care and warrants further studies.
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Affiliation(s)
- Ivar Sønbø Kristiansen
- Department of Health Management and Health Economics Institute of Health and Medicine University of Oslo Oslo Norway
- Oslo Economics Oslo Norway
| | | | - Øystein Kalsnes Jørstad
- Department of Ophthalmology Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Morten Carstens Moe
- Department of Ophthalmology Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
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Re: Couturier et al.: Widefield OCT-angiography and fluorescein angiography assessments of nonperfusion in diabetic retinopathy and edema treated with anti–vascular endothelial growth factor (Ophthalmology. 2019;126:1685–1694). Ophthalmology 2020; 127:e32-e34. [DOI: 10.1016/j.ophtha.2020.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/03/2020] [Indexed: 11/24/2022] Open
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Bandello F, Toni D, Porta M, Varano M. Diabetic retinopathy, diabetic macular edema, and cardiovascular risk: the importance of a long-term perspective and a multidisciplinary approach to optimal intravitreal therapy. Acta Diabetol 2020; 57:513-526. [PMID: 31749046 DOI: 10.1007/s00592-019-01453-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 11/05/2019] [Indexed: 12/17/2022]
Abstract
Diabetic retinopathy (DR), diabetic macular edema (DME), and cardiovascular disease (CVD) resulting from vascular damage from persistently elevated blood glucose levels are among the serious secondary pathologies associated with long-standing diabetes mellitus. The established link between DR and CVD suggests the need for appropriate and early management of patients with diabetes to minimize CV risk. This is of particular importance in patients with recent, or a history of, major CV events. Early management of DR is a complex task that requires comprehensive evaluation and a multidisciplinary approach to manage complications, risk factors, and interactions between different aspects of the disease. Anti-vascular endothelial growth factor (VEGF) agents have become an important therapeutic modality in ophthalmology. However, their use is contraindicated in patients with DR and/or DME with a CV event in the previous 3 months. In patients with DME, corticosteroids target the multifaceted inflammatory pathways involved in the pathogenesis of DR, with a broader spectrum of action than anti-VEGF agents. In this context, recent guidelines suggest the use of corticosteroids, and in particular dexamethasone intravitreal implant, as a well-tolerated and efficacious first-line treatment in patients with high CV risk, such as a history of or recent major CV events. This review focuses on the subset of diabetic patients with a prior CV event, DR, and DME and discusses the need for a holistic approach in evaluating the optimal therapeutic choice for the care of the individual patient, supported by real-world clinical experience on long-term dexamethasone intravitreal implant therapy.
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Affiliation(s)
- Francesco Bandello
- Department of Ophthalmology, IRCCS Ospedale San Raffaele, Scientific Institute San Raffaele, University Vita-Salute, Via Olgettina Milano, 58, 20132, Milan, Italy.
| | - Danilo Toni
- Department of Human Neurosciences, Sapienza University, Rome, Italy
| | - Massimo Porta
- Department of Medical Sciences, University of Turin, Turin, Italy
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A 12-month prospective study to evaluate the efficacy of using the treat-and-extend regimen with intravitreal aflibercept as a Second-Line Treatment for Diabetic Macular Oedema (the TADI Study). Eye (Lond) 2020; 35:559-567. [PMID: 32350452 DOI: 10.1038/s41433-020-0901-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To evaluate the efficacy of intravitreal aflibercept as a second-line therapy in eyes with persistent diabetic macular oedema (DMO) despite receiving initial bevacizumab treatment. METHODS A prospective multicentre study was conducted in nine academic clinics in Israel. Starting from the first follow-up visit, a treat-and-extend regimen was applied in which the treatment intervals were extended by 2 weeks based on macular thickness using SD-OCT. The primary outcome was central subfield thickness (CST) at week 52. RESULTS Forty-four patients (n = 48 eyes) were recruited to the study, and 43 eyes completed 52 weeks of follow-up. Patients received a mean (±SD) of 7.9 ± 3.5 bevacizumab injections before enrolment. The mean (±SD) CST under aflibercept therapy decreased from 468 ± 131 μm at baseline to 303 ± 67 μm at 52 weeks (p = 0.002), and best corrected visual acuity improved from 64 ± 15 ETDRS letters at baseline to 75 ± 8 letters at week 52 (p = 0.001). Twenty (46%) eyes met the treat-and-extend criteria and received a mean (±SD) of 10.9 ± 2 aflibercept injections. CONCLUSIONS Eyes with persistent DMO following initial bevacizumab therapy had a marked reduction in macular thickness and improved visual acuity following 1 year of treatment with intravitreal aflibercept. Less than half of the patients met eligibility criteria for extension of the treatment interval; for these patients, the treat-and-extend regimen resulted in a maximum treatment interval of 10 weeks during the first year.
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Long JC, Blakely B, Mahmoud Z, Ly A, Zangerl B, Kalloniatis M, Assaad N, Yapp M, Clay-Williams R, Braithwaite J. Evaluation of a hospital-based integrated model of eye care for diabetic retinopathy assessment: a multimethod study. BMJ Open 2020; 10:e034699. [PMID: 32354779 PMCID: PMC7213850 DOI: 10.1136/bmjopen-2019-034699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Diabetic eye disease is a leading cause of blindness but can be mitigated by regular eye assessment. A framework of issues, developed from the literature of barriers to eye assessment, was used to structure an examination of perceptions of a new model of care for diabetic retinopathy from the perspective of staff using the model, and health professionals referring patients to the new service. DESIGN Multimethod: interviews and focus groups, and a separate survey. SETTING A new clinic based on an integrated model of care was established at a hospital in outer metropolitan Sydney, Australia in 2017. Funded jointly by Centre for Eye Health (CFEH) and the hospital, the clinic was equipped and staffed by optometrists who work alongside the ophthalmologists in the existing hospital eye clinic. PARTICIPANTS Five (of seven) hospital staff working in the clinic (ophthalmologists and administrative officers) or referring to it from other departments (endocrinologists); nine optometrists from CFEH who developed or worked in the clinic; 10 community-based optometrists as potential referrers. RESULTS The new clinic was considered to have addressed known barriers to eye assessment, including access, assistance for patients unable/unwilling to organise eye checks and efficient management of human resources. The clinic optimised known drivers of this model of care: providing clear scope of practice and protocols for shared care between optometrists and ophthalmologists, good communication between referrers and eye professionals and a collegial approach promoting interprofessional trust. Remaining areas of concern were few referrals from general practitioners, fewer referrals from hospital endocrinologists than expected and issues with stretched administrative capacity. There were also perceived mismatches between the priorities of hospital management and aims of the clinic. CONCLUSIONS The new model was considered to have addressed many of the barriers to assessment. While there remain issues with the model, there were also unexpected benefits.
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Affiliation(s)
- Janet C Long
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Brette Blakely
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Zeyad Mahmoud
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Angelica Ly
- School of Optometry and Vision Health, University of New South Wales, Sydney, New South Wales, Australia
- Centre for Eye Health, Sydney, New South Wales, Australia
| | - Barbara Zangerl
- School of Optometry and Vision Health, University of New South Wales, Sydney, New South Wales, Australia
- Centre for Eye Health, Sydney, New South Wales, Australia
| | - Michael Kalloniatis
- School of Optometry and Vision Health, University of New South Wales, Sydney, New South Wales, Australia
- Centre for Eye Health, Sydney, New South Wales, Australia
| | - Nagi Assaad
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Michael Yapp
- School of Optometry and Vision Health, University of New South Wales, Sydney, New South Wales, Australia
- Centre for Eye Health, Sydney, New South Wales, Australia
| | - Robyn Clay-Williams
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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Chen JT, Chen LJ, Chen SN, Chen WL, Cheng CK, Hsu SM, Sheu SJ, Wu WC, Yang CH, Yang CM, Yeung L, Hwang DK, Chen SJ. Management of diabetic macular edema: experts' consensus in Taiwan. Jpn J Ophthalmol 2020; 64:235-242. [PMID: 32342244 DOI: 10.1007/s10384-020-00741-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 03/18/2020] [Indexed: 01/29/2023]
Abstract
Diabetic macular edema (DME) is the most common cause of vision loss among patients with diabetes mellitus (DM), rendering it an important growing challenge in ophthalmology. In the past decades, the management strategies for DME had a few paradigm shifts, and the advent of an expanding number of anti-vascular endothelial growth factor (VEGF) agents also calls for an in-depth examination of the currently available evidence. This article was composed with the intention to provide recommendations for practicing clinicians to improve the management and, through it the outcomes of DME. Drawing from current guideline recommendations, clinical trial findings and local clinical experiences, these consensus recommendations for the management of DME were formed by an expert panel through iterations of discussion and voting. First, the treatment goal of DME is to achieve best visual outcome with edema improvement while minimizing treatment burden. Second, anti-VEGF therapy should be considered as the first-line treatment for patients with center-involving DME causing vision loss. Baseline visual acuity (VA) and central subfield thickness (CST) should be taken into consideration when choosing anti-VEGF agents. Third, early intensive anti-VEGF therapy (at least 3 monthly doses) is important for better patients' VA and anatomical improvement. In non-responders who have already been treated with 3-5 injections of anti-VEGF agents, it is reasonable to switch to other modalities, such as steroids. Finally, for the follow-up phase, fixed or individualized dosing should be considered based on VA and OCT.
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Affiliation(s)
- Jiann-Torng Chen
- Department of Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Lee-Jen Chen
- Department of Ophthalmology, Mackay Memorial Hospital, Taipei, Taiwan
| | - San-Ni Chen
- Department of Ophthalmology, Changhua Christian Hospital, Changhua, Taiwan
| | - Wen-Lu Chen
- Department of Ophthalmology, China Medical University Hospital, Taichung, Taiwan
| | - Cheng-Kuo Cheng
- Department of Ophthalmology, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.,Department of Ophthalmology, School of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Ophthalmology, School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
| | - Sheng-Min Hsu
- Department of Ophthalmology, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Ophthalmology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Shwu-Jiuan Sheu
- Department of Ophthalmology, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan.,Department of Ophthalmology, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wen-Chuan Wu
- Department of Ophthalmology, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan.,Department of Ophthalmology, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chang-Hao Yang
- Department of Ophthalmology, National Taiwan University Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan
| | - Chung-May Yang
- Department of Ophthalmology, National Taiwan University Hospital, No. 201, Sec. 2, Shih-Pai Road, Taipei, 11217, Taiwan
| | - Ling Yeung
- Department of Ophthalmology, Chang Gung Memorial Hospital, Keelung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - De-Kuang Hwang
- Department of Ophthalmology, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Jen Chen
- Department of Ophthalmology, School of Medicine, National Yang-Ming University, Taipei, Taiwan. .,Department of Ophthalmology, Taipei Veterans General Hospital, Taipei, Taiwan.
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Evaluation of Changes in Macular Perfusion Detected by Optical Coherence Tomography Angiography following 3 Intravitreal Monthly Bevacizumab Injections for Diabetic Macular Edema in the IMPACT Study. J Ophthalmol 2020; 2020:5814165. [PMID: 32411431 PMCID: PMC7201518 DOI: 10.1155/2020/5814165] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 03/30/2020] [Indexed: 12/19/2022] Open
Abstract
Objective To evaluate macular perfusion changes following intravitreal bevacizumab injections for diabetic macular edema (DME) using spectral domain optical coherence tomography angiography (SD-OCTA). Methods This study was a prospective noncomparative interventional case series. Treatment naïve patients with DME underwent full ophthalmological examination and SD-OCTA scanning at baseline and after 3 intravitreal bevacizumab injections. Both the 6 × 6 and 3 × 3 mm macular scan protocols were used. Pretreatment and posttreatment OCTA images were automatically aligned using a commercially available retina alignment software (i2k Align Retina software); then the fractal dimension (FD), vascular density (VD), and skeleton VD changes were obtained at the full retinal thickness (Full) and superficial (SCP) and deep (DCP) capillary plexuses after processing images using a semiautomated program. The foveal avascular zone (FAZ) was manually measured and FD was calculated using the FracLac plugin of ImageJ. Results Forty eyes of 26 patients were included. Following injections, there were an 8.1% increase in FAZ, 1.3% decrease in FD-Full and FD-SCP, 1.9% decrease in FD-DCP, 8% decrease in VD-Full, 9.1% decrease in VD-SCP, 10.6% decrease in VD-DCP, 13.3% decrease in skeleton VD-Full, 12.5% decrease in skeleton VD-SCP, and 16.3% decrease in skeleton VD-DCP in the 6 × 6 mm macular area and a 2.6% decrease in FD-Full, 3.4% decrease in FD-SCP, 11.5% decrease in VD-Full, 14.3% decrease in VD-SCP, and 25.1% decrease in skeleton VD-SCP in the 3 × 3 mm macular area which were all statistically significant (p < 0.05). Using univariate and multivariate analysis, the pretreatment FD, VD, and skeleton VD at each capillary layer significantly negatively correlated with the change in FD, VD, and skeleton VD at the corresponding capillary layer, respectively (p < 0.05). Conclusion OCTA is a useful noninvasive tool for quantitative evaluation of macular perfusion changes following DME treatment. This trial is registered with NCT03246152.
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240
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Efficacy of navigated focal laser photocoagulation in diabetic macular edema planned with en face optical coherence tomography versus fluorescein angiography. Int Ophthalmol 2020; 40:1913-1921. [PMID: 32285237 DOI: 10.1007/s10792-020-01363-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 04/01/2020] [Indexed: 11/27/2022]
Abstract
AIM To analyze the efficacy of navigated focal laser photocoagulation (FLP) of microaneurysms in diabetic macular edema (DME) planned using en face optical coherence tomography (OCT) as against fluorescein angiography (FA). METHODS Twenty-six eyes of 21 DME patients (12 males, 9 females, 69.5 ± 12.3 years) with mean BCVA of 0.52 ± 0.44 LogMAR were included. En face OCT images of deep capillary plexus slab and FA images were used to plan FLP targeting of leaky microaneurysms. The primary outcome measures were central retinal thickness (CRT) and macular volume. The secondary outcome measure was best-corrected visual acuity (BCVA). RESULTS The difference in the change of CRT and macular volume between en face OCT and FA-planned FLP after 1 month and at the end of follow-up was not statistically significant (p > 0.05), except for a higher CRT reduction in the en face OCT-planning group (p = 0.007) at the end of mean follow-up of 2.6 ± 0.9 months. There was no difference in BCVA change between the two planning options (p = 0.42). CONCLUSION En face OCT is a non-inferior alternative for FA in the planning of navigated FLP of microaneurysms in DME.
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241
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Cabrera AP, Mankad RN, Marek L, Das R, Rangasamy S, Monickaraj F, Das A. Genotypes and Phenotypes: A Search for Influential Genes in Diabetic Retinopathy. Int J Mol Sci 2020; 21:ijms21082712. [PMID: 32295293 PMCID: PMC7215289 DOI: 10.3390/ijms21082712] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/06/2020] [Accepted: 04/07/2020] [Indexed: 12/13/2022] Open
Abstract
Although gene–environment interactions are known to play an important role in the inheritance of complex traits, it is still unknown how a genotype and the environmental factors result in an observable phenotype. Understanding this complex interaction in the pathogenesis of diabetic retinopathy (DR) remains a big challenge as DR appears to be a disease with heterogenous phenotypes with multifactorial influence. In this review, we examine the natural history and risk factors related to DR, emphasizing distinct clinical phenotypes and their natural course in retinopathy. Although there is strong evidence that duration of diabetes and metabolic factors play a key role in the pathogenesis of DR, accumulating new clinical studies reveal that this disease can develop independently of duration of diabetes and metabolic dysfunction. More recently, studies have emphasized the role of genetic factors in DR. However, linkage analyses, candidate gene studies, and genome-wide association studies (GWAS) have not produced any statistically significant results. Our recently initiated genomics study, the Diabetic Retinopathy Genomics (DRGen) Study, aims to examine the contribution of rare and common variants in the development DR, and how they can contribute to clinical phenotype, rate of progression, and response to available therapies. Our preliminary findings reveal a novel set of genetic variants associated with proangiogenic and inflammatory pathways that may contribute to DR pathogenesis. Further investigation of these variants is necessary and may lead to development of novel biomarkers and new therapeutic targets in DR.
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Affiliation(s)
- Andrea P. Cabrera
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA; (A.P.C.); (R.N.M.); (L.M.); (R.D.); (F.M.)
| | - Rushi N. Mankad
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA; (A.P.C.); (R.N.M.); (L.M.); (R.D.); (F.M.)
| | - Lauren Marek
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA; (A.P.C.); (R.N.M.); (L.M.); (R.D.); (F.M.)
| | - Ryan Das
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA; (A.P.C.); (R.N.M.); (L.M.); (R.D.); (F.M.)
| | - Sampath Rangasamy
- Translational & Genomics Research Institute, Phoenix, AZ 85004, USA;
| | - Finny Monickaraj
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA; (A.P.C.); (R.N.M.); (L.M.); (R.D.); (F.M.)
- New Mexico VA Health Care System, Albuquerque, NM 87108, USA
| | - Arup Das
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA; (A.P.C.); (R.N.M.); (L.M.); (R.D.); (F.M.)
- New Mexico VA Health Care System, Albuquerque, NM 87108, USA
- Correspondence: ; Tel.: +1-505-272-6120
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242
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Ciulla TA, Pollack JS, Williams DF. Visual acuity outcomes and anti-VEGF therapy intensity in diabetic macular oedema: a real-world analysis of 28 658 patient eyes. Br J Ophthalmol 2020; 105:216-221. [PMID: 32265201 PMCID: PMC7848066 DOI: 10.1136/bjophthalmol-2020-315933] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/17/2020] [Accepted: 03/19/2020] [Indexed: 12/31/2022]
Abstract
Background/Aim To assess visual acuity (VA) outcomes and antivascular endothelial growth factor (anti-VEGF) treatment intensity in diabetic macular oedema (DMO). Methods Retrospective analysis was performed in treatment-naïve patients with DMO from 2013 to 2018 using a database of aggregated de-identified electronic medical records (Vestrum Health). Results At 1 year, 28 658 patient eyes underwent a mean of 6.4 anti-VEGF injections, gaining a mean of +4.2 letters (95% confidence interval for mean gain: +4.0 to +4.5 letters, p<0.001). When stratified by anti-VEGF medication and by years 2013–2018, no clinically meaningful differences in injection frequency or 1-year VA change resulted. At 1 year, 50% of eyes received ≤6 injections, while <20% received 10–13 injections, representing monthly treatment. Mean letters gained at 1 year generally showed a linear relationship with mean number of anti-VEGF injections, beyond two injections. Eyes with good baseline VA (≥20/40) generally were at risk of VA loss at 1 year; those with moderately severe baseline impairment (20/70 to 20/200) who received ≥10 injections improved by a mean of +10.3 letters. Conclusion In clinical practice, patients with DMO undergo fewer anti-VEGF injections and exhibit worse visual gains compared with patients in randomised clinical trials. Visual outcomes correlate with treatment intensity at 1 year, with ceiling effects related to baseline VA.
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Affiliation(s)
- Thomas A Ciulla
- Ophthalmology, Indiana University School of Medicine, Indianapolis, Indiana, USA .,Retina Service, Midwest Eye Institute, Indianapolis, Indiana, USA
| | - John S Pollack
- Rush University, Chicago, Illinois, USA.,Illinois Retina Associates, Chicago, IL, USA
| | - David F Williams
- University of Minnesota, Minneapolis, Minnesota, USA.,VitreoRetinal Surgery, PA, Minneapolis, MN, USA
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243
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Cost-Minimization Analysis of Ranibizumab Versus Aflibercept for Treating Saudi Patients With Visual Impairment Owing to Age-Related Macular Degeneration or Diabetic Macular Edema. Value Health Reg Issues 2020; 22:23-26. [PMID: 32247191 DOI: 10.1016/j.vhri.2019.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 09/04/2019] [Accepted: 09/22/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The standard-of-care treatment for age-related macular degeneration (AMD) and diabetic macular edema (DME) includes inhibiting blood vessel proliferation and reducing macular edema or swelling using anti-vascular endothelial growth factor therapies, such as ranibizumab and aflibercept. To conduct a cost-minimization analysis of ranibizumab and aflibercept for treating Saudi patients with visual impairment owing to AMD or DME. METHODS Cost minimization was analyzed assuming that ranibizumab and aflibercept have equivalent clinical effectiveness. The third-party payer's perspective was used in several clinical scenarios. The base-case scenario was DME cases followed monthly using a protocol-specific follow-up. In scenario 1, AMD cases followed a treat-and-extend protocol over 2 years. In scenario 2, AMD cases followed the PRN (pro re nata) regimen over 2 years. In scenario 3, DME cases followed the PRN regimen for 1 year only. RESULTS Aflibercept yielded cost savings of 25.75%, 31.54%, 51.30%, and 9.28% compared with ranibizumab for the base case, scenario 1, scenario 2, and scenario 3, respectively, which supports the premise that aflibercept is more cost saving than ranibizumab. CONCLUSIONS From the third-party payer perspective, aflibercept is a cost-containment option that provides substantial savings over ranibizumab for treating Saudi patients with AMD or DME.
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244
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Zas M, Cotic M, Wu M, Wu A, Wu L. Macular laser photocoagulation in the management of diabetic macular edema: Still relevant in 2020? Taiwan J Ophthalmol 2020; 10:87-94. [PMID: 32874835 PMCID: PMC7442095 DOI: 10.4103/tjo.tjo_16_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 03/30/2020] [Indexed: 11/13/2022] Open
Abstract
Macular laser photocoagulation (MLP) is inferior to intravitreal vascular endothelial growth factor (VEGF) inhibitors in the treatment of center-involved diabetic macular edema (DME). Ultra-widefield fluorescein angiography-guided laser photocoagulation to presumed ischemic areas of the peripheral retina or MLP do not reduce the treatment burden nor improve the visual outcomes of eyes treated with anti-VEGF drugs. Destruction of retinal tissue is not necessary to induce a therapeutic response in DME. Modern lasers are capable of producing invisible laser "burns" that do not destroy the targeted tissue using micropulse subthreshold (ST) mode where the laser's duty cycle is modified or alternatively selective retinal therapy (SRT) where ultrashort pulses of continuous wave laser selectively target the RPE. The best results with micropulse ST laser are obtained in eyes with a central macular thickness ≤400 μm. Eyes need to be treated in a continuous manner with no spaces between burns in the edematous area. Micropulse ST-MLP downregulates inflammatory biomarkers produced by activated microglial cells and Müller cells. Micropulse ST-MLP may reduce the anti-VEGF injection burden in DME. In SRT, the diseased RPE is targeted and heated with the laser with the hope that the adjacent RPE migrates and proliferates into these areas to heal the diseased RPE. There is much less experience with SRT, but the results are promising and deserve further study.
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Affiliation(s)
- Marcelo Zas
- Department of Ophthalmology, Jose de San Martin Clinics Hospital, Universidad de Buenos Aires, Buenos Aires, Argentina, USA
| | - Mariano Cotic
- Department of Ophthalmology, Jose de San Martin Clinics Hospital, Universidad de Buenos Aires, Buenos Aires, Argentina, USA
| | - Max Wu
- Department of Ophthalmology, Jose de San Martin Clinics Hospital, College of Engineering, Cornell University, Ithaca, NY, USA
- Macula, Vitreous and Retina Associates of Costa Rica, San José, Costa Rica, USA
| | - Andres Wu
- Macula, Vitreous and Retina Associates of Costa Rica, San José, Costa Rica, USA
| | - Lihteh Wu
- Macula, Vitreous and Retina Associates of Costa Rica, San José, Costa Rica, USA
- Macula, Vitreous and Retina Associates of Costa Rica, Illinois Eye and Ear Infirmary, University of Illinois, Chicago, IL, USA
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245
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Volkmann I, Knoll K, Wiezorrek M, Greb O, Framme C. Individualized treat-and-extend regime for optimization of real-world vision outcome and improved patients' persistence. BMC Ophthalmol 2020; 20:122. [PMID: 32228517 PMCID: PMC7104494 DOI: 10.1186/s12886-020-01397-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 03/20/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Intravitreal injections are a mandatory treatment for macular edema due to nAMD, DME and RVO. These chronic diseases usually need chronic treatment using intravitreal injections with anti-VEGF agents. Thus, many trials were performed to define the best treatment interval using pro re nata regimes (PRN), fixed regimes or treat-and-extend regimes (TE). However, real-world studies reveal a high rate of losing patients within a 2-year interval of treatment observation causing worse results. In this study we analyzed retrospectively 2 years of real-world experience with an individualized treat-and-extend injection scheme. METHODS Since 2015 our treatment scheme for intravitreal injections has been switched from PRN to TE. Out of 102 patients 59 completed a follow up time of 2 years. Every patient received visual acuity testing, SD-OCT and slit lamp examination prior to every injection. At each visit an injection was performed and the treatment interval was adjusted mainly on SD-OCT based morphologic changes by increasing or reducing in 2-week steps. Individual changes of the treatment protocol by face-to-face communication between physician and patient were possible. RESULTS After 1 year of treatment visual acuity gain in nAMD was 7.4 ± 2.2 ETDRS letters (n = 34; injection frequency: 7.4 ± 0.4) respectively 6.1 ± 4.7 in DME (n = 9; injection frequency: 8.4 ± 1.1) and 9.7 ± 4.5 in RVO (n = 16; injection frequency: 7.6 ± 0.5). After 2 years of treatment results were as following: nAMD: visual acuity gain 6.9 ± 2.1 (injection frequency: 12.6 ± 0.7); DME: 11.1 ± 5.1 (injection frequency: 14.0 ± 1.0); RVO: 7.5 ± 5.0 (injection frequency: 11.2 ± 0.9). Planned treatment exit after 2 year was achieved in 29.4% of patients in nAMD (0% after 1 year); 0% in DME (0% after 1 year); and 31.3% in RVO (0% after 1 year). Patients' persistence was 94.1% during the follow-up. CONCLUSION Using a consequent and individualized TE regime in daily practice may lead to a high patients' persistence and visual acuity gains nearly comparable to those of large prospective clinical trials. Crucial factors are face-to-face communication with the patient as well as a stringent management regime. At this time TE may be the only instrument for proactive therapy which should therefore be regarded as a first-line tool in daily practice.
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Affiliation(s)
- Ingo Volkmann
- Hannover Medical School, University Eye Hospital, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - Katharina Knoll
- Hannover Medical School, University Eye Hospital, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Mareile Wiezorrek
- Hannover Medical School, University Eye Hospital, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Oliver Greb
- Hannover Medical School, University Eye Hospital, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Carsten Framme
- Hannover Medical School, University Eye Hospital, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
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246
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Glassman AR, Wells JA, Josic K, Maguire MG, Antoszyk AN, Baker C, Beaulieu WT, Elman MJ, Jampol LM, Sun JK. Five-Year Outcomes after Initial Aflibercept, Bevacizumab, or Ranibizumab Treatment for Diabetic Macular Edema (Protocol T Extension Study). Ophthalmology 2020; 127:1201-1210. [PMID: 32402554 DOI: 10.1016/j.ophtha.2020.03.021] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/10/2020] [Accepted: 03/17/2020] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Assess follow-up treatment and clinical outcomes at 5 years in eyes initially treated with anti-VEGF therapy for center-involved diabetic macular edema (CI-DME) in a 2-year randomized clinical trial. DESIGN Multicenter cohort study. PARTICIPANTS Participants with diabetic macular edema (DME) and visual acuity (VA) 20/32 to 20/320 enrolled in DRCR.net Protocol T with visits 5 years after randomization (3 years after Protocol T completion). METHODS Participants were assigned randomly to aflibercept, bevacizumab, or ranibizumab with protocol-defined follow-up and re-treatment for 2 years. Thereafter, participants were managed at clinician discretion and recalled for a 5-year visit. MAIN OUTCOME MEASURES Anti-vascular endothelial growth factor (VEGF) treatment, VA letter score, and central subfield thickness (CST). RESULTS Sixty-eight percent (317/463) of eligible participants completed the 5-year visit. Between years 2 and 5, 68% (217/317) of study eyes received at least 1 anti-VEGF treatment (median, 4; interquartile range [IQR], 0-12). At 5 years, mean VA improved from baseline by 7.4 letters (95% confidence interval [CI], 5.9-9.0) but decreased by 4.7 letters (95% CI, 3.3-6.0) between 2 and 5 years. When baseline VA was 20/50 to 20/320, mean 5-year VA was 11.9 letters (95% CI, 9.3-14.5) better than baseline but 4.8 letters (95% CI, 2.5-7.0) worse than 2 years. When baseline VA was 20/32 to 20/40, mean 5-year VA was 3.2 letters (95% CI, 1.4-5.0) better than baseline but 4.6 letters (95% CI, 3.1-6.1) worse than 2 years. Mean CST decreased from baseline to 5 years by 154 μm (95% CI, 142-166) and was stable between 2 and 5 years (-1 μm; 95% CI, -12 to 9). CONCLUSIONS Among the two-thirds of eligible Protocol T participants who completed a 5-year visit, mean VA improved from baseline to 5 years without protocol-defined treatment after follow-up ended at 2 years. Although mean retinal thickness was similar at 2 and 5 years, mean VA worsened during this period. Additional investigation into strategies to improve long-term outcomes in eyes with DME seems warranted to determine if VA can be better maintained with different management approaches.
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Affiliation(s)
| | - John A Wells
- Palmetto Retina Center, Columbia, South Carolina
| | | | - Maureen G Maguire
- Department of Ophthalmology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew N Antoszyk
- Charlotte Eye, Ear, Nose and Throat Associates, Charlotte, North Carolina
| | - Carl Baker
- Paducah Retinal Center, Paducah, Kentucky
| | | | | | - Lee M Jampol
- Feinberg School of Medicine, Northwestern University Medical School, Chicago, Illinois
| | - Jennifer K Sun
- Joslin Diabetes Center, Beetham Eye Institute, Harvard Department of Ophthalmology, Boston, Massachusetts
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Chen YX, Li XX, Yoon YH, Sun X, Astakhov Y, Xu G, Wang H, Ren X, Asmus F. Intravitreal Aflibercept versus Laser Photocoagulation in Asian Patients with Diabetic Macular Edema: The VIVID-East Study. Clin Ophthalmol 2020; 14:741-750. [PMID: 32210527 PMCID: PMC7069586 DOI: 10.2147/opth.s235267] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 02/04/2020] [Indexed: 01/24/2023] Open
Abstract
Purpose The prevalence of diabetes and diabetes-related complications, including diabetic macular edema (DME), is increasing in Asia and worldwide. Methods VIVID-East was a 12-month, double-masked, randomized, active-controlled, Phase 3 trial (NCT01783886) enrolling adult patients (aged ≥18 years) with DME at 25 centers across China, Hong Kong, Republic of Korea, and Russia. Eyes were randomized 1:1:1 to 2 mg intravitreal aflibercept (IVT-AFL) every 4 weeks (2q4; N=127), 2 mg IVT-AFL every 8 weeks (after 5 initial monthly doses from baseline to week 16) with sham injections on nontreatment visits (2q8; N=127), or macular laser photocoagulation at baseline and sham injections at every visit (laser control group; N=124). The primary efficacy endpoint was mean change in best corrected visual acuity (BCVA) from baseline to week 52. Results Compared with baseline, at week 52 the mean (SE) BCVA in the 2q4 and 2q8 groups gained +13.6 (0.9) and +13.1 (1.0) letters, respectively, versus −0.5 (1.4) letters in the laser group (P<0.0001 for both). A significantly higher proportion of patients treated with IVT-AFL (2q4 and 2q8) achieved a ≥10-letter or ≥15-letter gain compared with laser (both P<0.0001) (≥10-letter gain: 70.9%, 62.7%, and 23.4%, respectively; ≥15-letter gain: 43.3%, 36.5%, and 12.1%, respectively). Mean reduction in central retinal thickness from baseline to week 52 was significantly greater with IVT-AFL versus laser treatment. Incidence of treatment-emergent adverse events was low and similar across groups; conjunctival hemorrhage (11.8%), retinal hemorrhage (8.7%), retinal aneurysm (7.5%), and retinal exudates (5.5%) being the most frequently reported. Visual and anatomic outcomes in the Chinese subgroup were consistent with the overall population. Conclusion IVT-AFL treatment resulted in significant visual and anatomic improvements in Asian patients with DME. Treatment benefits observed in the overall study population were mirrored in the subgroup of Chinese patients, who made up the largest population group in the study. Study Registration NCT01783886.
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Affiliation(s)
- You-Xin Chen
- Department of Ophthalmology, Peking Union Medical College, Beijing, People's Republic of China
| | - Xiao-Xin Li
- Ophthalmology Department, People's Eye Center of Peking University People's Hospital, Beijing, People's Republic of China
| | - Young Hee Yoon
- Department of Ophthalmology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Xiaodong Sun
- Department of Ophthalmology, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Yury Astakhov
- Department of Ophthalmology, Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - Gezhi Xu
- Department of Ophthalmology and Vision Sciences, Eye and ENT Hospital, Shanghai Medical College, Fudan University, Shanghai, People's Republic of China
| | - Hui Wang
- Clinical Development, Ophthalmology, Bayer Healthcare Inc, Shanghai, People's Republic of China
| | - Xiaowei Ren
- Statistics and Data Insights, Bayer Healthcare Inc, Beijing, People's Republic of China
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248
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Abu-Yaghi NE, Abed AM, Khlaifat DF, Nawaiseh MB, Emoush LO, AlHajjaj HZ, Abojaradeh AM, Hattar MN, Abusaleem SK, Sabbagh HM, Abu Gharbieh YA, Quaqazeh SA. Factors Affecting Compliance to Anti-Vascular Endothelial Growth Factor Treatment of Diabetic Macular Edema in a Cohort of Jordanian Patients. Clin Ophthalmol 2020; 14:921-929. [PMID: 32273676 PMCID: PMC7102883 DOI: 10.2147/opth.s248661] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 03/04/2020] [Indexed: 12/27/2022] Open
Abstract
Purpose To determine compliance rates and characteristics and to investigate factors affecting patients’ adherence to treatment with anti-vascular endothelial growth factors (anti-VEGFs) for diabetic macular edema (DME) in a cohort of Jordanian patients. Methods A retrospective case series wherein the files of DME patients treated with anti-VEGFs were reviewed and analyzed for factors affecting treatment compliance was undertaken. Demographic, clinical and ocular characteristics were recorded. All patients were also interviewed by phone using a structured questionnaire. Univariate and multivariate analyses were performed to determine factors associated with compliance. Results A total of 117 patients (65 males 52 females) were included in this study with a mean age of 62.93 years (±9.75). Approximately, 85% of patients were compliant to their treatment and follow-up plan during the first year of management. Subjective perception of visual improvement after receiving three loading doses was the only independent variable with a unique statistically significant contribution to compliance. All other studied factors in this group of patients were not significantly associated with patient compliance. Conclusion VEGF suppression via the intravitreal route to treat DME is a long-term process that requires caregiver dedication but also proper patient compliance. Addressing real-life barriers in those patients may help guide future strategies to improve the treatment experience, lower the financial burden and contribute to better outcomes. Patients' perceptions of possible treatment outcomes at the short term may influence their long-term commitment to therapy.
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Affiliation(s)
- Nakhleh E Abu-Yaghi
- Department of Special Surgery, Ophthalmology Division, The University of Jordan, Amman, Jordan
| | - Alaa M Abed
- Department of Special Surgery, Ophthalmology Division, The University of Jordan, Amman, Jordan
| | | | | | - Laith O Emoush
- School of Medicine, The University of Jordan, Amman, Jordan
| | | | | | | | | | - Hashem M Sabbagh
- Department of Special Surgery, Ophthalmology Division, The University of Jordan, Amman, Jordan
| | - Yazan A Abu Gharbieh
- Department of Special Surgery, Ophthalmology Division, The University of Jordan, Amman, Jordan
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249
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Systemic Factors Associated with Treatment Response in Diabetic Macular Edema. J Ophthalmol 2020; 2020:1875860. [PMID: 32280516 PMCID: PMC7125481 DOI: 10.1155/2020/1875860] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 02/15/2020] [Accepted: 02/26/2020] [Indexed: 01/26/2023] Open
Abstract
Purpose To identify systemic factors that may influence the response to anti-VEGF therapy in patients with diabetic macular edema (DME). Methods 35 patients undergoing anti-VEGF injections for centre-involving DME were studied in this prospective observational study. The primary outcome was change in macular thickness one month after treatment, measured using spectral-domain optical coherence tomography (OCT). At baseline, information on various systemic factors was collected including glycosylated hemoglobin (HbA1c), serum VEGF levels, lipid profile and markers of renal function, and blood pressure. Thirty-three of the 35 patients were included in this study. Nonparametric statistical tests were used for the analysis of the data in view of the nonnormal distribution of the outcome variables. Multivariate analysis was performed using logistic regression. Stata 12.1 software was used for the analysis. Main Outcome Measures. Reduction in macular central subfield thickness (on spectral-domain OCT) and change in logMAR visual acuity at one month after injection. Results Lower HbA1c levels (7% or less) were significantly associated with greater reduction in central macular subfield thickness at one month after injection of bevacizumab or ranibizumab on both univariate analysis (p=0.012) and multivariate analysis (p=0.012) and multivariate analysis (. Conclusions Better glycemic control is associated with a greater reduction in central macular thickness after the first injection of bevacizumab or ranibizumab in diabetic macular edema. Patients with high levels of HbA1c and poor response to anti-VEGF may benefit from strict control of their blood glucose.
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250
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Shimura M, Kitano S, Muramatsu D, Fukushima H, Takamura Y, Matsumoto M, Kokado M, Kogo J, Sasaki M, Morizane Y, Utsumi T, Koto T, Sonoda S, Hirano T, Ishikawa H, Mitamura Y, Okamoto F, Kinoshita T, Kimura K, Sugimoto M, Yamashiro K, Suzuki Y, Hikichi T, Washio N, Sato T, Ohkoshi K, Tsujinaka H, Kusuhara S, Kondo M, Takagi H, Murata T, Sakamoto T. Real-world management of treatment-naïve diabetic macular oedema: 2-year visual outcome focusing on the starting year of intervention from STREAT-DMO study. Br J Ophthalmol 2020; 104:1755-1761. [PMID: 32169861 PMCID: PMC7785163 DOI: 10.1136/bjophthalmol-2019-315726] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 02/17/2020] [Accepted: 02/20/2020] [Indexed: 12/19/2022]
Abstract
Background/aims To investigate the yearly change of real-world outcomes for best corrected visual acuity (BCVA) after 2-year clinical intervention for treatment-naïve diabetic macular oedema (DMO). Methods Retrospective analysis of aggregated, longitudinal medical records obtained from 27 retina specialised institutions in Japan from Survey of Treatment for DMO database. A total of 2049 treatment-naïve centre involving DMO eyes of which the initial intervention started between 2010 and 2015, and had been followed for 2 years, were eligible. As interventions, antivascular endothelial growth factor (VEGF) agents, local corticosteroids, macular photocoagulation and vitrectomy were defined. In each eye, baseline and final BCVA, the number of each intervention for 2 years was extracted. Each eye was classified by starting year of interventional treatment. Results Although baseline BCVA did not change by year, 2-year improvement of BCVA had been increased, and reached to +6.5 letters in the latest term. There is little difference among starting year about proportions of eyes which BCVA gained >15 letters, in contrast to those which lost >15 letters were decreased by year. The proportion of eyes receiving anti-VEGF therapy was dramatically increased, while those receiving the other therapies were gradually decreased. The proportion of eyes which maintained socially good vision of BCVA>20/40 has been increased and reached to 59.0% in the latest term. Conclusion For recent years, treatment patterns for DMO have been gradually but certainly changed; as a result, better visual gain, suppression of worsened eyes and better final BCVA have been obtained. Anti-VEGF therapy has become the first-line therapy and its injection frequency has been increasing.
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Affiliation(s)
- Masahiko Shimura
- Department of Ophthalmology, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Shigehiko Kitano
- Diabetes Center, Tokyo Women's Medical University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Daisuke Muramatsu
- Department of Ophthalmology, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan
| | - Harumi Fukushima
- Diabetes Center, Tokyo Women's Medical University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | | | - Makiko Matsumoto
- Department of Ophthalmology, Nagasaki University School of Medicine Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masahide Kokado
- Department of Ophthalmology, Wakayama Medical University, Wakayama, Japan
| | - Jiro Kogo
- Department of Ophthalmology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Mariko Sasaki
- Department of Ophthalmology, Tachikawa Hospital, Tachikawa, Japan.,Department of Ophthalmology, National Hospital Organisation Tokyo Medical Center, Meguro-ku, Tokyo, Japan
| | - Yuki Morizane
- Department of Ophthalmology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takuya Utsumi
- Department of Ophthalmology, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Takashi Koto
- Kyorin Eye Center, Kyorin University School of Medicine, Mitaka, Tokyo, Japan
| | - Shozo Sonoda
- Department of Ophthalmology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Takao Hirano
- Deparment of Ophthalmology, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Hiroto Ishikawa
- Department of Ophthalmology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Yoshinori Mitamura
- Department of Ophthalmology, Institute of Biomedical Sciences, Tokushima University Graduate School, Tokushima, Tokushima, Japan
| | - Fumiki Okamoto
- Department of Ophthalmology, University of Tsukuba Faculty of Medicine, Tsukuba, Ibaraki, Japan
| | - Takamasa Kinoshita
- Department of Ophthalmology, Sapporo City General Hospital, Sapporo, Japan
| | - Kazuhiro Kimura
- Department of Ophthalmology, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Masahiko Sugimoto
- Department of Ophthalmology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Kenji Yamashiro
- Department of Ophthalmology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Yukihiko Suzuki
- Department of Ophthalmology, Hirosaki University School of Medicine Graduate School of Medicine, Hirosaki, Aomori, Japan
| | | | - Noriaki Washio
- Department of Ophthalmology, Showa General Hospital, Kodaira, Tokyo, Japan
| | - Tomohito Sato
- Department of Ophthalmology, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Kishiko Ohkoshi
- Department of Ophthalmology, St. Luke's International Hospital, Tokyo, Japan
| | - Hiroki Tsujinaka
- Department of Ophthalmology, Nara Medical University, Kashihara, Nara, Japan
| | - Sentaro Kusuhara
- Department of Surgery Related, Division of Ophthalmology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Mineo Kondo
- Department of Ophthalmology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Hitoshi Takagi
- Department of Ophthalmology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
| | - Toshinori Murata
- Deparment of Ophthalmology, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Taiji Sakamoto
- Department of Ophthalmology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
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