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Tang HX, Li JJ, Yuan Y, Ling Y, Mei Z, Zou H. Comparing the efficacy of dexamethasone implant and anti-VEGF for the treatment of macular edema: A systematic review and meta-analysis. PLoS One 2024; 19:e0305573. [PMID: 38985778 PMCID: PMC11236136 DOI: 10.1371/journal.pone.0305573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/02/2024] [Indexed: 07/12/2024] Open
Abstract
OBJECTIVES To evaluate the clinical efficacy of dexamethasone (DEX) implant, for the treatment of macular edema (ME) caused by retinal vein occlusion (RVO) and diabetic retinopathy (DR) through a systematic review and meta-analysis. METHODS The PubMed, Embase and Cochrane Library databases were comprehensively searched from inception to November 21, 2022, for studies evaluating the clinical efficacy of DEX implant for patients with retinal vein occlusion macular edema (RVO-ME) or diabetic macular edema (DME). Randomized controlled trials (RCTs) published in English were considered eligible. The Cochrane Collaboration tool was applied to assess the risk of bias in each study. Effect estimates with 95% confidence intervals (CIs) were pooled using the random effects model. We also conducted subgroup analyses to explore the sources of heterogeneity and the stability of the results. RESULTS This meta-analysis included 8 RCTs (RVO-ME [n = 2] and DME [n = 6]) assessing a total of 336 eyes. Compared with anti-VEGF therapy, DEX implant treatment achieved superior outcomes in terms of best corrected visual acuity (BCVA) (mean difference [MD] = -3.68 ([95% CI, -6.11 to -1.25], P = 0.003), and no heterogeneity was observed (P = 0.43, I2 = 0%). DEX implant treatment also significantly reduced central macular thickness (CMT) compared with anti-VEGF treatment (MD = -31.32 [95% CI, -57.92 to -4.72], P = 0.02), and there was a high level of heterogeneity between trials (P = 0.04, I2 = 54%). In terms of severe adverse events, DEX implant treatment had a higher risk of elevated intraocular pressure than anti-VEGF therapy (RR = 6.98; 95% CI: 2.16 to 22.50; P = 0.001), and there was no significant difference in cataract progression between the two groups (RR = 1.83; 95% CI: 0.63 to 5.27, P = 0.31). CONCLUSIONS Compared with anti-VEGF therapy, DEX implant treatment is more effective in improving BCVA and reducing ME. Additionally, DEX implant treatment has a higher risk of elevated intraocular pressure. Due to the small number of studies and the short follow-up period, the results should be interpreted with caution. The long-term effects of the two treatments need to be further determined. TRIAL REGISTRATION Prospero Registration Number CRD42021243185.
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Affiliation(s)
- Hui-xin Tang
- Department of Ophthalmology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jing-jing Li
- Department of Ophthalmology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ying Yuan
- Department of Pediatrics, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yun Ling
- Department of Ophthalmology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zubing Mei
- Department of Anorectal Surgery, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- Anorectal Disease Institute of Shuguang Hospital, Shanghai, China
| | - Hong Zou
- Department of Ophthalmology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
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Chakraborty D, Mondal S, Sengupta S, Maiti A, Boral S, Das A, Sinha TK, Nandi K. Aflibercept vs. dexamethasone implant for recalcitrant diabetic macular edema in pseudophakic eyes - 1-year outcomes from a quazi-randomized study in India. Indian J Ophthalmol 2024; 72:1001-1006. [PMID: 38622856 DOI: 10.4103/ijo.ijo_1447_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 01/04/2024] [Indexed: 04/17/2024] Open
Abstract
PURPOSE To assess the safety and efficacy of intravitreal Aflibercept (IVA) versus dexamethasone (DEX) implant for treating recalcitrant diabetic macular edema (DME) in pseudophakic eyes at 1-year follow-up. DESIGN Retrospective comparative case series. PARTICIPANTS Data of all patients diagnosed with DME between January 2019 and December 2021, who underwent 4-monthly doses of intravitreal ranibizumab but had persistent DME [central macular thickness (CMT) within 10% of baseline value] were extracted from a computerized database. Of these, only pseudophakic eyes that underwent either IVA or DEX implant and had at least 1-year follow-up were included for analysis. METHODS DEX implant was preferred before December 2020 and IVA after this time point. In the IVA group, patients were followed up every month while DEX were followed at least every 3 months. Reinjections were considered when vision dropped by at least 1 Snellen's line or CMT increased by at least 10% from the previous visit in both groups. MAIN OUTCOME MEASURES Comparison of change in vision and CMT at 1-year follow-up in DEX versus IVA groups. RESULTS Eighty-four eyes of 84 patients aged 54.4 + 4.4 years were included, 39 (46%) received DEX and 45 (54%) received IVA. Groups were comparable for baseline vision and CMT. Vision improved equally in both groups from 0.83 + 0.15 logMAR to 0.52 + 0.10 logMAR at 3 months ( P < 0.01) and then stabilized till 1 year. However, eyes in the IVA group were 6.5 times more likely (Odds ratio = 6.45, 95% CI = 1.3 - 31.9) to achieve >3-line improvement in vision. The CMT reduction was also comparable between groups (-169 + 51 in DEX vs. -174 + 49 in IVA, P = 0.67). More eyes in the IVA group required >3 injections (91% vs. 69% in DEX, P = 0.01). The IOP was significantly higher at 6 and 9 months in the DEX group and 5 eyes (13%) required IOP lowering medications. CONCLUSION In pseudophakic eyes with recalcitrant DME not responding to ranibizumab, switching to IVA or DEX implant results in equal visual improvement and CMT reduction. Though >3-line improvement occurs more frequently with IVA, this comes at the expense of a greater number of injections and follow-up visits.
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Affiliation(s)
- Debdulal Chakraborty
- Department of Vitreo-Retina Services, Disha Eye Hospitals, 88 Ghosh Para Road Barrackpore, Kolkata, West Bengal, India
| | - Soumen Mondal
- Department of Vitreo-Retina Services, Disha Eye Hospitals, 88 Ghosh Para Road Barrackpore, Kolkata, West Bengal, India
| | - Sabyasachi Sengupta
- Department of Retina, Future Vision Eye Care and Research Centre, Mumbai, Maharashtra, India
| | - Aniruddha Maiti
- Department of Retina, Global Eye Hospitals, Salt Lake, Kolkata, West Bengal, India
| | - Subhendu Boral
- Department of Vitreo-Retina Services, Disha Eye Hospitals, 88 Ghosh Para Road Barrackpore, Kolkata, West Bengal, India
| | - Arnab Das
- Department of Vitreo-Retina Services, Disha Eye Hospitals, 88 Ghosh Para Road Barrackpore, Kolkata, West Bengal, India
| | - Tushar K Sinha
- Department of Vitreo-Retina Services, Disha Eye Hospitals, 88 Ghosh Para Road Barrackpore, Kolkata, West Bengal, India
| | - Krishnendu Nandi
- Department of Retina, Nethralayam Superspeciality Eye Care, EM Bye Pass, Kolkata, West Bengal, India
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Ammari W, Chaabene H, Messaoud R. [Anatomical and functional outcomes of the "3+PRN" therapeutic protocol in the treatment of diabetic macular edema]. J Fr Ophtalmol 2024; 47:104234. [PMID: 38875945 DOI: 10.1016/j.jfo.2024.104234] [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: 09/17/2023] [Revised: 02/04/2024] [Accepted: 03/12/2024] [Indexed: 06/16/2024]
Abstract
PURPOSE To evaluate the anatomical and functional results of the "3+PRN" protocol in the treatment of diabetic macular edema (DME), determine the predictive factors for good final visual acuity, and compare it to other protocols. MATERIALS AND METHODS We conducted a retrospective, descriptive, comparative, cross-sectional study of patients with DME, which we dubbed HTSM. All patients were treated with three monthly initial intravitreal injections (IVT) of 1.25mg bevacizumab and followed according to the pro re nata (PRN) protocol for a period of 3years. The protocol was based on a monthly monitoring schedule for the first 3months, then increasingly spaced out over time. "On-demand" treatment was indicated with resumption of bevacizumab IVT in the event of worsening of DME. RESULTS A total of 52 patients were included. The mean age was 65years. Type 2 was the most frequently observed type of diabetes. The mean duration of the PRN protocol was 6months, and the mean number of injections was 6. The mean visual acuity (VA), initially 1/10, improved to 3/10 by the conclusion of the 3+PRN protocol, with an improvement of more than 5 letters in 77.6% of cases. The mean initial central macular thickness (CMT) was 451.5μm. The final mean EMC decreased to 298.5μm, which corresponds to a reduction of 153μm compared to the initial value. The mean subfoveal choroidal thickness, initially 304.2μm, decreased to a mean of 284.5μm at completion. Comparative analysis of the results before and after the PRN protocol confirmed the existence of a statistically significant correlation between VA and CMT (P<0.05). No correlation was observed between age and visual acuity or between initial and final VA. The analysis of the various tomographic parameters and VA revealed a significantly better visual improvement in the group in whom the external limiting membrane (MLE) and ellipsoid zone (ZE) were intact (P=0.04), as well as in the group in whom serous retinal detachment (SRD) was absent (P<0.001). Posterior vitreous detachment (PVD) was the most frequently observed vitreomacular anomaly. The final VA was similar in the groups with and without PVD (P=0.04). CONCLUSION The 3+PRN protocol is effective both functionally and tomographically in the treatment of DME. Various tomographic parameters might influence therapeutic efficacy. However, further in-depth studies are needed to better investigate these parameters.
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Affiliation(s)
- W Ammari
- Service d'ophtalmologie, hôpital universitaire Taher Sfar Mahdia, Jbel Dar Waja 5100, Tunisie; Faculté de médecine de Monastir, Monastir, Tunisie.
| | - H Chaabene
- Service d'ophtalmologie, hôpital universitaire Taher Sfar Mahdia, Jbel Dar Waja 5100, Tunisie; Faculté de médecine de Monastir, Monastir, Tunisie
| | - R Messaoud
- Service d'ophtalmologie, hôpital universitaire Taher Sfar Mahdia, Jbel Dar Waja 5100, Tunisie; Faculté de médecine de Monastir, Monastir, Tunisie
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Hatamnejad A, Orr S, Dadak R, Khanani A, Singh R, Choudhry N. Anti-VEGF and steroid combination therapy relative to anti-VEGF mono therapy for the treatment of refractory DME: A systematic review of efficacy and meta-analysis of safety. Acta Ophthalmol 2024; 102:e204-e214. [PMID: 37365698 DOI: 10.1111/aos.15724] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 04/23/2023] [Accepted: 06/12/2023] [Indexed: 06/28/2023]
Abstract
The aim of the study was to determine the efficacy and safety of combined anti-VEGF and steroid therapy in treatment refractory DME patients. We conducted a systematic review and meta-analysis of peer-reviewed articles reporting on visual, anatomical and adverse outcomes to compare the efficacy and safety of combined intravitreal anti-VEGF/steroids versus anti-VEGF monotherapy for refractory DME. Seven studies (4 RCTs and 3 observational studies) reporting on 452 eyes were included. Our systematic review showed that combination therapy is significantly more effective for anatomical outcomes in the treatment of resistant DME compared to anti-VEGF monotherapy in six studies. Two studies found that addition of intravitreal steroids promoted faster visual improvement, but not significantly better final visual outcomes compared to anti-VEGF monotherapy. Combination therapy was associated with a higher incidence of IOP-related adverse events (RR = 0.10, 95% CI = [0.02, 0.42], p = 0.002) and cataract-related adverse events (RR = 0.10, 95% CI = [0.01, 0.71], p = 0.02). Our systematic review and meta-analysis of seven studies and 452 eyes revealed that combination therapy of anti-VEGF and steroid intravitreal drugs in the management of treatment refractory DME resulted in superior anatomical outcomes in all but one study. Combination therapy led to superior short-term visual outcomes in two studies, while others reported no difference between treatment groups. Meta-analysis revealed that combination therapy was associated with more adverse events. Future research should provide guidance on the standard definitions for treatment resistance and therapeutic alternatives for DME patients with sub-optimal response to anti-VEGF treatment.
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Affiliation(s)
- Amin Hatamnejad
- Michael DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Octane Imaging Lab, Toronto, Ontario, Canada
| | - Samantha Orr
- Octane Imaging Lab, Toronto, Ontario, Canada
- Vitreous Retina Macula Specialists of Toronto, Etobicoke, Ontario, Canada
| | - Rohan Dadak
- Michael DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- Octane Imaging Lab, Toronto, Ontario, Canada
| | - Arshad Khanani
- Sierra Eye Associates, Reno, Nevada, USA
- The University of Nevada, Reno School of Medicine, Reno, Nevada, USA
| | - Rishi Singh
- Cleveland Clinic Martin Health System, Cleveland Clinic, Florida, USA
| | - Netan Choudhry
- Octane Imaging Lab, Toronto, Ontario, Canada
- Vitreous Retina Macula Specialists of Toronto, Etobicoke, Ontario, Canada
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
- Cleveland Clinic Canada, Toronto, Ontario, Canada
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Omar A, Williams RG, Whelan J, Noble J, Brent MH, Giunta M, Olivier S, Lhor M. Diabetic Disease of the Eye in Canada: Consensus Statements from a Retina Specialist Working Group. Ophthalmol Ther 2024; 13:1071-1102. [PMID: 38526804 DOI: 10.1007/s40123-024-00923-0] [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: 01/31/2024] [Accepted: 02/29/2024] [Indexed: 03/27/2024] Open
Abstract
Despite advances in systemic care, diabetic disease of the eye (DDE) remains the leading cause of blindness worldwide. There is a critical gap of up-to-date, evidence-based guidance for ophthalmologists in Canada that includes evidence from recent randomized controlled trials. Previous guidance has not always given special consideration to applying treatments and managing DDE in the context of the healthcare system. This consensus statement aims to assist practitioners in the field by providing a spectrum of acceptable opinions on DDE treatment and management from recognized experts in the field. In compiling evidence and generating consensus, a working group of retinal specialists in Canada addressed clinical questions surrounding the four themes of disease, patient, management, and collaboration. The working group reviewed literature representing the highest level of evidence on DDE and shared their opinions on topics surrounding the epidemiology and pathophysiology of diabetic retinopathy and diabetic macular edema; diagnosis and monitoring; considerations around diabetes medication use; strategic considerations for management given systemic comorbidities, ocular comorbidities, and pregnancy; treatment goals and modalities for diabetic macular edema, non-proliferative and proliferative diabetic retinopathy, and retinal detachment; and interdisciplinary collaboration. Ultimately, this work highlighted that the retinal examination in DDE not only informs the treating ophthalmologist but can serve as a global index for disease progression across many tissues of the body. It highlighted further that DDE can be treated regardless of diabetic control, that a systemic approach to patient care will result in the best health outcomes, and prevention of visual complications requires a multidisciplinary management approach. Ophthalmologists must tailor their clinical approach to the needs and circumstances of individual patients and work within the realities of their healthcare setting.
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Affiliation(s)
- Amer Omar
- Medical Retina Institute of Montreal, 2170 René-Lévesque Blvd Ouest, Bureau 101, Montréal, QC, H3H 2T8, Canada.
| | - R Geoff Williams
- Calgary Retina Consultants, University of Calgary, Calgary, AB, Canada
| | - James Whelan
- Faculty of Medicine, Memorial University, St. John's, NF, Canada
| | - Jason Noble
- Department of Ophthalmology and Vision Science, University of Toronto, Toronto, ON, Canada
| | - Michael H Brent
- Department of Ophthalmology and Vision Science, University of Toronto, Toronto, ON, Canada
| | - Michel Giunta
- Department of Ophthalmology, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Sébastien Olivier
- Centre Universitaire d'ophtalmologie, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, QC, Canada
| | - Mustapha Lhor
- Medical and Scientific Affairs Ophthalmology, Bayer Inc., Mississauga, ON, Canada
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Li DS, Liao HX, Zhang CH, Huang JG, Chen W, Zhang JL, Qin B. Aflibercept combined with triamcinolone acetonide in the treatment of diabetic macular edema: optical coherence tomography and optical coherence tomography angiography. Int J Ophthalmol 2024; 17:670-675. [PMID: 38638246 PMCID: PMC10988085 DOI: 10.18240/ijo.2024.04.10] [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: 01/07/2024] [Accepted: 02/08/2024] [Indexed: 04/20/2024] Open
Abstract
AIM To analyze the relationship between optical coherence tomography (OCT) and OCT angiography (OCTA) imaging in patients with diabetic macular edema (DME) who are treated with a combination of aflibercept and triamcinolone acetonide (TA). METHODS A total of 76 eyes newly diagnosed DME were included in this study. They were randomly assigned to receive either aflibercept or a combination of aflibercept and TA. Injections once a month for a total of three injections. Central macular thickness (CMT), number of hyperreflective foci (HRF), height of subretinal fluid (SRF), and area of foveal avascular zone (FAZ) were evaluated using OCT and OCTA at baseline and after each monthly treatment. RESULTS Both groups showed improvement in best corrected visual acuity (BCVA) and reduction in macular edema after treatment, and the difference in BCVA between the two groups was statistically significant after each treatment (P<0.05). The difference in CMT between the two groups was statistically significant after the first two injections (P<0.01), but not after the third injection (P=0.875). The number of HRF (1mo: 7.41±8.25 vs 10.86±7.22, P=0.027; 2mo: 5.33±6.13 vs 9.12±8.61, P=0.034; 3mo: 3.58±3.00 vs 6.37±5.97, P=0.007) and height of SRF (1mo: 82.39±39.12 vs 105.77±42.26 µm, P=0.011; 2mo: 36.84±10.02 vs 83.59±37.78 µm, P<0.01; 3mo: 11.57±3.29 vs 45.43±12.60 µm, P<0.01) in combined group were statistically significant less than aflibercept group after each injection, while the area of FAZ showed no significant change before and after treatment in both groups. CONCLUSION The combination therapy of aflibercept and TA shows more significant effects on DME eyes with decreased HRF and SRF. However, both aflibercept and combination therapy show no significant change in the area of FAZ.
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Affiliation(s)
- De-Shuang Li
- Shenzhen Aier Eye Hospital, Aier Eye Hospital, Jinan University, Shenzhen 518031, Guangdong Province, China
| | - Hong-Xia Liao
- Shenzhen Aier Eye Hospital, Aier Eye Hospital, Jinan University, Shenzhen 518031, Guangdong Province, China
| | - Chuan-He Zhang
- Shenzhen Aier Eye Hospital, Aier Eye Hospital, Jinan University, Shenzhen 518031, Guangdong Province, China
| | - Jian-Guo Huang
- Shenzhen Aier Eye Hospital, Aier Eye Hospital, Jinan University, Shenzhen 518031, Guangdong Province, China
| | - Wei Chen
- Department of Ophthalmology, the University of Hong Kong-Shenzhen Hospital, Shenzhen 518000, Guangdong Province, China
| | - Jing-Lin Zhang
- Guangzhou Aier Eye Hospital, Jinan University, Guangzhou 510040, Guangdong Province, China
| | - Bo Qin
- Shenzhen Aier Eye Hospital, Aier Eye Hospital, Jinan University, Shenzhen 518031, Guangdong Province, China
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Moreno JB, Medina DB, Rosellón-Escobar MF, García-Aguirre JG. Short-term effect of intravitreal dexamethasone implant in refractory diabetic macular edema. BMC Ophthalmol 2024; 24:113. [PMID: 38462613 PMCID: PMC10926656 DOI: 10.1186/s12886-024-03341-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/05/2024] [Indexed: 03/12/2024] Open
Abstract
PURPOSE To evaluate the short-term effects (hours-days) of intravitreal dexamethasone implant (IDI) in eyes with diabetic macular edema (DME) refractory to anti-vascular endothelial growth factor (VEGF) injections. METHODS This was a prospective, single-arm, interventional clinical series. Eyes with DME and 3-9 injections of ranibizumab without a good response were included. Patients underwent a single IDI. Best-corrected visual acuity (BCVA) measurement, complete ophthalmic evaluation, and spectral-domain optical coherence tomography (SD-OCT) were performed at baseline, 2 h, 3 h, 24 h, 7 days, and 1 month. The main outcomes were change in central retinal thickness (CRT) on SD-OCT and BCVA. RESULTS Fifteen eyes of 15 patients were included. Mean CRT decreased after treatment from 515.87 µm ± 220.00 µm at baseline to 489.60 µm ± 176.53 µm after 2 h (p = 0.126), and 450.13 µm ± 163.43 at 24 h (p = 0.006). Change in BCVA was from 0.85 ± 0.44 logMAR baseline to 0.58 ± 0.37 log MAR at 1 month (p = 0.003). CONCLUSIONS Eyes treated with IDI showed significant decrease in CRT detectable 1 day after injection. In some patients, the effect could be observed 3 h post-implantation. TRIAL REGISTRATION Clinicaltrials.gov NCT05736081 . Registered 20 February 2023, Retrospectively registered.
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Affiliation(s)
- Jazmín Baca Moreno
- Retina Department, Asociación para Evitar la Ceguera en México I.A.P., Mexico City, Mexico
| | - David Berrones Medina
- Retina Department, Asociación para Evitar la Ceguera en México I.A.P., Mexico City, Mexico
| | - María Fernanda Rosellón-Escobar
- Retina Department, Asociación para Evitar la Ceguera en México I.A.P., Mexico City, Mexico
- School of Medicine and Health Sciences, Tecnológico de Monterrey, Mexico City, Mexico
| | - José Gerardo García-Aguirre
- Retina Department, Asociación para Evitar la Ceguera en México I.A.P., Mexico City, Mexico.
- School of Medicine and Health Sciences, Tecnológico de Monterrey, Mexico City, Mexico.
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Choudhary A, Gopalakrishnan N, Joshi A, Balakrishnan D, Chhablani J, Yadav NK, Reddy NG, Rani PK, Gandhi P, Shetty R, Roy R, Bavaskar S, Prabhu V, Venkatesh R. Recommendations for diabetic macular edema management by retina specialists and large language model-based artificial intelligence platforms. Int J Retina Vitreous 2024; 10:22. [PMID: 38419083 PMCID: PMC10900631 DOI: 10.1186/s40942-024-00544-6] [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: 01/13/2024] [Accepted: 02/15/2024] [Indexed: 03/02/2024] Open
Abstract
PURPOSE To study the role of artificial intelligence (AI) in developing diabetic macular edema (DME) management recommendations by creating and comparing responses to clinicians in hypothetical AI-generated case scenarios. The study also examined whether its joint recommendations followed national DME management guidelines. METHODS The AI hypothetically generated 50 ocular case scenarios from 25 patients using keywords like age, gender, type, duration and control of diabetes, visual acuity, lens status, retinopathy stage, coexisting ocular and systemic co-morbidities, and DME-related retinal imaging findings. For DME and ocular co-morbidity management, we calculated inter-rater agreements (kappa analysis) separately for clinician responses, AI-platforms, and the "majority clinician response" (the maximum number of identical clinician responses) and "majority AI-platform" (the maximum number of identical AI responses). Treatment recommendations for various situations were compared to the Indian national guidelines. RESULTS For DME management, clinicians (ĸ=0.6), AI platforms (ĸ=0.58), and the 'majority clinician response' and 'majority AI response' (ĸ=0.69) had moderate to substantial inter-rate agreement. The study showed fair to substantial agreement for ocular co-morbidity management between clinicians (ĸ=0.8), AI platforms (ĸ=0.36), and the 'majority clinician response' and 'majority AI response' (ĸ=0.49). Many of the current study's recommendations and national clinical guidelines agreed and disagreed. When treating center-involving DME with very good visual acuity, lattice degeneration, renal disease, anaemia, and a recent history of cardiovascular disease, there were clear disagreements. CONCLUSION For the first time, this study recommends DME management using large language model-based generative AI. The study's findings could guide in revising the global DME management guidelines.
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Affiliation(s)
- Ayushi Choudhary
- Dept. of Retina and Vitreous, Narayana Nethralaya, #121/C, 1st R Block, Chord Road, Rajaji Nagar, 560010, Bengaluru, Karnataka, India
| | - Nikhil Gopalakrishnan
- Dept. of Retina and Vitreous, Narayana Nethralaya, #121/C, 1st R Block, Chord Road, Rajaji Nagar, 560010, Bengaluru, Karnataka, India
| | - Aishwarya Joshi
- Dept. of Retina and Vitreous, Narayana Nethralaya, #121/C, 1st R Block, Chord Road, Rajaji Nagar, 560010, Bengaluru, Karnataka, India
| | - Divya Balakrishnan
- Dept of Retina and Vitreous, Little Flower Hospital and Research Centre, 683572, Angamaly, Kerala, India
| | - Jay Chhablani
- Medical Retina and Vitreoretinal Surgery, University of Pittsburgh School of Medicine, 203 Lothrop Street, Suite 800, 15213, Pittsburg, PA, USA
| | - Naresh Kumar Yadav
- Dept. of Retina and Vitreous, Narayana Nethralaya, #121/C, 1st R Block, Chord Road, Rajaji Nagar, 560010, Bengaluru, Karnataka, India
| | - Nikitha Gurram Reddy
- Anant Bajaj Retina Institute, L V Prasad Eye Institute, Kallam Anji Reddy Campus, 500034, Hyderabad, Telangana, India
| | - Padmaja Kumari Rani
- Anant Bajaj Retina Institute, L V Prasad Eye Institute, Kallam Anji Reddy Campus, 500034, Hyderabad, Telangana, India
| | - Priyanka Gandhi
- Dept. of Retina and Vitreous, Narayana Nethralaya, #121/C, 1st R Block, Chord Road, Rajaji Nagar, 560010, Bengaluru, Karnataka, India
| | - Rohit Shetty
- Dept. of Cornea and Refractive Services, Narayana Nethralaya, #121/C, 1st R Block, Chord Road, Rajaji Nagar, 560010, Bengaluru, Karnataka, India
| | - Rupak Roy
- Dept. of Vitreo-Retina, Aditya Birla Sankara Nethralaya, 700099, Kolkata, India
| | - Snehal Bavaskar
- Dept. of Retina and Vitreous, Narayana Nethralaya, #121/C, 1st R Block, Chord Road, Rajaji Nagar, 560010, Bengaluru, Karnataka, India
| | - Vishma Prabhu
- Dept. of Retina and Vitreous, Narayana Nethralaya, #121/C, 1st R Block, Chord Road, Rajaji Nagar, 560010, Bengaluru, Karnataka, India
| | - Ramesh Venkatesh
- Dept. of Retina and Vitreous, Narayana Nethralaya, #121/C, 1st R Block, Chord Road, Rajaji Nagar, 560010, Bengaluru, Karnataka, India.
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Salvetat ML, Pellegrini F, Spadea L, Salati C, Musa M, Gagliano C, Zeppieri M. The Treatment of Diabetic Retinal Edema with Intravitreal Steroids: How and When. J Clin Med 2024; 13:1327. [PMID: 38592149 PMCID: PMC10932454 DOI: 10.3390/jcm13051327] [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: 12/11/2023] [Revised: 02/13/2024] [Accepted: 02/21/2024] [Indexed: 04/10/2024] Open
Abstract
Diabetic macular edema (DME) is a common complication of diabetes mellitus and a leading cause of visual impairment worldwide. It is defined as the diabetes-related accumulation of fluid, proteins, and lipids, with retinal thickening, within the macular area. DME affects a significant proportion of individuals with diabetes, with the prevalence increasing with disease duration and severity. It is estimated that approximately 25-30% of diabetic patients will develop DME during their lifetime. Poor glycemic control, hypertension, hyperlipidemia, diabetes duration, and genetic predisposition are recognized as risk factors for the development and progression of DME. Although the exact pathophysiology is still not completely understood, it has been demonstrated that chronic hyperglycemia triggers a cascade of biochemical processes, including increased oxidative stress, inflammation, activation of vascular endothelial growth factor (VEGF), cellular dysfunction, and apoptosis, with breakdown of the blood-retinal barriers and fluid accumulation within the macular area. Early diagnosis and appropriate management of DME are crucial for improving visual outcomes. Although the control of systemic risk factors still remains the most important strategy in DME treatment, intravitreal pharmacotherapy with anti-VEGF molecules or steroids is currently considered the first-line approach in DME patients, whereas macular laser photocoagulation and pars plana vitrectomy may be useful in selected cases. Available intravitreal steroids, including triamcinolone acetonide injections and dexamethasone and fluocinolone acetonide implants, exert their therapeutic effect by reducing inflammation, inhibiting VEGF expression, stabilizing the blood-retinal barrier and thus reducing vascular permeability. They have been demonstrated to be effective in reducing macular edema and improving visual outcomes in DME patients but are associated with a high risk of intraocular pressure elevation and cataract development, so their use requires an accurate patient selection. This manuscript aims to provide a comprehensive overview of the pathology, epidemiology, risk factors, physiopathology, clinical features, treatment mechanisms of actions, treatment options, prognosis, and ongoing clinical studies related to the treatment of DME, with particular consideration of intravitreal steroids therapy.
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Affiliation(s)
- Maria Letizia Salvetat
- Department of Ophthalmology, Azienda Sanitaria Friuli Occidentale, 33170 Pordenone, Italy; (M.L.S.)
| | - Francesco Pellegrini
- Department of Ophthalmology, Azienda Sanitaria Friuli Occidentale, 33170 Pordenone, Italy; (M.L.S.)
| | - Leopoldo Spadea
- Eye Clinic, Policlinico Umberto I, “Sapienza” University of Rome, 00142 Rome, Italy
| | - Carlo Salati
- Department of Ophthalmology, University Hospital of Udine, 33100 Udine, Italy
| | - Mutali Musa
- Department of Optometry, University of Benin, Benin City 300238, Edo State, Nigeria
| | - Caterina Gagliano
- Faculty of Medicine and Surgery, University of Enna “Kore”, Piazza dell’Università, 94100 Enna, Italy
- Eye Clinic, Catania University, San Marco Hospital, Viale Carlo Azeglio Ciampi, 95121 Catania, Italy
| | - Marco Zeppieri
- Department of Ophthalmology, University Hospital of Udine, 33100 Udine, Italy
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Li DS, Liao HX, Zhang JL, Qin B. Effect of aflibercept combined with triamcinolone acetonide on aqueous humor growth factor and inflammatory mediators in diabetic macular edema. Int J Ophthalmol 2024; 17:297-303. [PMID: 38371257 PMCID: PMC10827616 DOI: 10.18240/ijo.2024.02.11] [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: 10/19/2023] [Accepted: 11/28/2023] [Indexed: 02/20/2024] Open
Abstract
AIM To investigate the efficacy of aflibercept combined with sub-tenon injection of triamcinolone acetonide (TA) in treating diabetic macular edema (DME) and to examine changes in growth factors and inflammatory mediator levels in aqueous humor after injection. METHODS Totally 67 DME patients (67 eyes) and 30 cataract patients (32 eyes) were enrolled as the DME group and the control group, respectively. The DME group was divided into the aflibercept group (34 cases) and the aflibercept combined with TA group (combined group, 33 cases). The aqueous humor of both groups was collected during the study period. The aqueous levels of vascular endothelial growth factor (VEGF), monocyte chemoattractant protein-1 (MCP-1), interleukin-6 (IL-6), interleukin-8 (IL-8), and interleukin-1β (IL-1β) were detected using a microsphere suspension array technology (Luminex 200TM). Aqueous cytokines, best-corrected visual acuity (BCVA), central macular thickness (CMT), and complications before and after treatment were compared between the aflibercept group and combined group. RESULTS The concentrations of VEGF, MCP-1, IL-6, and IL-8 in the aqueous humor were significantly higher in the DME group than those of the control group (all P<0.01). After 1mo of surgery, the concentrations of VEGF, MCP-1, IL-6, and IL-8 in the aqueous humor were significantly lower in the combined group than those of the aflibercept group (all P<0.01). The BCVA and CMT values of the two groups were statistically different after 1 and 2mo of treatment (P<0.01). However, the difference was not statistically significant after 3mo of treatment (P>0.05). CONCLUSION The cytokines VEGF, MCP-1, IL-6, and IL-8 in the aqueous humor of DME patients are significantly increased. Aflibercept and aflibercept combined with TA have good efficacy in DME patients, can effectively reduce CMT, improve the patient's vision, and have high safety. Aflibercept combined with TA can quickly down-regulate the aqueous humor cytokines and help to relieve macular edema rapidly. However, the long-term efficacy is comparable to that of aflibercept alone.
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Affiliation(s)
- De-Shuang Li
- Shenzhen Aier Eye Hospital, Aier Eye Hospital, Jinan University, Shenzhen 518031, Guangdong Province, China
| | - Hong-Xia Liao
- Shenzhen Aier Eye Hospital, Aier Eye Hospital, Jinan University, Shenzhen 518031, Guangdong Province, China
| | - Jing-Lin Zhang
- Guangzhou Aier Eye Hospital, Jinan University, Guangzhou 510040, Guangdong Province, China
| | - Bo Qin
- Shenzhen Aier Eye Hospital, Aier Eye Hospital, Jinan University, Shenzhen 518031, Guangdong Province, China
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11
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Moreno-Martinez A, Blanco-Marchite C, Copete S. Influence of prior treatment protocol on intravitreal dexamethasone implant behavior in patients with diabetic macular edema in real-world practice. Expert Opin Drug Saf 2024; 23:199-205. [PMID: 38234187 DOI: 10.1080/14740338.2024.2305361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 09/15/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND AND OBJECTIVE Intravitreal dexamethasone implant (DEXI) has been placed as an effective option to treat diabetic macular edema (DME). However, there is no consensus on the best time to introduce it. We conducted a study to evaluate anatomical and functional behavior after the first DEXI according to previous treatment. RESEARCH DESIGN AND METHODS This retrospective, real-world study between 2013 and 2020 investigated changes in best-corrected visual acuity (BCVA) and central macular thickness (CMT at months 2 and 6 after the first DEXI in DME. Patients were divided into naive, early switch (≤3 anti-VEGF injections), or late switch (>3 anti-VEGF injections) groups. RESULTS Among 112 consecutive eyes, mean BCVA and CMT improved significantly in all groups at month 2, with no difference between them. However, this improvement was not maintained at 6 months. The Naíve group presented better BCVA all over the study period. The previously treated groups, which started with worse initial visual acuity, showed more visual gain without reaching the BCVA of the naive group. CMT performance was similar between groups. CONCLUSIONS There was similar anatomical and functional behavior in all groups. Poorer visual acuity at baseline was associated with worse functional outcome despite good anatomic response.
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Affiliation(s)
| | | | - Sergio Copete
- Department of Ophthalmology, Albacete University Hospital Complex, Albacete, Spain
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12
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Szeto SK, Lai TY, Vujosevic S, Sun JK, Sadda SR, Tan G, Sivaprasad S, Wong TY, Cheung CY. Optical coherence tomography in the management of diabetic macular oedema. Prog Retin Eye Res 2024; 98:101220. [PMID: 37944588 DOI: 10.1016/j.preteyeres.2023.101220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 10/24/2023] [Accepted: 10/24/2023] [Indexed: 11/12/2023]
Abstract
Diabetic macular oedema (DMO) is the major cause of visual impairment in people with diabetes. Optical coherence tomography (OCT) is now the most widely used modality to assess presence and severity of DMO. DMO is currently broadly classified based on the involvement to the central 1 mm of the macula into non-centre or centre involved DMO (CI-DMO) and DMO can occur with or without visual acuity (VA) loss. This classification forms the basis of management strategies of DMO. Despite years of research on quantitative and qualitative DMO related features assessed by OCT, these do not fully inform physicians of the prognosis and severity of DMO relative to visual function. Having said that, recent research on novel OCT biomarkers development and re-defined classification of DMO show better correlation with visual function and treatment response. This review summarises the current evidence of the association of OCT biomarkers in DMO management and its potential clinical importance in predicting VA and anatomical treatment response. The review also discusses some future directions in this field, such as the use of artificial intelligence to quantify and monitor OCT biomarkers and retinal fluid and identify phenotypes of DMO, and the need for standardisation and classification of OCT biomarkers to use in future clinical trials and clinical practice settings as prognostic markers and secondary treatment outcome measures in the management of DMO.
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Affiliation(s)
- Simon Kh Szeto
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Timothy Yy Lai
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Stela Vujosevic
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy; Eye Clinic, IRCCS MultiMedica, Milan, Italy
| | - Jennifer K Sun
- Beetham Eye Institute, Harvard Medical School, Boston, USA
| | - SriniVas R Sadda
- Doheny Eye Institute, University of California Los Angeles, Los Angeles, USA
| | - Gavin Tan
- Singapore Eye Research Institute, SingHealth Duke-National University of Singapore, Singapore
| | - Sobha Sivaprasad
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Tien Y Wong
- Tsinghua Medicine, Tsinghua University, Beijing, China; Singapore Eye Research Institute, Singapore
| | - Carol Y Cheung
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China.
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13
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Bhatnagar A, Ting DSW, Weng CY. Treatment Options for Diabetic Macular Edema. Int Ophthalmol Clin 2024; 64:57-69. [PMID: 38146881 DOI: 10.1097/iio.0000000000000518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023]
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14
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Peng W, Zhang M, Yi X. Systemic Inflammatory Mediator Levels in Non-Proliferative Diabetic Retinopathy Patients with Diabetic Macular Edema. Curr Eye Res 2024; 49:80-87. [PMID: 37804222 DOI: 10.1080/02713683.2023.2268306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 10/04/2023] [Indexed: 10/09/2023]
Abstract
PURPOSE To study the systemic inflammatory mediator levels in non-proliferative diabetic retinopathy (NPDR) patients with diabetic macular edema (DME) and explore the correlation between systemic inflammatory mediators and DME. METHODS In this prospective study, we included 25 patients without diabetes (control group) and 75 patients with type 2 diabetes mellitus (diabetic group). According to fundus examination, the diabetic group patients were divided into: diabetic patients without diabetic retinopathy (DR) (Non-DR group), NPDR patients without DME (Non-DME group), and NPDR patients with DME (DME group). Serum levels of a broad panel of inflammatory mediators were analysed by multiplex protein quantitative detection technology based on a flow cytometry detection system. RESULTS The interferon-γ (IFN-γ) levels were significantly higher in DME group and Non-DME group as compared to control group (p = 0.023 and p = 0.033) and Non-DR group (p = 0.009 and p = 0.015). Significantly higher values were obtained in DME group and Non-DME group as compared to control group for the interleukin-8 (IL-8) (p = 0.003 and p = 0.003). The IL-23 levels were significantly elevated in DME group and Non-DR group than in Non-DME group (p = 0.013 and p = 0.004). The diabetic group had significantly higher serum levels of IL-8 and IL-33 (p = 0.001 and p = 0.011), and lower serum levels of tumor necrosis factor-α (TNF-α) (p = 0.027) in comparison with control group. CONCLUSIONS The changed levels of serum inflammatory mediators suggest that the systemic inflammatory mediators are involved in the pathogenesis of NPDR patients with DME. Such effects can guide clinical monitoring, diagnostic and therapeutic approaches for DME patients at an early stage.
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Affiliation(s)
- Wenyi Peng
- Department of Ophthalmology, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia, Xinjiang Medical University, Urumchi, China
| | - Mingmei Zhang
- Department of Ophthalmology, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia, Xinjiang Medical University, Urumchi, China
| | - Xianglong Yi
- Department of Ophthalmology, The First Affiliated Hospital of Xinjiang Medical University, Urumchi, China
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Myslík Manethová K. Central Serous Chorioretinopathy. A Review. CESKA A SLOVENSKA OFTALMOLOGIE : CASOPIS CESKE OFTALMOLOGICKE SPOLECNOSTI A SLOVENSKE OFTALMOLOGICKE SPOLECNOSTI 2024; 80:59-75. [PMID: 38531681 DOI: 10.31348/2023/27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
Central serous chorioretinopathy (CSC) is a disease characterized by serous detachment of the neuroretina, especially in the posterior pole of the eye. It is often accompanied by serous detachment of the retinal pigment epithelium (RPE) and associated with the leakage of fluid into the subretinal space through the defective RPE. CSC most often affects men of working age. The exact pathophysiology of the disease is not completely known. Based on indocyanine green angiography (ICG), which revealed increased permeability of choroidal vessels, and optical coherence tomography (OCT) showing increased choroidal thickness, choroidal vasculopathy is assumed to be the primary cause of CSC. In most cases, CSC has a good prognosis with spontaneous resorption of the subretinal fluid (SRF) and improvement of visual functions. However, in a small percentage of patients the disease progresses to a chronic or recurrent course, and can lead to irreversible functional and anatomical changes of the retina with a final clinical picture of diffuse retinal pigment epitheliopathy (DRPE). The optimal treatment approach for patients with CSC remains controversial. In recent decades, myriad therapeutic approaches have been used in the treatment of chronic forms of CSC (cCSC); these included for example laser photocoagulation, pharmaceutical treatment, standard photodynamic therapy (PDT) or anti-VEGF. In recent years a less destructive method, specifically PDT in reduced dose regimens, either with a reduced dose of verteporfin or the laser beam energy used, has been preferred in the treatment of cCSC. Comparable efficacy and safety has been demonstrated using reduced-dose or reduced-fluence PDT regimens in patients with cCSC, with an improvement in best-corrected visual acuity and reduction of SRF.
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16
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Kour V, Swain J, Singh J, Singh H, Kour H. A Review on Diabetic Retinopathy. Curr Diabetes Rev 2024; 20:e201023222418. [PMID: 37867267 DOI: 10.2174/0115733998253672231011161400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 07/08/2023] [Accepted: 08/23/2023] [Indexed: 10/24/2023]
Abstract
Diabetic retinopathy is a well-recognised microvascular complication of diabetes and is among the leading cause of blindness all over the world. Over the last decade, there have been advances in the diagnosis of diabetic retinopathy and diabetic macular edema. At the same time, newer therapies for the management of diabetic retinopathy have evolved. As a result of these advances, a decline in severe vision loss due to diabetes has been witnessed in some developing countries. However, there is a steady increase in the number of people affected with diabetes, and is expected to rise further in the coming years. Therefore, it is prudent to identify diabetic retinopathy, and timely intervention is needed to decrease the burden of severe vision loss. An effort has been made to review all the existing knowledge regarding diabetic retinopathy in this article and summarize the present treatment options for diabetic retinopathy.
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Affiliation(s)
- Vijender Kour
- Consultant Ophthalmology, Department of Ophthalmology, Sub District Hospital, Tral, Pulwama, India
| | - Jayshree Swain
- Department of Endocrinology, IMS and Sum Hospital, Siksha O Anusandhan (SOA) University, Bhubaneswar, India
| | - Jaspreet Singh
- Department of Endocrinology, IMS and Sum Hospital, Siksha O Anusandhan (SOA) University, Bhubaneswar, India
| | - Hershdeep Singh
- Consultant Neurosurgeon, Department of Neurosurgery, Fortis Ludhiana, Bhubaneswar, India
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17
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Rennie C, Lotery A, Payne J, Singh M, Ghanchi F. Suboptimal outcomes and treatment burden of anti-vascular endothelial growth factor treatment for diabetic macular oedema in phakic patients. Eye (Lond) 2024; 38:215-223. [PMID: 37542174 PMCID: PMC10764926 DOI: 10.1038/s41433-023-02667-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 06/27/2023] [Accepted: 07/14/2023] [Indexed: 08/06/2023] Open
Abstract
OBJECTIVES In England and Wales, treatment options were limited for patients with diabetic macular oedema (DMO) with phakic eyes that failed anti-vascular endothelial growth factor (anti-VEGF) treatment pre-2022. This study aimed to quantify the response to, and treatment burden of, anti-VEGF treatment in phakic eyes. METHODS Retrospective, cohort study using electronic patient record data from two UK centres between 2015 and 2020. Primary objective was proportion of phakic eyes with a suboptimal response after initial 6 months of anti-VEGF treatment. Data were available for 500 eyes from 399 patients. RESULTS At 6 months significantly more eyes had a suboptimal response to anti-VEGF treatment: 65.8% (95% CI 61.5-70.0%) vs 34.2% (95% CI 30.0-38.5%), p < 0.0001. Baseline visual acuity (VA) predicted VA outcome, however, despite greater gains in eyes with poorer VA, such eyes did not achieve the same VA levels as those who started treatment with better VA. Only 53.6% of eyes had more than three injections in the first 6 months indicating difficulties in delivering high volume/high frequency treatment. Treatment and review burden were similar over the following years regardless of response to anti-VEGF treatment. CONCLUSIONS Data confirm previous real world evidence around response to anti-VEGF treatment, importance of baseline VA and frequency of injections in predicting outcomes in a UK setting. Continuing treatment beyond 6 months in suboptimal responders imposes unnecessary treatment burden without significant change in VA. In suboptimal responders, consideration of early switch to longer acting steroid treatments may help to reduce treatment burden, whilst maintaining or improving vision.
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Affiliation(s)
- Christina Rennie
- University Hospital Southampton NHS Foundation Trust, Southampton, UK.
| | - Andrew Lotery
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Jo Payne
- AbbVie Ltd, AbbVie House, Vanwall Business Park, Maidenhead, UK
| | - Moushmi Singh
- AbbVie Ltd, AbbVie House, Vanwall Business Park, Maidenhead, UK
| | - Faruque Ghanchi
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
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18
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Taloni A, Coco G, Rastelli D, Buffon G, Scorcia V, Giannaccare G. Safety and Efficacy of Dexamethasone Intravitreal Implant Given Either First-Line or Second-Line in Diabetic Macular Edema. Patient Prefer Adherence 2023; 17:3307-3329. [PMID: 38106365 PMCID: PMC10725633 DOI: 10.2147/ppa.s427209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 12/06/2023] [Indexed: 12/19/2023] Open
Abstract
Diabetic macular edema (DME) is a common sight-threatening complication of diabetic retinopathy (DR) and the leading cause of severe visual impairment among the working-age population. Several therapeutic options are available for the management of DME, including intravitreal corticosteroids. They have been traditionally used as second-line treatment, due to the risk of intraocular pressure increase and cataract-related adverse events. However, attention has recently been focused on the primary or early use of intravitreal corticosteroids, due to growing evidence of the crucial role of inflammation in the pathogenesis of DME. Furthermore, intravitreal steroid implants offer the additional advantage of a longer duration of action compared to anti-vascular endothelial growth factor agents (anti-VEGF). This review aims to summarize the available evidence on the efficacy and safety profile of dexamethasone (DEX) intravitreal implant, with a specific focus on clinical scenarios in which it might be considered or even preferred as first-line treatment option by adequate selection of patients, considering both advantages and possible adverse events. Patients with contraindications to anti-VEGF, DME with high inflammatory OCT biomarkers, pseudophakic patients and phakic patients' candidates to cataract surgery as well as vitrectomized eyes may all benefit from first-line DEX implant. Additionally, DME not responders to anti-VEGF should be considered for a switch to DEX implant and a combination therapy of DEX implant and anti-VEGF could be a valid option in severe and persistent DME.
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Affiliation(s)
- Andrea Taloni
- Department of Ophthalmology, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Giulia Coco
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Davide Rastelli
- Department of Ophthalmology, Policlinico Casilino, Rome, Italy
| | - Giacinta Buffon
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Vincenzo Scorcia
- Department of Ophthalmology, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Giuseppe Giannaccare
- Eye Clinic, Department of Surgical Sciences, University of Cagliari, Cagliari, Italy
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Gabrielle PH, Mehta H, Barthelmes D, Daien V, Nguyen V, Gillies MC, Creuzot-Garcher CP. From randomised controlled trials to real-world data: Clinical evidence to guide management of diabetic macular oedema. Prog Retin Eye Res 2023; 97:101219. [PMID: 37898362 DOI: 10.1016/j.preteyeres.2023.101219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 10/12/2023] [Accepted: 10/13/2023] [Indexed: 10/30/2023]
Abstract
Randomised clinical trials (RCTs) are generally considered the gold-standard for providing scientific evidence for treatments' effectiveness and safety but their findings may not always be generalisable to the broader population treated in routine clinical practice. RCTs include highly selected patient populations that fit specific inclusion and exclusion criteria. Although they may have a lower level of certainty than RCTs on the evidence hierarchy, real-world data (RWD), such as observational studies, registries and databases, provide real-world evidence (RWE) that can complement RCTs. For example, RWE may help satisfy requirements for a new indication of an already approved drug and help us better understand long-term treatment effectiveness, safety and patterns of use in clinical practice. Many countries have set up registries, observational studies and databases containing information on patients with retinal diseases, such as diabetic macular oedema (DMO). These DMO RWD have produced significant clinical evidence in the past decade that has changed the management of DMO. RWD and medico-administrative databases are a useful resource to identify low frequency safety signals. They often have long-term follow-up with a large number of patients and minimal exclusion criteria. We will discuss improvements in healthcare information exchange technologies, such as blockchain technology and FHIR (Fast Healthcare Interoperability Resources), which will connect and extend databases already available. These registries can be linked with existing or emerging retinal imaging modalities using artificial intelligence to aid diagnosis, treatment decisions and provide prognostic information. The results of RCTs and RWE are combined to provide evidence-based guidelines.
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Affiliation(s)
- Pierre-Henry Gabrielle
- Department of Ophthalmology, Dijon University Hospital, Dijon, Burgundy, France; The Save Sight Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Hemal Mehta
- The Save Sight Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; Ophthalmology Department, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Daniel Barthelmes
- The Save Sight Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; Department of Ophthalmology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Vincent Daien
- The Save Sight Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; Department of Ophthalmology, Montpellier University Hospital, Montpellier, France; Institute for Neurosciences of Montpellier, Univ Montpellier, INSERM, Montpellier, France
| | - Vuong Nguyen
- The Save Sight Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Mark C Gillies
- The Save Sight Institute, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
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Muns SM, Villegas VM, Flynn HW, Schwartz SG. Update on current pharmacologic therapies for diabetic retinopathy. Expert Opin Pharmacother 2023; 24:1577-1593. [PMID: 37431888 DOI: 10.1080/14656566.2023.2230139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/16/2023] [Accepted: 06/23/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Diabetic retinopathy is a major cause of visual loss worldwide. The most important clinical findings include diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR). AREAS COVERED PubMed was used for our literature review. Articles from 1995 to 2023 were included. Pharmacologic treatment of diabetic retinopathy generally involves the use of intravitreal anti-vascular endothelial growth factor (VEGF) therapy for DME and PDR. Corticosteroids remain important second-line therapies for patients with DME. Most emerging therapies focus on newly identified inflammatory mediators and biochemical signaling pathways involved in disease pathogenesis. EXPERT OPINION Emerging anti-VEGF modalities, integrin antagonists, and anti-inflammatory agents have the potential to improve outcomes with reduced treatment burdens.
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Affiliation(s)
- Sofía M Muns
- Department of Ophthalmology, University of Puerto Rico, San Juan, Puerto Rico
| | - Victor M Villegas
- Department of Ophthalmology, University of Puerto Rico, San Juan, Puerto Rico
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Harry W Flynn
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Stephen G Schwartz
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
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Ilochonwu BC, van der Lugt SA, Annala A, Di Marco G, Sampon T, Siepmann J, Siepmann F, Hennink WE, Vermonden T. Thermo-responsive Diels-Alder stabilized hydrogels for ocular drug delivery of a corticosteroid and an anti-VEGF fab fragment. J Control Release 2023; 361:334-349. [PMID: 37532147 DOI: 10.1016/j.jconrel.2023.07.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 07/03/2023] [Accepted: 07/30/2023] [Indexed: 08/04/2023]
Abstract
In the present study, a novel in situ forming thermosensitive hydrogel system was investigated as a versatile drug delivery system for ocular therapy. For this purpose, two thermosensitive ABA triblock copolymers bearing either furan or maleimide moieties were synthesized, named respectively poly(NIPAM-co-HEA/Furan)-PEG6K-P(NIPAM-co-HEA/Furan) (PNF) and poly(NIPAM-co-HEA/Maleimide)-PEG6K-P(NIPAM-co-HEA/-Maleimide) (PNM). Hydrogels were obtained upon mixing aqueous PNF and PNM solutions followed by incubation at 37 °C. The hydrogel undergoes an immediate (<1 min) sol-gel transition at 37 °C. In situ hydrogel formation at 37 °C was also observed after intravitreal injection of the formulation into an ex vivo rabbit eye. The hydrogel network formation was due to physical self-assembly of the PNIPAM blocks and a catalyst-free furan-maleimide Diels-Alder (DA) chemical crosslinking in the hydrophobic domains of the polymer network. Rheological studies demonstrated sol-gel transition at 23 °C, and DA crosslinks were formed in time within 60 min by increasing the temperature from 4 to 37 °C. When incubated at 37 °C, these hydrogels were stable for at least one year in phosphate buffer of pH 7.4. However, the gels degraded at basic pH 10 and 11 after 13 and 3 days, respectively, due to hydrolysis of ester bonds in the crosslinks of the hydrogel network. The hydrogel was loaded with an anti-VEGF antibody fragment (FAB; 48.4 kDa) or with corticosteroid dexamethasone (dex) by dissolving (FAB) or dispersing (DEX) in the hydrogel precursor solution. The FAB fragment in unmodified form was quantitatively released over 13 days after an initial burst release of 46, 45 and 28 % of the loading for the 5, 10 and 20 wt% hydrogel, respectively, due to gel dehydration during formation. The low molecular weight drug dexamethasone was almost quantitively released in 35 days. The slower release of dexamethasone compared to the FAB fragment can likely be explained by the solubilization of this hydrophobic drug in the hydrophobic domains of the gel. The thermosensitive gels showed good cytocompatibility when brought in contact with macrophage-like mural cells (RAW 264.7) and human retinal pigment epithelium-derived (ARPE-19) cells. This study demonstrates that PNF-PNM thermogel may be a suitable formulation for sustained release of bioactive agents into the eye for treating posterior segment eye diseases.
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Affiliation(s)
- Blessing C Ilochonwu
- Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, PO box 80082, 3508, TB, Utrecht, the Netherlands
| | - Simone A van der Lugt
- Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, PO box 80082, 3508, TB, Utrecht, the Netherlands
| | - Ada Annala
- Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, PO box 80082, 3508, TB, Utrecht, the Netherlands
| | - Greta Di Marco
- Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, PO box 80082, 3508, TB, Utrecht, the Netherlands
| | - Thibault Sampon
- Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, PO box 80082, 3508, TB, Utrecht, the Netherlands
| | - Juergen Siepmann
- University of Lille, College of Pharmacy, 3 Rue du Prof. Laguesse, 59006 Lille, France; INSERM U 1008, Controlled Drug Delivery Systems and Biomaterials, 3 Rue du Prof. Laguesse, 59006 Lille, France
| | - Florence Siepmann
- University of Lille, College of Pharmacy, 3 Rue du Prof. Laguesse, 59006 Lille, France; INSERM U 1008, Controlled Drug Delivery Systems and Biomaterials, 3 Rue du Prof. Laguesse, 59006 Lille, France
| | - Wim E Hennink
- Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, PO box 80082, 3508, TB, Utrecht, the Netherlands
| | - Tina Vermonden
- Department of Pharmaceutics, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, PO box 80082, 3508, TB, Utrecht, the Netherlands.
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Roan VD, Kuo BL, Liu BJ, Valentim CCS, Singh RP. Macular Thickness Fluctuations in Eyes With Diabetic Macular Edema Treated With Intravitreal Steroid. Ophthalmic Surg Lasers Imaging Retina 2023; 54:454-460. [PMID: 37535650 DOI: 10.3928/23258160-20230615-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
BACKGROUND AND OBJECTIVE Macular thickness fluctuations (MTF) over time may be more predictive of visual outcomes than absolute macular thickness in patients with diabetic macular edema (DME) treated with anti-vascular endothelial growth factor (anti-VEGF). It is unclear whether this association exists in DME patients treated with intravitreal steroids or whether steroids confer reduced MTF versus anti-VEGF treatments. PATIENTS AND METHODS MTF was compared before and after initiation of steroids in DME patients treated with intravitreal steroids. A mixed-effects linear regression model was used to determine the association between MTF and best-corrected visual acuity (BCVA). RESULTS Mean 12-month MTF significantly decreased after steroid initiation (61.1 μm versus 53.5 μm, P = 0.04, n = 105 eyes). Mean BCVA after 12 months was not significantly different from baseline. No significant association between post-steroid MTF and 12-month BCVA was found. CONCLUSION Steroid treatment decreases MTF while BCVA remains stable in DME patients previously treated with anti-VEGF. [Ophthalmic Surg Lasers Imaging Retina 2023;54:454-460.].
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Mitchell P, Arnold J, Fraser-Bell S, Kang HK, Chang AA, Tainton J, Simonyi S. Dexamethasone intravitreal implant in diabetic macular oedema refractory to anti-vascular endothelial growth factors: the AUSSIEDEX study. BMJ Open Ophthalmol 2023; 8:e001224. [PMID: 37541745 PMCID: PMC10407411 DOI: 10.1136/bmjophth-2022-001224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 04/26/2023] [Indexed: 08/06/2023] Open
Abstract
AIM To evaluate effectiveness of dexamethasone intravitreal implant 0.7 mg (DEX) monotherapy in the AUSSIEDEX study non-responder subgroup, defined by diabetic macular oedema (DME) refractory to anti-vascular endothelial growth factor (anti-VEGF) agents. METHODS This prospective, open-label, observational, real-world study included pseudophakic and phakic (scheduled for cataract surgery) eyes that did not achieve a ≥5-letter best corrected visual acuity (BCVA) gain and/or clinically significant central subfield retinal thickness (CRT) improvement after 3-6 anti-VEGF injections for DME (N=143 eyes), regardless of baseline BCVA and CRT. After an initial DEX injection (baseline visit), reinjection was permitted at ≥16-week intervals. PRIMARY ENDPOINTS changes in mean BCVA and CRT from baseline to week 52. Safety assessments included adverse events. RESULTS Of 143 eyes, 53 (37.1%) and 89 (62.2%) switched to DEX after 3-6 (early) and >6 (late) anti-VEGF injections, respectively; 1 (0.7%) had missing information. With 2.3 injections (mean) over 52 weeks, the change in mean BCVA from a baseline of 57.8 letters was not significant at week 52. Mean CRT improved significantly from a baseline of 417.8 μm at week 52 (mean change -60.9 μm; p<0.001). Outcomes were similar in eyes switched to DEX early and late. No unexpected adverse events were reported; no filtration surgeries were required. CONCLUSION To date, AUSSIEDEX is the largest prospective, real-world study of DEX monotherapy for treatment-naïve or anti-VEGF-refractory DME. Following early or late switch from anti-VEGF agents, DEX significantly improved anatomic outcomes at 52 weeks without new safety concerns, supporting use in anti-VEGF-refractory DME. TRIAL REGISTRATION NUMBER NCT02731911.
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Affiliation(s)
- Paul Mitchell
- Westmead Institute for Medical Research / Sydney West Retina, University of Sydney, Sydney, New South Wales, Australia
| | | | - Samantha Fraser-Bell
- The University of Sydney Save Sight Institute, Sydney, New South Wales, Australia
- Sydney Hospital and Sydney Eye Hospital, Sydney, New South Wales, Australia
| | - Hyong Kwon Kang
- Retina & Vitreous Centre, Sydney, New South Wales, Australia
| | - Andrew A Chang
- Sydney Retina Clinic & Day Surgery, Sydney, New South Wales, Australia
| | - Jodi Tainton
- Allergan, an AbbVie Company, Gordon, New South Wales, Australia
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Han YE, Jo J, Kim YJ, Lee J. Factors Affecting Intensive Aflibercept Treatment Response in Diabetic Macular Edema: A Real-World Study. J Diabetes Res 2023; 2023:1485059. [PMID: 37497120 PMCID: PMC10368507 DOI: 10.1155/2023/1485059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 05/15/2023] [Accepted: 06/29/2023] [Indexed: 07/28/2023] Open
Abstract
Objective To investigate the systemic and ocular factors that affect the response to intensive aflibercept treatment in diabetic macular edema (DME) in a real-world setting. Methods This retrospective cohort study evaluated 30 eyes of 23 patients with DME who underwent intensive intravitreal aflibercept injections (five monthly loading doses). Treatment response was assessed by central retinal thickness (CRT) and best-corrected visual acuity (BCVA) at each monthly visit. The patients were categorized as good (<300 μm) and suboptimal (≥300 μm) responders based on CRT after the loading phase. Baseline systemic and ocular factors associated with treatment response were investigated. Results The mean CRT and BCVA significantly improved after five loading injections (486.87 ± 95.46 to 334.90 ± 69.47 μm and 0.51 ± 0.30 to 0.35 ± 0.25 LogMAR, respectively, all p < 0.05). During 12 months of follow-up, 16 eyes (53.33%) maintained CRT without additional treatment. Eyes with diabetes mellitus (DM) for ≥15 years, estimated glomerular filtration rate (eGFR) < 80 mL/min/1.73 m2, serum creatinine ≥ 0.95 mg/dL and potassium ≥ 4.7 mmol/L, and presence of epiretinal membrane (ERM) were more likely to have a suboptimal response to the treatment. Conclusions Five monthly loading doses of intravitreal aflibercept injection provided significant anatomical and visual improvements in patients with DME. Patients with longer DM duration, lower eGFR, higher serum creatinine or potassium levels, or ERM were predisposed to a suboptimal treatment response. Individual response to intensive aflibercept treatment for DME can be predicted by these systemic and ocular risk factors.
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Affiliation(s)
- Ye Eun Han
- Department of Ophthalmology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
- Asan Diabetes Center, Asan Medical Center, Seoul, Republic of Korea
| | - Jaehyuck Jo
- Department of Ophthalmology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
- Asan Diabetes Center, Asan Medical Center, Seoul, Republic of Korea
| | - Yoon Jeon Kim
- Department of Ophthalmology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
- Asan Diabetes Center, Asan Medical Center, Seoul, Republic of Korea
| | - Junyeop Lee
- Department of Ophthalmology, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Republic of Korea
- Asan Diabetes Center, Asan Medical Center, Seoul, Republic of Korea
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Shughoury A, Bhatwadekar A, Jusufbegovic D, Hajrasouliha A, Ciulla TA. The evolving therapeutic landscape of diabetic retinopathy. Expert Opin Biol Ther 2023; 23:969-985. [PMID: 37578843 PMCID: PMC10592121 DOI: 10.1080/14712598.2023.2247987] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 07/30/2023] [Accepted: 08/11/2023] [Indexed: 08/16/2023]
Abstract
INTRODUCTION Diabetic retinopathy (DR) is a leading cause of blindness worldwide. Recent decades have seen rapid progress in the management of diabetic eye disease, evolving from pituitary ablation to photocoagulation and intravitreal pharmacotherapy. The advent of effective intravitreal drugs inhibiting vascular endothelial growth factor (VEGF) marked a new era in DR therapy. Sustained innovation has since produced several promising biologics targeting angiogenesis, inflammation, oxidative stress, and neurodegeneration. AREAS COVERED This review surveys traditional, contemporary, and emerging therapeutics for DR, with an emphasis on anti-VEGF therapies, receptor tyrosine kinase inhibitors, angiopoietin-Tie2 pathway inhibitors, integrin pathway inhibitors, gene therapy 'biofactory' approaches, and novel systemic therapies. Some of these investigational therapies are being delivered intravitreally via sustained release technologies for extended durability. Other investigational agents are being delivered non-invasively via topical and systemic routes. These strategies hold promise for early and long-lasting treatment of DR. EXPERT OPINION The evolving therapeutic landscape of DR is rapidly expanding our toolkit for the effective and durable treatment of blinding eye disease. However, further research is required to validate the efficacy of novel therapeutics and characterize real world outcomes.
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Affiliation(s)
- Aumer Shughoury
- Department of Ophthalmology, Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, IN, USA 46202
| | - Ashay Bhatwadekar
- Department of Ophthalmology, Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, IN, USA 46202
| | - Denis Jusufbegovic
- Department of Ophthalmology, Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, IN, USA 46202
| | - Amir Hajrasouliha
- Department of Ophthalmology, Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, IN, USA 46202
| | - Thomas A Ciulla
- Department of Ophthalmology, Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, IN, USA 46202
- Midwest Eye Institute, Indianapolis, IN, USA 46290
- Clearside Biomedical, Inc., Alpharetta, GA, USA 30005
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Pavelchek C, Lee DS, Walia A, Michelson AP, Ortmann A, Gentile B, Herzog JA, Buchman CA, Shew MA. Responsible Imputation of Missing Speech Perception Testing Data & Analysis of 4,739 Observations and Predictors of Performance. Otol Neurotol 2023; 44:e369-e378. [PMID: 37231531 PMCID: PMC10330090 DOI: 10.1097/mao.0000000000003903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To address outcome heterogeneity in cochlear implant (CI) research, we built imputation models using multiple imputation by chained equations (MICEs) and K-nearest neighbors (KNNs) to convert between four common open-set testing scenarios: Consonant-Nucleus-Consonant word (CNCw), Arizona Biomedical (AzBio) in quiet, AzBio +5, and AzBio +10. We then analyzed raw and imputed data sets to evaluate factors affecting CI outcome variability. STUDY DESIGN Retrospective cohort study of a national CI database (HERMES) and a nonoverlapping single-institution CI database. SETTING Multi-institutional (32 CI centers). PATIENTS Adult CI recipients (n = 4,046 patients). MAIN OUTCOME MEASURES Mean absolute error (MAE) between imputed and observed speech perception scores. RESULTS Imputation models of preoperative speech perception measures demonstrate a MAE of less than 10% for feature triplets of CNCw/AzBio in quiet/AzBio +10 (MICE: MAE, 9.52%; 95% confidence interval [CI], 9.40-9.64; KNN: MAE, 8.93%; 95% CI, 8.83-9.03) and AzBio in quiet/AzBio +5/AzBio +10 (MICE: MAE, 8.85%; 95% CI, 8.68-9.02; KNN: MAE, 8.95%; 95% CI, 8.74-9.16) with one feature missing. Postoperative imputation can be safely performed with up to four of six features missing in a set of CNCw and AzBio in quiet at 3, 6, and 12 months postcochlear implantation using MICE (MAE, 9.69%; 95% CI, 9.63-9.76). For multivariable analysis of CI performance prediction, imputation increased sample size by 72%, from 2,756 to 4,739, with marginal change in adjusted R2 (0.13 raw, 0.14 imputed). CONCLUSIONS Missing data across certain sets of common speech perception tests may be safely imputed, enabling multivariate analysis of one of the largest CI outcomes data sets to date.
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Affiliation(s)
- Cole Pavelchek
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - David S Lee
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Amit Walia
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri
| | | | - Amanda Ortmann
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Brynn Gentile
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Jacques A Herzog
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Craig A Buchman
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew A Shew
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri
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Marolo P, Borrelli E, Gelormini F, Boscia G, Parisi G, Fallico M, Barresi C, Lari G, Berni A, Bandello F, Reibaldi M. Retinal Thickness Deviation: A New OCT Parameter for Assessing Diabetic Macular Edema. J Clin Med 2023; 12:3976. [PMID: 37373669 DOI: 10.3390/jcm12123976] [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: 05/12/2023] [Revised: 06/05/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
(1) Purpose: To determine the "retinal thickness deviation" (RTD) in diabetic macular edema (DME) eyes treated with intravitreal therapy and to establish associations between RTD and best-corrected visual acuity (BCVA). (2) Methods: We conducted a retrospective study, including consecutive patients with DME eyes undergoing intravitreal therapy with two years of follow-up. BCVA and central subfield thickness (CST) were collected at baseline and at 12 months and 24 months of follow-up. RTD was calculated as the absolute difference between measured and normative CST values at each time point. Linear regression analyses were performed between RTD and BCVA and between CST and BCVA. (3) Results: One hundred and four eyes were included in the analysis. The RTD was 177.0 (117.2) μm at baseline, 97.0 (99.7) μm at 12 months and 89.9 (75.3) μm at 24 months of follow-up (p < 0.001). RTD showed a moderate association with BCVA at baseline (R2 = 0.134, p < 0.001) and 12 months (R2 = 0.197, p < 0.001) and a substantial association at 24 months (R2 = 0.272, p < 0.001). The CST showed a moderate association with BCVA at baseline (R2 = 0.132, p < 0.001) and 12 months (R2 = 0.136, p < 0.001), while the association was weak at 24 months (R2 = 0.065, p = 0.009). (4) Conclusions: RTD showed a good association with visual outcome in patients with DME eyes undergoing intravitreal treatment.
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Affiliation(s)
- Paola Marolo
- Department of Ophthalmology, University of Turin, 10126 Turin, Italy
| | - Enrico Borrelli
- Ophthalmology Department, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | | | - Giacomo Boscia
- Department of Ophthalmology, University of Turin, 10126 Turin, Italy
| | - Guglielmo Parisi
- Department of Ophthalmology, University of Turin, 10126 Turin, Italy
| | - Matteo Fallico
- Department of Ophthalmology, University of Catania, 95123 Catania, Italy
| | - Costanza Barresi
- Ophthalmology Department, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Giorgio Lari
- Ophthalmology Department, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Alessandro Berni
- Ophthalmology Department, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Francesco Bandello
- Ophthalmology Department, Vita-Salute San Raffaele University, 20132 Milan, Italy
| | - Michele Reibaldi
- Department of Ophthalmology, University of Turin, 10126 Turin, Italy
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Ohara H, Harada Y, Hiyama T, Sadahide A, Minamoto A, Kiuchi Y. Faricimab for Diabetic Macular Edema in Patients Refractory to Ranibizumab or Aflibercept. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1125. [PMID: 37374329 DOI: 10.3390/medicina59061125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/23/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023]
Abstract
Background and Objectives: Faricimab is the first intravitreal injection of vascular endothelial growth factor-A and angiopoietin-2 bispecific monoclonal antibody. Here, we evaluate the functional and anatomical outcomes of faricimab treatment in patients with diabetic macular edema (DME) that was refractory to ranibizumab or aflibercept. Materials and Methods: We performed a retrospective, observational, consecutive-case study of patients who had DME that was refractory to treatment with ranibizumab or aflibercept and were treated with faricimab between July 2022 and January 2023 under a pro re nata regimen. All the participants were followed for ≥4 months after the initiation of faricimab. The primary outcome was a recurrence interval of ≥12 weeks, and the secondary outcomes were the changes in best-corrected visual acuity (BCVA) and central macular thickness (CMT). Results: We analyzed 18 eyes of 18 patients. The mean recurrence interval of previous anti-VEGF injection was 5.8 ± 2.5 weeks, which was significantly extended to 10.8 ± 4.9 weeks (p = 0.0005) by the switch to faricimab. Eight patients (44.4%) achieved a recurrence interval of ≥12 weeks. A history of subtenon injection of triamcinolone acetonide (p = 0.0034) and the presence of disorganization of the retinal inner layers (p = 0.0326) were found to be significantly associated with a recurrence interval of <12 weeks. The mean BCVAs were 0.23 ± 0.28 logMAR and 0.19 ± 0.23 logMAR, and the mean CMTs were 473.8 ± 222.0 µm and 381.3 ± 219.4 µm at baseline and 4 months, respectively, but these changes were not statistically significant. None of the patients experienced serious adverse events. Conclusions: Faricimab may extend the treatment interval for patients with DME that is refractory to ranibizumab or aflibercept. DME previously treated with the subtenon injection of triamcinolone acetonide or associated with disorganization of the retinal inner layers may be less likely to be associated with a longer recurrence interval after switching to faricimab.
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Affiliation(s)
- Hiromi Ohara
- Department of Ophthalmology and Visual Science, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima 734-8551, Japan
| | - Yosuke Harada
- Department of Ophthalmology and Visual Science, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima 734-8551, Japan
| | - Tomona Hiyama
- Department of Ophthalmology and Visual Science, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima 734-8551, Japan
| | - Ayako Sadahide
- Department of Ophthalmology and Visual Science, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima 734-8551, Japan
| | - Akira Minamoto
- Department of Ophthalmology and Visual Science, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima 734-8551, Japan
| | - Yoshiaki Kiuchi
- Department of Ophthalmology and Visual Science, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima 734-8551, Japan
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Faes L, Mishra AV, Lipkova V, Balaskas K, Quek C, Hamilton R, Held U, Sim D, Sivaprasad S, Fu DJ. Visual and Anatomical Outcomes of a Single Intravitreal Dexamethasone in Diabetic Macular Edema: An 8 Year Real-World Study. J Clin Med 2023; 12:3878. [PMID: 37373573 DOI: 10.3390/jcm12123878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 05/24/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
IMPORTANCE Diabetic macular edema (DME) is a major cause of vision loss in patients with diabetes mellitus. Intravitreal dexamethasone is a treatment option for patients unsuitable for or non-responsive to anti-angiogenic agents. OBJECTIVE To quantify visual and anatomical outcomes from an initial intravitreal dexamethasone injection over the expected 6-month period of dexamethasone release by the implant. Design and enrolment: This is a retrospective cohort study using electronic medical records of patients reviewed between 1 January 2012 and 1 April 2022. SETTING A tertiary eye-care center in London, United Kingdom; Moorfields Eye Hospital National Healthcare System Foundation Trust. PARTICIPANTS The cohort comprised 418 adult patients with DME who received an initial treatment of 700 µg intravitreal dexamethasone in the study period. Of these, 240 patients met the inclusion criteria of ≥2 hospital visits following initial injection (≥1 beyond 6 months) and no previous ocular corticosteroid treatment or missing assessment at baseline. EXPOSURE(S) Intravitreal dexamethasone implant (700 µg). MAIN OUTCOME(S) AND MEASURE(S) Probability of a positive visual outcome, defined as ≥5 or ≥10 Early Treatment Diabetic Retinopathy Study (ETDRS)-letter gain after treatment when compared to baseline (Kaplan-Meier models). RESULTS From the initial intravitreal dexamethasone injection alone, we observed a >75% chance of gaining ≥5 ETDRS letters and >50% chance of gaining ≥10 ETDRS letters within 6 months. There was less than a 50% chance of sustaining either positive visual outcome beyond 4 months. CONCLUSIONS AND RELEVANCE Most patients can be expected to have a positive visual outcome following an initial injection of dexamethasone implants that subsides within 4 months. Real-world re-treatment was observed to be delayed until after visual benefits were lost in half of the cohort. Further research will be needed to study the effects of delays in re-treatment.
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Affiliation(s)
- Livia Faes
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, UCL Institute of Ophthalmology, London EC1V 9EL, UK
| | - Amit V Mishra
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, UCL Institute of Ophthalmology, London EC1V 9EL, UK
| | | | - Konstantinos Balaskas
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, UCL Institute of Ophthalmology, London EC1V 9EL, UK
| | - Chrystie Quek
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, UCL Institute of Ophthalmology, London EC1V 9EL, UK
| | - Robin Hamilton
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, UCL Institute of Ophthalmology, London EC1V 9EL, UK
| | - Ulrike Held
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, 8057 Zurich, Switzerland
| | - Dawn Sim
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, UCL Institute of Ophthalmology, London EC1V 9EL, UK
- Genentech Roche, 1 DNA Way, South San Francisco, CA 940980, USA
| | - Sobha Sivaprasad
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, UCL Institute of Ophthalmology, London EC1V 9EL, UK
| | - Dun Jack Fu
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, UCL Institute of Ophthalmology, London EC1V 9EL, UK
- Kings College London, London WC2R 2LS, UK
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Vofo BN, Chowers I. Suppressing Inflammation for the Treatment of Diabetic Retinopathy and Age-Related Macular Degeneration: Dazdotuftide as a Potential New Multitarget Therapeutic Candidate. Biomedicines 2023; 11:1562. [PMID: 37371657 DOI: 10.3390/biomedicines11061562] [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: 05/11/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 06/29/2023] Open
Abstract
Diabetic retinopathy (DR) and age-related macular degeneration (AMD) are major causes of blindness globally. The primary treatment option for DME and neovascular AMD (nAMD) is anti-vascular endothelial growth factor (VEGF) compounds, but this treatment modality often yields insufficient results, and monthly injections can place a burden on the health system and patients. Although various inflammatory pathways and mediators have been recognized as key players in the development of DR and AMD, there are limited treatment options targeting these pathways. Molecular pathways that are interlinked, or triggers of multiple inflammatory pathways, could be promising targets for drug development. This review focuses on the role of inflammation in the pathogenesis of DME and AMD and presents current anti-inflammatory compounds, as well as a potential multitarget anti-inflammatory compound (dazdotuftide) that could be a candidate treatment option for the management of DME and AMD.
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Affiliation(s)
- Brice Nguedia Vofo
- Department of Ophthalmology, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel
| | - Itay Chowers
- Department of Ophthalmology, Hadassah-Hebrew University Medical Center, Jerusalem 91120, Israel
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Petrovic N, Todorovic D, Sarenac Vulovic T, Sreckovic S, Zivic F, Risimic D. Combined Treatment of Persistent Diabetic Macular Edema with Aflibercept and Triamcinolone Acetonide in Pseudophakic Eyes. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050982. [PMID: 37241214 DOI: 10.3390/medicina59050982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 05/04/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023]
Abstract
Background and Objectives: The main cause of the vision loss in diabetics is the development of diabetic macular edema, regardless of the stage of diabetic retinopathy. The paper aimed to examine whether the additional intravitreal application of triamcinolone acetonide to continuous anti-vascular endothelial growth factor therapy could improve therapeutic outcomes for pseudophakic eyes with persistent diabetic macular edema. Materials and Methods: twenty-four pseudophakic eyes with refractory diabetic macular edema, that had appeared despite three previously administered intravitreal injections of aflibercept, were divided into two groups (twelve eyes in each group). The first group continued to have aflibercept administered according to a fixed dosing regimen (once in two months). Triamcinolone acetonide 10 mg/0.1 mL (administered once per four months) was included for the second group, i.e., their treatment continued with a combination of aflibercept + triamcinolone acetonide. Results: The reduction in central macular thickness was higher in the eyes treated with combined therapy (aflibercept + triamcinolone acetonide) compared with the use of aflibercept alone during the entire 12-month follow-up period (3rd month p = 0.019; 6th month p = 0.023; 9th month p = 0.027; 12th month p = 0.031). As was evident from the p-values, the differences were statistically significant. No statistically significant difference was recorded for visual acuity: 3rd month p = 0.423; 6th month p = 0.392; 9th month p = 0.413; 12th month p = 0.418. Conclusions: Combined anti-vascular endothelial growth factor and steroid therapy leads to a better anatomical outcome of persistent diabetic macular edema in pseudophakic eyes, but does not lead to a more significant improvement in visual acuity than continuous anti-VEGF therapy alone.
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Affiliation(s)
- Nenad Petrovic
- Clinic of Ophthalmology, University Clinical Center Kragujevac, 34000 Kragujevac, Serbia
- Faculty of Medical Sciences, Department of Ophthalmology, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Dusan Todorovic
- Clinic of Ophthalmology, University Clinical Center Kragujevac, 34000 Kragujevac, Serbia
- Faculty of Medical Sciences, Department of Ophthalmology, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Tatjana Sarenac Vulovic
- Clinic of Ophthalmology, University Clinical Center Kragujevac, 34000 Kragujevac, Serbia
- Faculty of Medical Sciences, Department of Ophthalmology, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Suncica Sreckovic
- Clinic of Ophthalmology, University Clinical Center Kragujevac, 34000 Kragujevac, Serbia
- Faculty of Medical Sciences, Department of Ophthalmology, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Fatima Zivic
- Faculty of Engineering, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Dijana Risimic
- Clinic for Eye Diseases, University Clinical Center of Serbia, 34000 Kragujevac, Serbia
- Medical Faculty, University of Belgrade, 11000 Beograd, Serbia
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Chi SC, Kang YN, Huang YM. Efficacy and safety profile of intravitreal dexamethasone implant versus antivascular endothelial growth factor treatment in diabetic macular edema: a systematic review and meta-analysis. Sci Rep 2023; 13:7428. [PMID: 37156823 PMCID: PMC10167345 DOI: 10.1038/s41598-023-34673-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 05/05/2023] [Indexed: 05/10/2023] Open
Abstract
To better understand the efficacy of intravitreal dexamethasone implant (Ozurdex) versus antivascular endothelial growth factor (anti-VEGF) treatment in patients with diabetic macular edema (DME). A systematic review and meta-analysis. The study included randomized control trials (RCTs) and non-randomized control trials (Non-RCTs) before December 2021 that compare the efficacy of Ozurdex-related therapyand anti-VEGF therapy. We searched PubMed, Cochrane Library, and EMBASE. The quality of the included studies was assessed carefully. 30 studies were included. Regarding BCVA change, the overall result revealed no significant differences between Ozurdex and anti-VEGF therapies in patients with nonresistant DME, but Ozurdex group had significantly more VA improvement than anti-VEGF therapies in patients with resistant DME (MD 0.12, 95% CI 0.02-0.21). In terms of central retinal thickness (CRT) decrease, there was a significant difference between Ozurdex therapy and anti-VEGF therapy in patients with nonresistant DME (MD 48.10, 95% CI 19.06-77.13) and resistant DME (MD 65.37, 95% CI 3.62-127.13). Overall, Ozurdex therapy resulted in significantly greater VA improvement and CRT decrease than anti-VEGF therapy in resistant DME patients. Ozurdex therapy was not inferior to anti-VEGF therapy in patients with nonresistant DME.
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Affiliation(s)
- Sheng-Chu Chi
- Department of Ophthalmology, Faculty of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-No Kang
- Evidence-Based Medicine Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Yi-Ming Huang
- Department of Ophthalmology, Faculty of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
- National Yang Ming Chiao Tung University, Taipei, Taiwan.
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Koc H, Alpay A, Ugurbas SH. Comparison of the efficacy of intravitreal Anti-VEGF versus intravitreal dexamethasone implant in treatment resistant diabetic Macular Edema. BMC Ophthalmol 2023; 23:97. [PMID: 36915060 PMCID: PMC10009964 DOI: 10.1186/s12886-023-02831-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 02/27/2023] [Indexed: 03/16/2023] Open
Abstract
PURPOSE Comparison of the efficacy of monthly anti-VEGF versus dexamethasone (DEX) implant in patients with diabetic macular edema (DME) whose macular edema persists despite three doses of anti-VEGF therapy. MATERIALS AND METHODS This retrospective study included 94 eyes of 94 patients with central macular thickness (CMT) > 300 μm despite previously receiving three doses of anti-VGEF (aflibercept or ranibizumab) injections between January 2014 and January 2019. The patients were divided into four groups. The first and second groups were the patients who received three more doses of initial anti-VGEF treatment after the initial anti-VGEF treatment. The third and fourth groups were patients switched to intravitreal dexamethasone implants. Patients were followed up every month for six months after the injection. The primary outcome measures were best-corrected visual acuity (BCVA), central macular thickness (CMT), and intraocular pressure (IOP) at six months. RESULTS The mean age of the patients included in the study was 64.64 ± 7; there were 58 men (61.7%) and 36 women (38.3%). There was no statistically significant difference between the groups regarding age, stage of retinopathy, and lens status. When CMT, BCVA, and IOP were assessed among the four groups at the end of the sixth month, no statistical difference between the groups was found. There was no need for medical intervention despite the statistically significant increase in IOP at the end of the sixth month compared to the third month in the dexamethasone implanted groups. In contrast to the decrease in CMT, which was statistically significant in all four groups at the end of the sixth month compared to the third month, the increase in BCVA was not statistically significant in any of the four groups at the end of the sixth month. CONCLUSION According to the results of our study, there is no superiority between continuing with existing anti-VEGF or switching to a dexamethasone implant after three doses of anti-VEGF.
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Affiliation(s)
- Hakan Koc
- grid.411709.a0000 0004 0399 3319Faculty of Medicine, Department of Ophthalmology, Giresun University, Giresun, Turkey
| | - Atilla Alpay
- grid.411822.c0000 0001 2033 6079Faculty of Medicine, Department of Ophthalmology, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Suat Hayri Ugurbas
- grid.411822.c0000 0001 2033 6079Faculty of Medicine, Department of Ophthalmology, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
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Sorour OA, Levine ES, Baumal CR, Elnahry AG, Braun P, Girgis J, Waheed NK. Persistent diabetic macular edema: Definition, incidence, biomarkers, and treatment methods. Surv Ophthalmol 2023; 68:147-174. [PMID: 36436614 DOI: 10.1016/j.survophthal.2022.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 11/20/2022] [Accepted: 11/21/2022] [Indexed: 11/27/2022]
Abstract
Intravitreal antivascular endothelial growth factor (anti-VEGF) treatment has drastically improved the visual and anatomical outcomes in patients with diabetic macular edema (DME); however, success is not always guaranteed, and a proportion of these eyes demonstrate persistent DME (pDME) despite intensive treatment. While standardized criteria to define these treatment-resistant eyes have not yet been established, many studies refer to eyes with no clinical response or an unsatisfactory partial response as having pDME. A patient is considered to have pDME if the retinal thickness improves less than 10-25% after 6 months of treatment. A range of treatment options have been recommended for eyes with pDME, including switching anti-VEGF agents, using corticosteroids and/or antioxidant drugs in adjunct with anti-VEGF therapy, and vitrectomy. In addition, multimodal imaging of DME eyes may be advantageous in predicting the responsiveness to treatment; this is beneficial when initiating alternative therapies. We explore the literature on persistent DME regarding its defining criteria, incidence, the baseline biological markers that may be useful in anticipating the response to treatment, and the available treatment options.
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Affiliation(s)
- Osama A Sorour
- New England Eye Center, Tufts Medical Center, Boston, Massachusetts, USA; Department of Ophthalmology, Tanta University, Tanta, Egypt
| | - Emily S Levine
- New England Eye Center, Tufts Medical Center, Boston, Massachusetts, USA; Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Caroline R Baumal
- New England Eye Center, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - Phillip Braun
- New England Eye Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Jessica Girgis
- New England Eye Center, Tufts Medical Center, Boston, Massachusetts, USA
| | - Nadia K Waheed
- New England Eye Center, Tufts Medical Center, Boston, Massachusetts, USA.
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Capelanes NC, Malerbi FK, Novais EA, Regatieri CVS. Optical Coherence Tomography Angiographic Evaluation of Macular Vessel Density in Diabetic Macular Edema After Intravitreal Dexamethasone Implants: A Prospective Interventional Trial. Ophthalmic Surg Lasers Imaging Retina 2023; 54:174-182. [PMID: 36944070 DOI: 10.3928/23258160-20230221-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND AND OBJECTIVE The goal of this study was to assess macular vascular density evolution, macular thickness, and functional outcomes after intravitreal dexamethasone implants for diabetic macular edema. PATIENTS AND METHODS Vascular density was evaluated with optical coherence tomography (OCT) angiography in 21 eyes. Macular thickness was evaluated with structural OCT. Visual acuity and contrast sensitivity were evaluated before and after treatment, and these functional outcomes were analyzed for association with anatomic outcomes. Macular vessel density in the superficial capillary plexus was evaluated with OCT angiography and quantified in areas with no fluid, allowing a more accurate measurement and eliminating the segmentation bias in areas with intra-retinal fluid. Such a methodology was possible by positioning the scans only in areas with no fluid before and after the implant. The absence of fluid in these areas was confirmed by three experienced evaluators using both the B-scan and the en face. Visual acuity and contrast sensitivity were evaluated before and after treatment, and these functional outcomes were analyzed for association with anatomic outcomes. RESULTS At 30, 60, and 90 days after implantation, there was improvement in macular perfusion in areas without fluid after intravitreal dexamethasone implantation, accompanied by reduced macular thickness and improved visual acuity (P < .001). However, there was no improvement in contrast sensitivity after treatment. CONCLUSIONS Improved macular perfusion after treatment with intravitreal dexamethasone implantation may be associated with modulation of leukostasis, when the release of cytokines leads to capillary endothelial damage and obstruction of the micro-vasculature, leading to impaired capillary perfusion and ischemic damage. Despite the anatomical and functional findings demonstrated, further studies are needed to prove the relationship between the inflammatory mechanisms of diabetic macular edema and its relationship with macular perfusion and functional aspects. [Ophthalmic Surg Lasers Imaging Retina 2023;54(3):174-182.].
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Yuen YS, Gilhotra JS, Dalton M, Aujla JS, Mehta H, Wickremasinghe S, Uppal G, Arnold J, Chen F, Chang A, Fraser-Bell S, Lim L, Shah J, Bowditch E, Broadhead GK. Diabetic Macular Oedema Guidelines: An Australian Perspective. J Ophthalmol 2023; 2023:6329819. [PMID: 36824442 PMCID: PMC9943607 DOI: 10.1155/2023/6329819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 12/21/2022] [Accepted: 12/30/2022] [Indexed: 02/16/2023] Open
Abstract
The number of people living with diabetes is expected to rise to 578 million by 2030 and to 700 million by 2045, exacting a severe socioeconomic burden on healthcare systems around the globe. This is also reflected in the increasing numbers of people with ocular complications of diabetes (namely, diabetic macular oedema (DMO) and diabetic retinopathy (DR)). In one study examining the global prevalence of DR, 35% of people with diabetes had some form of DR, 7% had PDR, 7% had DMO, and 10% were affected by these vision-threatening stages. In many regions of the world (Australia included), DR is one of the top three leading causes of vision loss amongst working age adults (20-74 years). In the management of DMO, the landmark ETDRS study demonstrated that moderate visual loss, defined as doubling of the visual angle, can be reduced by 50% or more by focal/grid laser photocoagulation. However, over the last 20 years, antivascular endothelial growth factor (VEGF) and corticosteroid therapies have emerged as alternative options for the management of DMO and provided patients with choices that have higher chances of improving vision than laser alone. In Australia, since the 2008 NHMRC guidelines, there have been significant developments in both the treatment options and treatment schedules for DMO. This working group was therefore assembled to review and address the current management options available in Australia.
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Affiliation(s)
| | | | | | - Jaskirat S. Aujla
- South Australian Institute of Ophthalmology, Adelaide, SA, Australia
| | - Hemal Mehta
- Save Sight Registries, University of Sydney, Sydney, NSW, Australia
- Strathfield Retina Clinic, Sydney, Australia
| | - Sanj Wickremasinghe
- Centre for Eye Research Australia, The Royal Victorian Eye and Ear Hospital, University of Melbourne, Melbourne, Australia
| | - Gurmit Uppal
- Moreton Eye Group, Brisbane, Queensland, Australia
| | | | - Fred Chen
- Centre for Ophthalmology and Visual Sciences (Incorporating Lions Eye Institute), The University of Western Australia, Nedlands, WA, Australia
- Ophthalmology, Department of Surgery, University of Melbourne, Victoria, Australia
| | - Andrew Chang
- Sydney Institute of Vision Science, University of Sydney, Sydney, NSW, Australia
- Sydney Retina Clinic and Day Surgery, University of Sydney, Sydney, NSW, Australia
- Save Sight Institute, University of Sydney, Sydney, NSW, Australia
| | - Samantha Fraser-Bell
- Department of Ophthalmology, Save Sight Institute, University of Sydney, Sydney, NSW, Australia
| | - Lyndell Lim
- Centre for Eye Research Australia, The Royal Victorian Eye and Ear Hospital, University of Melbourne, Melbourne, Australia
| | - Janika Shah
- Sydney Eye Hospital, Sydney, Australia
- Singapore National Eye Centre, Singapore
| | - Ellie Bowditch
- Save Sight Institute, University of Sydney, Sydney, NSW, Australia
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Fazel F, Malekahmadi M, Feizi A, Oliya B, Tavakoli M, Fazel M. Suprachoroidal injection of triamcinolone acetonide plus intravitreal bevacizumab in diabetic macular edema: a randomized pilot trial. BMC Ophthalmol 2023; 23:40. [PMID: 36707790 PMCID: PMC9881520 DOI: 10.1186/s12886-023-02790-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 01/20/2023] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND To investigate the efficacy of injecting suprachoroidal triamcinolone acetonide (SCTA) plus intravitreal bevacizumab (IVB) into patients with center-involving diabetic macular edema (CI-DME). METHODS In this phase 2/3 randomized controlled pilot trial, sixty-six eyes with CI-DME and best-corrected visual acuity (BCVA) of at most 20/50 Snellen chart were randomly assigned into two groups. Monotherapy arm received sham injection plus 3 monthly IVB doses and combination arm received a single dose of SCTA and 3 monthly IVB doses. The mean improvements in BCVA and Central subfield thickness (CST), over the three-month was considered the main efficacy outcomes. RESULTS The mean BCVA improvements were obtained respectively as - 0.20 ± 0.20 log [minimum angle of resolution (MAR)] (P = 0.004) and 0.37 ± 0.24 log MAR (P < 0.001) in monotherapy and combination arms [between-group analysis (P = 0.014)]. Significant improvements were also observed in CST (P = 0.019) in the combination arm compared to the other. No adverse events (elevated intraocular pressure, cataract) were observed in any of the study arms. CONCLUSION Significant improvements in BCVA and retinal anatomical outcomes demonstrated the additive effects of SCTA to those of anti-vascular endothelial growth factors with no short-term side effects and this combination appears to be a promising option in the management of patients with CI-DME. TRIAL REGISTRATION The trial was registered in Iranian Registry of Clinical Trials (IRCT20200314046761N1).
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Affiliation(s)
- Farhad Fazel
- grid.411036.10000 0001 1498 685XIsfahan Eye Research Center, Department of Ophthalmology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Malekahmadi
- grid.411036.10000 0001 1498 685XIsfahan Eye Research Center, Department of Ophthalmology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Awat Feizi
- grid.411036.10000 0001 1498 685XCardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Behrooz Oliya
- grid.411036.10000 0001 1498 685XIsfahan Eye Research Center, Department of Ophthalmology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehdi Tavakoli
- grid.411036.10000 0001 1498 685XIsfahan Eye Research Center, Department of Ophthalmology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammadreza Fazel
- grid.411036.10000 0001 1498 685XIsfahan Eye Research Center, Department of Ophthalmology, Isfahan University of Medical Sciences, Isfahan, Iran
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Kaya M, Atas F, Kocak N, Ozturk T, Ayhan Z, Kaynak S. Intravitreal Ranibizumab and Dexamethasone Implant Injections as Primary Treatment of Diabetic Macular Edema: The Month 24 Results from Simultaneously Double Protocol. Curr Eye Res 2023; 48:498-505. [PMID: 36629472 DOI: 10.1080/02713683.2023.2168013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE To compare efficacy of simultaneously administered intravitreal dexamethasone implant (DEX implant) and ranibizumab (simultaneous double protocol) injections with ranibizumab monotherapy for diabetic macular edema (DME) at month 24. METHODS This is a prospective, consecutive, clinical interventional study. Naïve eyes with DME were randomized into two groups: 34 eyes received simultaneous double-protocol therapy and 34 eyes received ranibizumab monotherapy. The primary efficacy endpoint was change in visual acuity in month 24. The secondary efficacy endpoints were to evaluate gain of ≥15 letters, morphological changes and central foveal thickness. Decreased vision from DME (study eye BCVA, 20/40 or worse Snellen equivalent using ETDRS testing), the presence of DME with ≥300 μm foveal intraretinal cystoid spaces (within 1000 μm of the centre of the fovea), subfoveal neuroretinal detachment (SND), intraretinal hyperreflective foci (HRF, within 500 μm of the centre of the fovea) or foveal lipid exudates and external limiting membrane (ELM) and ellipsoid zone (EZ) disruption (within 500 μm of the centre of the fovea) on SD-OCT were eligible to enrol. RESULTS The mean baseline BCVA was 48 ± 23 letters in double protocol group and 52 ± 14 letters ranibizumab monotherapy group (p = 0.416). The mean number of ETDRS letters changed from baseline at 12 months versus change from baseline at month 24 in double protocol group and ranibizumab monotherapy group were +21.6 versus +20.2 and +9.6 versus +9.1, respectively. At the month 24 time point, 65.4% of patients in double protocol group and 26.2% of patients in ranibizumab monotherapy group had gained ≥15 ETDRS letters in BCVA from baseline (p < 0.001). The external limiting membrane (ELM) and ellipsoid zone (EZ) integrity were better in the double protocol group in comparison to ranibizumab monotherapy group at month 24. In addition, there was no statistically significant increase in the proportion of patients with epiretinal membrane in double protocol group at month 24, by the contrast with ranibizumab monotherapy group (p = 0.06 and p = 0.04 in the double protocol and ranibizumab monotherapy groups, respectively). From baseline to month 24, the mean central foveal thickness (CFT) was 672 ± 293 μm reduced to 278 ± 84 μm in double protocol group and was 631 ± 279 μm reduced to 356 ± 108 μm in ranibizumab monotherapy group (p < 0.001 and p < 0.001). From baseline to month 24, 38% (13/34) of eyes in double protocol group and 18% (6/34) of eyes in ranibizumab monotherapy group had at least 5 mmHg of IOP elevation (p = 0.012). Two grades or more increased cataract density were detected 27% (6/22) of eyes in the double protocol group and in 12.5% (3/24) of eyes in the ranibizumab monotherapy group from baseline to month 24 (p = 0.032). CONCLUSION According to the improvements in visual acuity and morphological changes achieved at month 24, the simultaneous double protocol therapy can be an effective treatment option for DME with inflammatory biomarkers on OCT or/and decreased visual acuity.
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Affiliation(s)
- Mahmut Kaya
- Department of Ophthalmology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | | | - Nilufer Kocak
- Department of Ophthalmology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Taylan Ozturk
- Department of Ophthalmology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Ziya Ayhan
- Department of Ophthalmology, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Suleyman Kaynak
- Department of Ophthalmology, Izmir Tinaztepe University, Izmir, Turkey
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Vitrectomy with ILM peeling in diabetic macular edema in one eye vs. intravitreal anti-VEGF injections in the second eye: a comparative study. Graefes Arch Clin Exp Ophthalmol 2023; 261:67-76. [PMID: 35869998 DOI: 10.1007/s00417-022-05774-8] [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: 04/06/2022] [Revised: 06/29/2022] [Accepted: 07/15/2022] [Indexed: 01/04/2023] Open
Abstract
PURPOSE The aim of this study was to compare the results of vitrectomy performed in patients' worse eyes with diabetic macular edema to the results of continuous anti-VEGF treatment performed in patients' fellow eyes. METHODS A retrospective interventional study of 14 patients with diabetic macular edema in both eyes. The better eye was always qualified for aflibercept injections (group 1), and the worse eye was scheduled for vitrectomy (group 2). The follow-up lasted 12 months. The following parameters were measured: visual acuity (V), central retinal thickness (CRT), maximum retinal thickness (MRT), central choroidal thickness (CCT), superficial fovea avascular zone (sFAZ) and deep fovea avascular zone (dFAZ), and vessel density at the level of superficial (sVD) and deep (dVD) retinal vessels. RESULTS None of the analyzed factors differed between groups with statistical significance at any timepoint. The time of recovery of vision was identical in both eyes (F = 0.91, p = 0.449). The final sFAZ was significantly smaller for group 2 (median 196 μm) than for group 1 (median 375 μm; U = 101.0; p = 0.022; r = 0.44). CONCLUSION Both techniques resulted in similar improvements in visual acuity and decreases in CRT after 1 year. sFAZ decreased in all eyes, with a higher extent after vitrectomy.
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Tang B, Yeow CES, Harney F, Townley D. Safety and Effectiveness of Intravitreal Dexamethasone Implant (Ozurdex®) for the Treatment of Refractory Cystoid Macular Oedema (CMO) in Galway University Hospital. Open Ophthalmol J 2022. [DOI: 10.2174/e18743641-v16-e2210210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Aim:
The aim of this study is to assess the real-life effectiveness and safety of intravitreal Ozurdex in an Irish setting.
Background:
Ozurdex is an intravitreal dexamethasone implant that is used for the treatment of macular oedema secondary to retinal vein occlusion and diabetic macular oedema.
Methods:
This was a retrospective observational study of adult patients in University Hospital Galway who received an intravitreal dexamethasone implant (Ozurdex) for the treatment of cystoid macular oedema secondary to diabetic eye disease or retinal vein occlusion. The main outcome was the mean change in best-corrected visual acuity 3-6 months after the treatment.
Results and Discussion:
36 patients were included in the study. Overall, there was a 1.66 mean letter gain (SD 11.8) 3-6 months post-treatment. The proportion of patients who gained >10 letters was 15.6%. The mean reduction in CST was 110.6um (SD 255.7), and in the linear regression analysis, no variables were found to be significantly associated with a change in visual acuity. In terms of adverse events, 14.3% of patients had significant cataract progression and 20.6% of patients had a significant rise in IOP following intravitreal Ozurdex implant.
Conclusion:
Intravitreal Ozurdex was found to be safe and effective, supporting it as an appropriate second-line treatment in patients with refractory macular oedema secondary to diabetic eye disease and retinal vein occlusion. Further studies should be carried out to evaluate the possible predictors of visual acuity outcome.
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Zhang NT, Nesper PL, Ong JX, Wang JM, Fawzi AA, Lavine JA. Macrophage-like Cells Are Increased in Patients with Vision-Threatening Diabetic Retinopathy and Correlate with Macular Edema. Diagnostics (Basel) 2022; 12:2793. [PMID: 36428853 PMCID: PMC9689296 DOI: 10.3390/diagnostics12112793] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/10/2022] [Accepted: 11/12/2022] [Indexed: 11/16/2022] Open
Abstract
Macrophage-like cells (MLCs) are potential inflammatory biomarkers. We previously showed that MLCs are increased in proliferative diabetic retinopathy (PDR) eyes. Vision-threatening diabetic retinopathy (VTDR) includes PDR, severe non-PDR (NPDR), and diabetic macular edema (DME). No prior data exist on MLCs in eyes with severe NPDR or DME. This prospective, cross-sectional optical coherence tomography-angiography (OCT-A) imaging study included 40 eyes of 37 participants who had NPDR classified as non-VTDR (n = 18) or VTDR (n = 22). Repeated OCT-A images were registered, averaged, and used to quantify the main outcome measures: MLC density and percent area. MLC density and percent area were correlated with clinical characteristics, NPDR stage, presence of DME, and OCT central subfield thickness (CST). In VTDR eyes, MLC density (2.6-fold, p < 0.001) and MLC percent area (2.5-fold, p < 0.01) were increased compared with non-VTDR eyes. Multiple linear regression analysis between MLC metrics and clinical characteristics found that MLC density was positively correlated with worse NPDR severity (p = 0.023) and higher CST values (p = 0.010), while MLC percent area was only positively associated with increased CST values (p = 0.006). MLCs are increased in patients with VTDR. Macular edema is the most strongly associated factor with increased MLC numbers in NPDR eyes.
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Affiliation(s)
| | | | | | | | | | - Jeremy A. Lavine
- The Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, 240 E. Huron Street, Bldg. McGaw M343, Chicago, IL 60611, USA
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Ataş M, Ozsaygılı C, Bayram N, Unal S. Retrospective analysis of the efficacy of early switching from bevacizumab to aflibercept or ranibizumab in diabetic macular edema. Eur J Ophthalmol 2022; 33:11206721221137164. [PMID: 36330651 DOI: 10.1177/11206721221137164] [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: 02/17/2024]
Abstract
PURPOSE The study aimed to compare the anatomical and functional gains of switching to ranibizumab or aflibercept in eyes with treatment-naive diabetic macular edema (DME) which has an inadequate response to three consecutive bevacizumab injections. METHODS This observational, retrospective, comparative study presented 12-month results of 80 patients with DME. One eye of each patient was enrolled, and bevacizumab was switched as aflibercept (40 eyes) or ranibizumab (40 eyes). DME was diagnosed based on a fundoscopic examination, fundus fluorescein angiography (FFA), central macular thickness (CMT), and best-corrected visual acuity (BCVA). RESULTS Forty-one patients (51.2%) were male, and 39 (48.8%) were female, with a mean age of 62.3 ± 6.7 years. At the end of the study, the mean number of intravitreal injections was 8.1 ± 1.8 in the aflibercept group, whereas 8.9 ± 1.4 in the ranibizumab (p = 0.091). The mean CMT decreased from 449.2 ± 69.3 µm to 311.0 ± 48.9 µm in the aflibercept group, and from 444.9 ± 109.2 µm to 316.3 ± 54.5 µm in the ranibizumab group (for both, p < 0.0001). The mean BVCA increased from 49.2 ± 11.1 ETDRS letters to 62.5 ± 9.9 in the aflibercept group (p < 0.0001) and from 49.9 ± 12.0 ETDRS letters to 61.1 ± 9.1 in the ranibizumab group (p < 0.0001). Macular laser treatment was required in 17.5% of the aflibercept group and 22.5% of the ranibizumab group (p = 0.781). CONCLUSION Significant improvement was observed with ranibizumab and aflibercept treatments in initial bevacizumab-resistant DME. Early switching therapy may contribute to better visual and anatomical outcomes.
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Affiliation(s)
- Mustafa Ataş
- Department of Ophthalmology, 147026Kayseri City Training and Research Hospital, University of Health Science, Kayseri, Turkey
| | - Cemal Ozsaygılı
- Department of Ophthalmology, 147026Kayseri City Training and Research Hospital, University of Health Science, Kayseri, Turkey
| | - Nurettin Bayram
- Department of Ophthalmology, 147026Kayseri City Training and Research Hospital, University of Health Science, Kayseri, Turkey
| | - Sefa Unal
- Department of Ophthalmology, 147026Kayseri City Training and Research Hospital, University of Health Science, Kayseri, Turkey
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Reply. Retina 2022; 42:e46-e48. [PMID: 35413721 DOI: 10.1097/iae.0000000000003503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Uludag G, Hassan M, Matsumiya W, Pham BH, Chea S, Trong Tuong Than N, Doan HL, Akhavanrezayat A, Halim MS, Do DV, Nguyen QD. Efficacy and safety of intravitreal anti-VEGF therapy in diabetic retinopathy: what we have learned and what should we learn further? Expert Opin Biol Ther 2022; 22:1275-1291. [PMID: 35818801 PMCID: PMC10863998 DOI: 10.1080/14712598.2022.2100694] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 07/08/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Diabetic retinopathy (DR) is one of the most frequent microvascular complications of diabetes that can lead to blindness. Laser treatment has been the gold standard treatment for diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR) for many years. Recently, the role of vascular endothelial growth factor (VEGF) has been established in the pathogenesis of DR, and the use of intravitreal anti-VEGF therapy has gained popularity for the management of DR. AREAS COVERED This review includes a brief overview of the efficacy and safety of currently available (bevacizumab, ranibizumab, and aflibercept) and potential future (brolucizumab, faricimab, and KSI-301) anti-VEGF agents in patients with DR based mainly on publicly available data from phase 1, 2 and 3 clinical trials. EXPERT OPINION Clinical trials investigating the efficacy of intravitreal bevacizumab, ranibizumab, and aflibercept injections demonstrated favorable functional and anatomical outcomes in patients with DME. Moreover, the use of these anti-VEGF agents showed a significant improvement in the severity of DR. Recent clinical research for future anti-VEGF molecules aims to provide higher target-protein binding affinity and prolonged therapeutic effect. Brolucizumab, faricimab, and KSI-301 are three novel anti-VEGF agents that demonstrate promising data for the management of DME and potentially DR.
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Affiliation(s)
- Gunay Uludag
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Muhammad Hassan
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Wataru Matsumiya
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
- Department of Surgery, Division of Ophthalmology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Brandon Huy Pham
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
- Bascom Palmer Eye Institute, Department of Ophthalmology, University of Miami, Miami, FL, USA
| | - Sophaktra Chea
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | | | - Hien Luong Doan
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | | | - Muhammad Sohail Halim
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
- Ocular Imaging Research and Reading Center, Sunnyvale, CA, USA
| | - Diana V Do
- Byers Eye Institute, Stanford University, Palo Alto, CA, USA
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Ahrabi B, Omidvari S, Mollazadeh Ghomi S, Ahmady Roozbahany N, Vafaei-Nezhad S, Shirazi Tehrani A, Abbaszadeh HA, Darabi S. Therapeutic Effects of Combination Therapy and Photobiomodulation Therapy on Retinal Regeneration. J Lasers Med Sci 2022; 13:e36. [PMID: 36743147 PMCID: PMC9841384 DOI: 10.34172/jlms.2022.36] [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: 05/06/2022] [Accepted: 08/27/2022] [Indexed: 01/27/2023]
Abstract
Introduction: Many systemic and ocular diseases cause macular edema (ME). Macular edema is seen in two primary forms; the first is diffuse thickening of the macula, and the other is a macula with a distinct petaloid (cloverleaf) appearance called cystoid macular edema. Macular edema has a known role in the reduction of visual equity, and many options have been proposed for the reversal of this condition. Methods: Articles on the effects of macular laser grid photocoagulation on diabetic macular edema (DME) or cystoid macular edema published between 2000 and 2022 were collected from PubMed, Google Scholar, and Web of Science. The following keywords were used for the search: "macular laser photocoagulation", "macular edema", "cystoid macular edema", "intravitreal pharmacotherapies", and "antivascular endothelial growth factor". Two hundred nineteen articles were found in google scholar and 165 articles in PubMed, and a total of 58 articles were included in the study after applying the exclusion criteria. Results: We investigated the effects of various lasers photocoagulation such as Focal and/or grid macular laser, subthreshold micropulse laser (SMPL), as well as intravitreal pharmacotherapies with triamcinolone acetonide, and fluocinolone, and extended released intraocular implants such as Ozurdex, Retisert, Iluvien, and anti-vascular endothelial growth factors such as bevacizumab (Avastin), Eyela, and Lucentis. Corticosteroids were more effective than lasers, although some researchers have found that lasers and combined lasers and corticosteroids are more effective. In addition, some studies have shown that the frequency and concentrations of intravitreal pharmacotherapies are effective in increasing visual outcomes. Conclusion: The results of the studies showed that the combined intravitreal corticosteroids are much more effective in improving visual acuity (VA) than a single corticosteroid, and the low concentration of the drug is safer. Still, corticosteroids have side effects such as increased intraocular pressure and glaucoma. Therefore, combining the medication with a laser is much more reasonable than each alone. Also, the subthreshold photocoagulation laser (670 nm) is better at reducing the central macular thickness (CMT) and improving VA than the micro pulse yellow laser and pan-retinal photocoagulation (PRP).
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Affiliation(s)
- Behnaz Ahrabi
- Laser Application in Medical Sciences Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran,Hearing Disorders Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran,Department of Biology and Anatomical Sciences, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Samareh Omidvari
- Hearing Disorders Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shamim Mollazadeh Ghomi
- Cellular and Molecular Research Center, Research Institute for Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Navid Ahmady Roozbahany
- Hearing Disorders Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saeed Vafaei-Nezhad
- Department of Anatomical Sciences, School of Medicine, Cellular and Molecular Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Atefeh Shirazi Tehrani
- Hearing Disorders Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran,Department of Biology and Anatomical Sciences, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hojjat Allah Abbaszadeh
- Laser Application in Medical Sciences Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran,Hearing Disorders Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran,Department of Biology and Anatomical Sciences, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran,Correspondence to Hojjat Allah Abbaszadeh, Shahram Darabi,
| | - Shahram Darabi
- Cellular and Molecular Research Center, Research Institute for Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran,Correspondence to Hojjat Allah Abbaszadeh, Shahram Darabi,
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Study on BCVA, CMT, CME, Curative Effect, and Prognostic Value of DR Sufferers Based on Surgical Therapy Combined with VEGF Therapy at Different Times. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:1415659. [PMID: 36017028 PMCID: PMC9388298 DOI: 10.1155/2022/1415659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 07/11/2022] [Accepted: 07/13/2022] [Indexed: 11/18/2022]
Abstract
In order to explore the efficacy and prognostic value of best corrected visual acuity (BCVA), central macular retinal thickness (CMT), and cystoid macular edema (CME) in diabetic retinopathy (DR) sufferers based on surgical therapy combined with vascular endothelial growth factor (VEGF) therapy at different times, a total of 170 cases of DR sufferers who visited our hospital from March 2019 to March 2021 are analyzed. All patients are randomly divided into control group and study group, with 85 cases and 85 eyes in each group. In addition, the contrast set received 2 therapies for 1.5 months/time, and the study set received 3 therapies for 1 month/time. The experimental results show that the BCVA of the two sets is notoriously enhanced. Besides, CMT and CME in the study set decrease more than those in the contrast set, and the blood vessel density of retinal capillaries in the contrast set and the examination set is notoriously enhanced. For DR sufferers, 1 month/time of anti-VEGF therapy can effectively enhance the sufferers’ visual acuity, CMT and CME. It is suggested that the clinical application of 1 month/time of anti-VEGF to DR sufferers can enhance the clinical therapeutic effect of sufferers and reduce the prognosis and recurrence.
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Efficacy and Safety of Intravitreal Injection of Triamcinolone Acetonide and Conbercept for Intraocular Lens after Cataract Surgery. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:5606343. [PMID: 35664937 PMCID: PMC9159890 DOI: 10.1155/2022/5606343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/05/2022] [Accepted: 05/09/2022] [Indexed: 11/26/2022]
Abstract
Objective To investigate the effect of intravitreal injection of triamcinolone acetonide and conbercept on the efficacy and safety of diabetic macular edema (DME) after cataract intraocular lens (IOL) surgery. Methods A total of 350 patients with cataract complicated with diabetic macular edema in our hospital from January 2017 to July 2021 were randomly divided into conbercept group and triamcinolone acetonide group. Patients in the conbercept group were given intravitreal injection of conbercept during IOL surgery, and patients in the triamcinolone acetonide group were given injection of triamcinolone acetonide during surgery. Results Three months after treatment, the best-corrected visual acuity of the two groups was significantly higher than before, the corrected visual acuity of the conbercept group was more significant than the triamcinolone acetonide group, and the intraocular pressure of the triamcinolone acetonide group was higher than the conbercept group. The foveal thickness and macular volume were significantly reduced in both groups, and was reduced more in the conbercept group than in the triamcinolone acetonide group. The contents of VEGF, SDF-1, and IL-6 in both groups were significantly decreased, and the decrease was more significant in the conbercept group than in the triamcinolone acetonide group. The patients with elevated intraocular pressure, headache and vomiting, orbital swelling pain, eye swelling pain, and eye pain in the triamcinolone acetonide group were significantly higher than those in the conbercept group (P < 0.05). Conclusions Conbercept and triamcinolone acetonide has a good therapeutic effect on DME in pseudophakic eyes after cataract IOL surgery, which can reduce the degree of macular edema and improve the visual function. However, the therapeutic effect of injection therapy with conbercept is safe, the prognosis is better, and the complication rate is low.
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Cox L, Li Y, Fotuhi M, Vermeirsch S, Yeung I, Hamilton RD, Rajendram R, Lukic M. Treatment of chronic diabetic macular oedema with intravitreal fluocinolone acetonide implant; real-life analysis of outcomes during overall treatment period. Eur J Ophthalmol 2022; 32:3629-3636. [PMID: 35484812 DOI: 10.1177/11206721221097587] [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: 11/15/2022]
Abstract
PURPOSE To assess the clinical efficacy of the fluocinolone acetonide (FA) intravitreal implant (Iluvien, Alimera Sciences) over a 12-month period in a population resistant to treatment with first-line anti-VEGF agents. METHODS This study is a retrospective cohort study assessing functional and anatomical outcomes in 13 eyes of 12 patients treated for diabetic macular oedema (DMO) with a single fluocinolone implant (FA) (Iluvien) under real-world conditions. The follow-up period includes the time of first intravitreal treatment (incl anti-VEGF or short-lasting steroids) given until 12 months post FA implant insertion. Primary outcomes were best corrected visual acuity (BCVA), measured using the modified Early Treatment Diabetic Retinopathy Study (ETDRS) grading scale, and central foveal thickness (CFT), measured using Topcon 3DOCT-2000 (Topcon Inc) SD-OCT imaging. Mean BCVA and CFT were measured before anti-VEGF treatment, after anti-VEGF treatment, at the time of Iluvien implant insertion, and 6 and 12 months after Iluvien implant insertion. The t-paired sample test was used to ascertain statistical significance of changes in comparison of two samples while the ANOVA analysis was used in comparison of three or more samples. RESULTS The baseline BCVA (SD) of the cohort prior to initiation of anti-VEGF treatment was 47.45 (12.27) ETDRS letters whilst the mean CFT (SD) was 579 (203) microns. Following completion of anti-VEGF therapy, the mean improvement in vision was 8.9 ETDRS letters (p = 0.1) whilst the mean reduction in CFT was 197 microns (p = 0.028). Mean BCVA (SD) at the time of insertion of the FA implant was 55.15 (11.16) ETDRS letters and mean (SD) CFT at time of insertion of the FA was 454.62 μm (109.51). Following the 12-month treatment period with the FA implant, BCVA (SD) was 62.15 (10.25) ETDRS letters (p = 0.0331) and the mean (SD) CFT was 404.36 μm (142.92), a change of -50.26 μm from baseline (p = 0.0369). CONCLUSIONS This study has shown that statistically significant improvements in BCVA and CFT can be achieved over a 12-month period with the Iluvien implant. The implant has been shown to be a safe option in the treatment of DMO and may have a role to play in achieving good functional and anatomical outcomes in DMO while also reducing the frequency of follow-up appointments required to maintain stable vision in the working-age population.
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Affiliation(s)
- Laurence Cox
- NIHR Biomedical Research Centre, 4960Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Yanda Li
- NIHR Biomedical Research Centre, 4960Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Majid Fotuhi
- NIHR Biomedical Research Centre, 4960Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Sandra Vermeirsch
- NIHR Biomedical Research Centre, 4960Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Ian Yeung
- NIHR Biomedical Research Centre, 4960Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Robin D Hamilton
- NIHR Biomedical Research Centre, 4960Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Ranjan Rajendram
- NIHR Biomedical Research Centre, 4960Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
| | - Marko Lukic
- NIHR Biomedical Research Centre, 4960Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, UK
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Factors predicting the treatment frequency of ranibizumab injections during the second year in diabetic macular edema. Jpn J Ophthalmol 2022; 66:296-304. [PMID: 35438397 DOI: 10.1007/s10384-022-00905-4] [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: 07/24/2021] [Accepted: 12/23/2021] [Indexed: 10/18/2022]
Abstract
PURPOSE To investigate the predictors of annual treatment frequency in the second year of pro re nata (PRN) intravitreal ranibizumab (IVR) injections for diabetic macular edema (DME). STUDY DESIGN A retrospective study. METHODS We reviewed 65 eyes of 60 patients with center-involved DME who received PRN IVR injections after 3 monthly loading doses. The central subfield thickness (CST) and qualitative findings were assessed on the spectral domain optical coherence tomography (SD-OCT) images. We then investigated whether the parameters at the baseline or at the 12-month visit were associated with treatment frequency in the second year. RESULTS The number of ranibizumab injections decreased from 6 (4-8) during the first year to 2 (0-3) during the second year (P < .001). The injection numbers during the first year (ρ = 0.259, P = .037) but not during the second year (ρ = 0.152, P = .226) were modestly related to the logarithm of the minimum angle of resolution (logMAR) improvement at 24 months. Multivariate analyses revealed that the CST (β = 0.336, P = .005) and hyperreflective walls in the foveal cystoid spaces (β = 0.273, P = .020) at baseline were associated with the number of IVR injections during the second year. The treatment frequency during the second year was also related to the CST (β = 0.266, P = .012), hyperreflective walls (β = 0.394, P = .002), and cumulative doses of ranibizumab injections (β = 0.294, P = .006) at the 12-month visit. CONCLUSIONS The cumulative doses of ranibizumab injections, CST, and hyperreflective walls in the foveal cystoid spaces at the 12-month visit are designated predictors of the treatment frequency of ranibizumab injections during the second year in DME.
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Yao J, Peng Q, Li Y, Liang A, Xie J, Zhuang X, Chen R, Chen Y, Wang Z, Zhang L, Cao D. Clinical Relevance of Body Fluid Volume Status in Diabetic Patients With Macular Edema. Front Med (Lausanne) 2022; 9:857532. [PMID: 35492357 PMCID: PMC9039394 DOI: 10.3389/fmed.2022.857532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/21/2022] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To investigate body fluid status in diabetic macular edema (DME) patients and the extent to which it is affected by renal function. METHODS One hundred and thirty-two eyes from 132 patients with diabetes mellitus (DM) were prospectively collected in this cross-sectional, observational study. Thirty-five were DM patients without diabetic retinopathy (DR), 31 were DR patients without DME, and 66 were DME patients. The fluid status of each participant was quantified with extracellular water-to-total body water ratio (ECW/TBW) using a body composition monitor. Central subfield thickness (CST) and macular volume (MV) were obtained using optical coherence tomography (OCT). Urine albumin-to-creatinine ratio (UACR), estimated glomerular filtration rate (eGFR), and albumin was obtained using serum and urine laboratory data. RESULTS ECW/TBW was significantly increased in DME patients (39.2 ± 0.9, %) compared to DM (38.1 ± 0.7, %, P = 0.003) and DR patients without DME (38.7 ± 0.9, %, P < 0.001). In multilinear regression, fluid overload was positively related to DME and UACR (DME vs. DM: β = 2.418, P < 0.001; DME vs. DR: β = 1.641, P = 0.001; UACR, per 102, β = 1.017, P = 0.01). In the binary logistic regression for DME risk, the area under the receiver operating characteristic curve (AUROC) increased significantly by adding ECW/TBW along with UACR and age (AUC: 0.826 vs. 0.768). CONCLUSION DME patients had elevated body fluid volume independent of kidney functions. The assessment of extracellular fluid status may help in the management of DME.
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Affiliation(s)
- Jie Yao
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical College, Shantou, China
| | - Qingsheng Peng
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yuanhong Li
- Department of Nutrition, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Anyi Liang
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jianteng Xie
- Department of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xuenan Zhuang
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Ruoyu Chen
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Southern Medical University, Guangzhou, China
| | - Yesheng Chen
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Southern Medical University, Guangzhou, China
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zicheng Wang
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- School of Medicine, South China University of Technology, Guangzhou, China
| | - Liang Zhang
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical College, Shantou, China
- Southern Medical University, Guangzhou, China
| | - Dan Cao
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Southern Medical University, Guangzhou, China
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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