Ergänzende Stellungnahme der DOG, der RG und des BVA zur Therapie der proliferativen diabetischen Retinopathie

Observational outcomes in proliferative diabetic retinopathy patients following treatment with ranibizumab, panretinal laser photocoagulation or combination therapy - The non-interventional second year follow-up to the PRIDE study

PURPOSE

Ranibizumab monotherapy showed stronger effects on area of retinal neovascularization (NV) reduction while offering better visual acuity (VA) results than panretinal laser photocoagulation (PRP) monotherapy during the first 12 months of the PRIDE study. The second year of PRIDE was an observational, non-interventional follow-up, performed to evaluate long-term anatomical and functional outcomes in proliferative diabetic retinopathy (PDR) patients under real-life conditions, prior to the approval of ranibizumab for PDR.

METHODS

Seventy-three PDR patients (28 from the ranibizumab group; 20 from the PRP group; 25 from the combination group) were included in the observational follow-up phase and treated at the investigators discretion. Visual acuity (VA) measurements and retinal imaging were performed at Months 12, 18 and 24.

RESULTS

Mean (± SD) NV area in the ranibizumab monotherapy and combination follow-up groups increased from 3.16 ± 4.30 mm² and 1.13 ± 2.78 mm² at Month 12 to 6.09 ± 10.79 mm² and 2.14 ± 4.41 mm² at Month 18 and 10.00 ± 17.63 mm² and 3.26 ± 7.05 mm² at Month 24, respectively. In the PRP follow-up group, NV area declined from 5.44 ± 14.55 mm² at Month 12 to 1.22 ± 1.67 mm² at Month 18, but increased again to 4.05 ± 11.66 mm² at Month 24. During the observational phase, only 2 (6;8) patients in the ranibizumab (PRP;combination) follow-up group were treated with anti-VEGF medications, while 17 (6;10) patients received PRP laser therapy.

CONCLUSION

Discontinuation of ranibizumab treatment in PDR patients may result in an increase of NV area and VA loss. Tight monitoring of disease activity and continued treatment beyond the first year is needed to maintain disease control.

[Avoiding mistakes in anti-VEGF intravitreal injection therapy]

Intravitreal injection (IVI) of drugs for treatment of various macular diseases is now one of the most frequently performed surgical procedures worldwide. As mostly chronic diseases are treated, the indications for treatment often mean a continuous treatment over years with a corresponding effort regarding spatial, personnel and financial resources. The diagnosis and indications for treatment are nowadays mainly made by spectral domain optical coherence tomography (SD-OCT). The ability to clinically assess and evaluate a fluorescence angiography is less practiced, although these are still a component of the indications for intravitreal injections. Therefore, it can happen that despite all diligence patients may receive anti-vascular endothelial growth factor (VEGF) treatment, sometimes permanently, based on a misinterpretation of the macular diagnosis or disease activity and these indications, once made, are rarely questioned or retracted. Therefore, the aim of this manuscript is to point out possible and typical misinterpretations in the indications or continuation of IVI treatment with anti-VEGF by means of case studies and to sensitize for differential diagnoses.

[Diabetic retinopathy]

Diabetic retinopathy (DR) is a vision-threatening microvascular complication of diabetes and the leading cause of blindness in working-age people. At the beginning of the metabolic disorder and in early stages of DR the patient's eyesight is often not affected. Depending on the duration of diabetes and in more advanced stages of DR the vision is compromised through the presence of diabetic macular edema (DME) and/or proliferative retinal complications. The management of DR comprises regular ophthalmic examinations according to clinical guidelines, the targeted application of multimodal imaging, and the specific treatment of DME and proliferative DR including secondary disorders such as neovascular glaucoma or persistent vitreous haemorrhage. Innovative ocular imaging techniques like optical coherence tomography (OCT), OCT angiography (OCT-A) and ultrawide field imaging play an important role in the assessment of diabetic patients. Various non-invasive imaging modalities have become part of the routine clinical work-up and help to identify new biomarkers for early diagnosis and long-term prognosis. In early stages of DR, the multifactorial intervention including glucose level and blood pressure control as well as optimizing the patient's cardiovascular risk profile is essential. A specific ophthalmic therapy is available for DME and proliferative DR (PDR). In patients with PDR the treatment regime includes panretinal laser photocoagulation or alternatively intravitreal anti-VEGF (vascular endothelial growth factor)-injections accompanied by close-meshed clinical monitoring. In patients with both, DME and PDR, it is suggested to start with Anti-VEGF drugs. In severe PDR with persistent vitreous haemorrhage, tractional maculopathy or tractional retinal detachment vitreoretinal surgery is recommended.

Diabetische Retinopathie

Die diabetische Retinopathie (DR) ist die häufigste Ursache für schwere Sehbehinderung und Erblindung im erwerbstätigen Alter. Eine subjektive Beeinträchtigung des Sehvermögens tritt häufig erst in fortgeschrittenen Stadien der DR ein. Daher sind Screening-Maßnahmen asymptomatischer Patienten und eine stadiengerechte Behandlung essenziell. Dieser Beitrag gibt einen praxisbezogenen Überblick über diagnostische und therapeutische Prinzipien der nicht-proliferativen und proliferativen Form.

[The Eye in Internal Medicine: Diabetic retinopathy]

Diabetic retinopathy has seen tremendous progress in diagnostic tools and treatment in recent 15 years. Sight threatening stages like proliferative diabetic retinopathy (PDR) and diabetic macular edema (DME) can be treated much more effectively now. The recognition of vascular endothelial growth factor (VEGF) as a driver of proliferation and macular edema has led to the development of VEGF inhibiting drugs such as antibodies (Bevacizumab), fragments of an antibody (Ranibizumab), or a so called VEGF trap (Aflibercept). Laser treatment is no longer a gold standard. Today laser therapy is part of a combined treatment strategy. DME can be monitored quantitatively by ocular coherence tomography (OCT) measurements. For non-responders to VEGF inhibiting drugs, we have secondline corticosteroidal implants. However, screening examinations and early diagnosis of DME and PDR remain crucial. The same accounts for the collaboration of opthalmologists, general practioners, and diabetologists. Good control of diabetes and blood pressure is still important.