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Ma CC, Chen PH, Hsieh YH. Optimizing Diabetic Macular Edema Treatment: A Meta-Analysis of Subthreshold Micropulse Laser and Anti-Vascular Endothelial Growth Factor Combination Therapy. J Clin Med 2024; 13:4782. [PMID: 39200924 PMCID: PMC11355810 DOI: 10.3390/jcm13164782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 07/31/2024] [Accepted: 08/13/2024] [Indexed: 09/02/2024] Open
Abstract
Background: Diabetic macular edema (DME) is the primary cause of visual impairment in individuals with diabetes. Anti-vascular endothelial growth factor (VEGF) is the current first-line treatment for DME owing to its effectiveness. However, frequent anti-VEGF injections may be inconvenient for patients. Therefore, this study aimed to investigate whether the addition of subthreshold micropulse laser (SML) to anti-VEGF therapy could reduce the requirement for anti-VEGF injections while maintaining the treatment efficacy for DME. Methods: Clinical trials retrieved from the databases of PubMed, EMBASE, and the Cochrane Library were evaluated to determine the effectiveness of combination treatment with SML and anti-VEGF medication compared with that of anti-VEGF treatment alone. The primary outcome measures were the changes in CMT, best-corrected visual acuity (BCVA), and the total number of intravitreal injections (IVIs). Results: The IVI + SML group revealed a substantial increase in the logarithm of the minimum angle of the resolution BCVA and a reduction in CMT at the 12-month follow-up (BCVA: random-effects; mean difference [MD], -0.05; 95% confidence interval [CI]: -0.10 to -0.01; p-value = 0.28, and CMT: random-effects; MD, -18.27; 95% confidence interval, -27.36 to -9.18; p-value = 0.20). The number of required IVIs in the IVI + SML group was lower than that in the IVI only group (random-effects; MD, -2.22; 95% CI: -3.13 to -1.31; p-value < 0.01). Conclusions: Combining SML therapy with anti-VEGF injections may reduce the total number of injections required, improve VA, and reduce CMT at the 12-month follow-up. Although the included studies used different SML regimens and anti-VEGF agents, this review indicates that the application of additional SML therapy results in positive clinical outcomes.
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Affiliation(s)
- Ching-Chih Ma
- Department of Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan;
| | - Po-Huang Chen
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - Yun-Hsiu Hsieh
- Department of Ophthalmology, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan;
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Hosoya H, Ueta T, Hirasawa K, Toyama T, Shiraya T. Subthreshold micropulse laser combined with anti-vascular endothelial growth factor therapy for diabetic macular edema: a systematic review and meta-analysis. Graefes Arch Clin Exp Ophthalmol 2024:10.1007/s00417-024-06460-7. [PMID: 38662102 DOI: 10.1007/s00417-024-06460-7] [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: 11/18/2023] [Revised: 03/04/2024] [Accepted: 03/15/2024] [Indexed: 04/26/2024] Open
Abstract
PURPOSE To evaluate the effects of subthreshold micropulse laser (SML) in addition to anti-vascular endothelial growth factor (VEGF) therapy for diabetic macular edema (DME). METHODS MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were systematically searched for studies that compared anti-VEGF with SML and anti-VEGF monotherapy for DME. Outcome measures were best-corrected visual acuity (BCVA), central macular thickness (CMT), and the number of anti-VEGF injections. RESULTS Eight studies including 493 eyes were selected. Four studies were randomized controlled, and the other four were retrospective. Meta-analysis showed that there was no significant difference in BCVA (mean difference [MD] -0.04; 95%CI -0.09 to 0.01 logMAR; P = 0.13;). CMT was thinner in the group of anti-VEGF with SML (MD -11.08; 95%CI -21.04 to -1.12 µm; P = 0.03); however, it was due to a single study that weighed higher, and the sensitivity and subcategory analyses did not support the finding. The number of anti-VEGF injections was significantly decreased in the group of anti-VEGF with SML (MD -2.22; 95%CI -3.02 to -1.42; P < 0.0001). CONCLUSION Current evidence indicates that adding SML to anti-VEGF therapy could significantly reduce the number of anti-VEGF injections compared to anti-VEGF monotherapy, while achieve similar BCVA and CMT.
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Affiliation(s)
- Hironori Hosoya
- Department of Ophthalmology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takashi Ueta
- Department of Ophthalmology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Kazunori Hirasawa
- Department of Ophthalmology, Kitasato University School of Medicine, Tokyo, Japan
| | - Taku Toyama
- Department of Ophthalmology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomoyasu Shiraya
- Department of Ophthalmology, Showa General Hospital, Tokyo, Japan
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3
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Wijeweera C, Ni J, Petocz P, Preda V, Jabbour J. Efficacy of anti-VEGF monotherapy versus anti-VEGF therapy with subthreshold micropulse laser (SML) in the management of diabetic macular oedema (DMO): a systematic review and meta-analysis. Graefes Arch Clin Exp Ophthalmol 2024:10.1007/s00417-024-06405-0. [PMID: 38421412 DOI: 10.1007/s00417-024-06405-0] [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: 10/24/2023] [Revised: 01/31/2024] [Accepted: 02/06/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Intravitreal injection anti-vascular endothelial growth factor (IVI anti-VEGF) therapy serves as the primary treatment for centre involving diabetic macular oedema (DMO). Conventional laser therapy (CLT) adjunct has proven beneficial; however, it is not widely used due to significant risks of retinal scarring. Subthreshold micropulse laser (SML) therapy has, however, emerged as a comparable alternative to combination therapy, offering a distinct advantage by mitigating the risk of retinal scarring. METHODS A search of six databases was conducted. A meta-analysis of mean differences was performed including subgroup analyses where appropriate. Primary outcome was the number of injections at 12-14 months; secondary outcomes were changes in central macular thickness (CMT) and best corrected visual acuity (BCVA) at 6-8 months and 12-14 months. RESULTS A total of ten papers including six randomised clinical trials and four retrospective clinical studies were included in our study, capturing 563 eyes of 478 patients. Overall, the risk of bias was moderate for these studies. Significantly fewer anti-VEGF therapy injections were administered in the combination therapy versus anti-VEGF monotherapy patients at 12-14 months who had poor visual acuity (6/18 Snellen or worse) at baseline, mean difference - 2.25 (95% CI; - 3.35, - 1.15; p < 0.05). Combination therapy was not associated with significantly fewer intravitreal injections in patients with a higher visual acuity (6/15 Snellen or better) at baseline. Our analysis also showed significant improvements to both BCVA and CMT were reached at 6 - 8 month post-baseline at the 95% confidence intervals: - 1.13 (- 2.09, - 0.16) and - 4.04 (- 7.59, - 0.50). These improvements remained statistically significant at 12-14 months: - 0.94 (- 1.67, - 0.20) and - 1.92 (- 3.52, - 0.32) respectively with combination therapy. CONCLUSION Our findings demonstrate that combination therapy (SML + IVI anti-VEGF) is associated with fewer intravitreal injections. We report a better BCVA and a reduction in CMT at 6 and 12 months from baseline with combination treatment compared to the IVI anti-VEGF monotherapy comparator. SML is a proven non-scarring cost-effective therapy for DMO that should be readily available in the medical retinal therapy as it may reduce the burden of care.
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Affiliation(s)
- Chandana Wijeweera
- Faculty of Medicine, Health and Human Sciences, Macquarie University Macquarie Park, Sydney, Australia
| | - Jing Ni
- Faculty of Medicine, Health and Human Sciences, Macquarie University Macquarie Park, Sydney, Australia
| | - Peter Petocz
- Graduate Research Academy, Macquarie University Macquarie Park, Sydney, Australia
| | - Veronica Preda
- Faculty of Medicine, Health and Human Sciences, Macquarie University Macquarie Park, Sydney, Australia.
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Mei JH, Lin Z. Subthreshold micropulse diode laser treatment in diabetic macular edema: biological impact, therapeutic effects, and safety. Int Ophthalmol 2024; 44:3. [PMID: 38315299 DOI: 10.1007/s10792-024-02973-6] [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: 03/25/2023] [Accepted: 12/04/2023] [Indexed: 02/07/2024]
Abstract
PURPOSE To introduce the treatment of diabetic macular edema (DME) with subthreshold micropulse diode laser (SMPL), to summarize the biological impact, therapeutic effects, and safety of this treatment, and to discuss the response to DME when SMPL is combined with anti-vascular endothelial growth factor (anti-VEGF) or steroid. METHODS The literature search was performed on the PubMed database, with a selection of English-language articles published from 2000 to 2023 with the following combinations of search terms: diabetes macular (o) edema, micropulse laser or subthreshold micropulse laser, anti-vascular endothelial growth factor, and steroid. RESULTS SMPL is a popular, invisible retinal laser phototherapy that is inexpensive, safe, and effective in the treatment of DME. It can selectively target the retinal pigment epithelium, reduce the expression of pro-inflammatory factors, promote the absorption of macular edema, and exert a similar and lasting clinical effect to traditional lasers. No significant difference was found in the therapeutic effects of SMPL between different wavelengths. However, HbA1c level and pretreatment central macular thickness (CMT) may affect the therapeutic outcomes of SMPL. CONCLUSION SMPL has a slow onset and produces lasting clinical effects similar to conventional photocoagulation. It has been reported that SMPL combined with the intravitreal anti-VEGF injection can significantly reduce the number of injections without influencing the therapeutic effect, which is essential for clinical applications and research. Although 577 nm SMPL is widely used clinically, there are no standardized protocols for SMPL. Additionally, some important problems regarding the treatment of SMPL require further discussion and exploration.
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Affiliation(s)
- Jing Hao Mei
- The Eye Hospital, School of Ophthalmology and Optometry, Wenzhou Medical University, No. 207, Xueyuan West Road, Wenzhou, 325027, Zhejiang, China
- National Clinical Research Center for Ocular Diseases, No. 207, Xueyuan West Road, Wenzhou, 325027, Zhejiang, China
| | - Zhong Lin
- The Eye Hospital, School of Ophthalmology and Optometry, Wenzhou Medical University, No. 207, Xueyuan West Road, Wenzhou, 325027, Zhejiang, China.
- National Clinical Research Center for Ocular Diseases, No. 207, Xueyuan West Road, Wenzhou, 325027, Zhejiang, China.
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Xu D, Zhu T, Huang L, Wang X, Chen M. Clinical efficacy of subthreshold micropulse laser combined with anti-VEGF drugs in the treatment of diabetic macular edema: A meta-analysis. Medicine (Baltimore) 2024; 103:e34583. [PMID: 38306515 PMCID: PMC10843376 DOI: 10.1097/md.0000000000034583] [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: 04/26/2023] [Accepted: 07/13/2023] [Indexed: 02/04/2024] Open
Abstract
BACKGROUND To systematically evaluate the efficacy and safety of subthreshold micropulse laser (SML) combined with anti-vascular endothelial growth factor (VEGF) drugs for the treatment of diabetic macular edema (DME). METHODS The randomized controlled trials on SML combined with anti-VEGF drugs for DME were retrieved from China National Knowledge Infrastructure, Wan Fang Data, VIP Data, Sino Med (China Biomedical Literature Database), PubMed, Web of Science, The Cochrane Library, and Embase by computer from inception to April 19, 2022. The observation group was treated with SML combined with anti-VEGF drugs, while the control group was treated with anti-VEGF agents alone or SML. And the references of the included literature were manually searched. The Meta-analysis was performed using Revman 5.4 and STATA SE 15. RESULTS This study finally included 15 randomized controlled trials involving 891 eyes for Meta-analysis. The results showed that there was no statistically significant difference between the 2 groups in best-corrected visual acuity at 1, 3, 6, 9, and 12 months after treatment. There was no statistical difference between the 2 groups in central macular thickness (CMT) at 1, 3, and 6 months after treatment (P > .05). CMT in the observation group was lower than that in the control group at 9 and 12 months (P < .05). There was no statistical difference between the 2 groups in total macular volume at 3, 6, 9, and 12 months in CMT (P > .05). The number of anti-VEGF drugs injections in the observation was lower than that in the control group (P < .05). The occurrence of complications between the 2 groups was not statistically significant difference (P > .05). CONCLUSION SML in combination with anti-VEGF drugs in patients with DME are comparable in reducing the number of anti-VEGF drugs injections and CMT, thereby reducing the financial burden on patients. It does not differ in best-corrected visual acuity and total macular volume.
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Affiliation(s)
- Dahua Xu
- Aier School of Ophthalmology, Central South University, Changsha, Hunan Province, China
| | - Ting Zhu
- Aier School of Ophthalmology, Central South University, Changsha, Hunan Province, China
| | - Lin Huang
- Aier School of Ophthalmology, Central South University, Changsha, Hunan Province, China
| | - Xiaolin Wang
- Aier School of Ophthalmology, Central South University, Changsha, Hunan Province, China
| | - Mei Chen
- Chongqing Aier Eye Hospital, Chongqing, China
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Santamaría J, Caminal JM, Cobos E, Biarnes M, Rodriguez-Leor R, Morwani R, García-Mendieta M, Lorenzo D, García-Bru P, Arias L. Correlation between Topographic Vessel Density and Retinal Thickness Changes in Patients with Diabetic Macular Edema Treated with Anti-VEGF Therapy: Is It a Suitable OCTA Biomarker? J Pers Med 2023; 13:1718. [PMID: 38138945 PMCID: PMC10744775 DOI: 10.3390/jpm13121718] [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: 10/20/2023] [Revised: 11/29/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
The objective of this study was to determine the correlation between topographic vessel density (VD) and retinal thickness (RT) reductions induced by vascular endothelial growth factor inhibitors (anti-VEGF) in patients with diabetic macular edema (DME) using optical coherence tomography angiography (OCTA). This was a prospective, interventional case series. VD and RT measurements were separately taken in four parafoveal subfields at baseline and after six months of treatment. This correlation was statistically assessed using Spearman's rho correlation coefficient after adjustment for multiple comparisons. The study included a total of 48 eyes in the final analysis. Mean VD decreased from baseline to month 6 (from 45.2 (±3.5) to 44.6% (±3.2) in the superficial capillary plexus and from 50 (±3.3) to 49% (±3.9) in the deep capillary plexus). Statistically significant reductions in RT were observed in all ETDRS sectors (p < 0.0001). No significant association was found between RT and VD, even when analyzing responders and non-responders separately. After six months of anti-VEGF treatment, no significant correlation was observed between the topographic VD and RT values. These findings suggest that reductions in VD values may not solely result from a reduction in microaneurysms, also being affected by the repositioning of displaced vessels due to edema and a reduction in their caliber. Therefore, VD changes may not be a suitable indirect OCTA biomarker of microaneurysm turnover and treatment response.
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Affiliation(s)
- Juan Santamaría
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (J.S.); (E.C.); (R.M.); (D.L.); (P.G.-B.); (L.A.)
| | - José María Caminal
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (J.S.); (E.C.); (R.M.); (D.L.); (P.G.-B.); (L.A.)
| | - Estefanía Cobos
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (J.S.); (E.C.); (R.M.); (D.L.); (P.G.-B.); (L.A.)
| | - Marc Biarnes
- OMIQ Research, c/Tamarit 39, 08205 Sabadell, Spain;
| | | | - Rahul Morwani
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (J.S.); (E.C.); (R.M.); (D.L.); (P.G.-B.); (L.A.)
| | | | - Daniel Lorenzo
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (J.S.); (E.C.); (R.M.); (D.L.); (P.G.-B.); (L.A.)
| | - Pere García-Bru
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (J.S.); (E.C.); (R.M.); (D.L.); (P.G.-B.); (L.A.)
| | - Luis Arias
- Department of Ophthalmology, Ocular Oncology and Vitreoretinal Service, Bellvitge University Hospital, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (J.S.); (E.C.); (R.M.); (D.L.); (P.G.-B.); (L.A.)
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7
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Lubis PM, Prabaniswara MP, Victor AA. Comparison of micropulse subthreshold laser plus anti-VEGF versus anti-VEGF alone in diabetic macular edema: Systematic review. Indian J Ophthalmol 2023; 71:3448-3453. [PMID: 37870005 PMCID: PMC10752316 DOI: 10.4103/ijo.ijo_519_23] [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: 02/20/2023] [Revised: 06/07/2023] [Accepted: 06/22/2023] [Indexed: 10/24/2023] Open
Abstract
Intravitreal injection of anti- Vascular Endothelial Growth Factor (VEGF)is commonly used to treat patients with diabetic macular edema (DME). However, the injection alone requires high cost and compliance. Combining micropulse subthreshold laser (MPSL) and anti-VEGF is a new approach to treating DME. This study intended to answer the question of whether MPSL plus anti-VEGF is effective compared to anti-VEGF alone. The following terms were used in PubMed, clinicaltrial.gov, and Google Scholar: anti-VEGF, DME, MPSL, and diabetic retinopathy. All studies of DME comparing the intervention of MPSL plus anti-VEGF and VEGF alone between the years 2017-2021 were included. Studies with no comparison between the intervention and control group, abstract-only papers, case reports, case series, and systematic review studies were excluded. Five Randomized Controlled Trial (RCTs) and three retrospective studies were analyzed. Four studies found that best-corrected visual acuity (BCVA) improved in both therapies. Central macular thickness in six studies was also improved. The improvement differences between both therapies were insignificant and the number of anti-VEGF injections was significantly lower in combination therapy. These studies show equal outcomes of both therapies. The reduced number of anti-VEGF injections of the combination therapy could improve the management of DME in terms of cost-effectiveness. Further analysis should be conducted to pool the data from the studies and evaluate the overall outcome.
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Affiliation(s)
- Parangeni M Lubis
- Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada, Dr. Sardjito General Hospital, Yogyakarta
| | - Marcelius P Prabaniswara
- Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada, Dr. Sardjito General Hospital, Yogyakarta
| | - Andi Arus Victor
- Department of Ophthalmology, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
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Azzouz L, Durrani A, Zhou Y, Paulus YM. Adjunct Nondamaging Focal Laser Reduces Intravitreal Injection Burden in Diabetic Macular Edema. PHOTONICS 2023; 10:1165. [PMID: 39006749 PMCID: PMC11238598 DOI: 10.3390/photonics10101165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
This study aims to determine the impact of adjunct nondamaging focal laser therapy on the number of anti-vascular endothelial growth factor (anti-VEGF) injections and visual acuity (VA) and imaging in patients with diabetic macular edema (DME). A retrospective analysis of 18 eyes of 14 patients with DME treated with a single session of the PASCAL 532 nm Synthesis Photocoagulator with Endpoint Management was conducted. Demographic data, VA, imaging, laser parameters, and anti-VEGF injection burden six months before and after treatment were collected. Wilcoxon Signed-rank tests were used to assess changes in VA and injection burden before and after treatment. The mean number of intravitreal injections in the six-month period prior to laser treatment was 3.39 ± 2.57 injections compared to 2.33 ± 2.40 injections following laser treatment (p = 0.02). There was no significant difference between the mean VA on the day of treatment logMAR VA of 0.38 ± 0.27 (approx. Snellen equivalent 20/50) and the visual acuity on the most recent follow-up 6 months after laser logMAR VA of 0.35 ± 0.32 (approx. Snellen equivalent 20/40) (p = 0.34). There was also no significant difference in OCT central macular thickness before (311 μm) compared to 6 months after (301 μm, p = 0.64). Adjunct focal macular laser therapy is associated with a statistically and clinically significant decrease in the number of intravitreal injections required in the six-month period immediately following treatment, without compromising visual acuity or macular thickness. Nondamaging focal laser has the potential to alleviate the burden of injections for both patients and clinics.
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Affiliation(s)
- Lyna Azzouz
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI 48105, USA
- Department of Ophthalmology, Stanford University, Palo Alto, CA 94305, USA
| | - Asad Durrani
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI 48105, USA
| | - Yunshu Zhou
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI 48105, USA
| | - Yannis M. Paulus
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI 48105, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48105, USA
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Bodea F, Bungau SG, Bogdan MA, Vesa CM, Radu A, Tarce AG, Purza AL, Tit DM, Bustea C, Radu AF. Micropulse Laser Therapy as an Integral Part of Eye Disease Management. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1388. [PMID: 37629677 PMCID: PMC10456532 DOI: 10.3390/medicina59081388] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 07/25/2023] [Accepted: 07/28/2023] [Indexed: 08/27/2023]
Abstract
Ocular diseases can significantly impact vision and quality of life through pathophysiological alterations to the structure of the eye. The management of these conditions often involves a combination of pharmaceutical interventions, surgical procedures, and laser therapy. Laser technology has revolutionized many medical fields, including ophthalmology, offering precise and targeted treatment options that solve some of the unmet needs of other therapeutic strategies. Conventional laser techniques, while effective, can generate excessive thermal energy, leading to collateral tissue damage and potential side effects. Compared to conventional laser techniques, micropulse laser therapy delivers laser energy in a pulsed manner, minimizing collateral damage while effectively treating target tissues. The present paper highlights the advantages of micropulse laser therapy over conventional laser treatments, presents the implications of applying these strategies to some of the most prevalent ocular diseases, and highlights several types and mechanisms of micropulse lasers. Although micropulse laser therapy shows great potential in the management of ocular diseases, further research is needed to optimize treatment protocols, evaluate long-term efficacy, and explore its role in combination therapies.
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Affiliation(s)
- Flaviu Bodea
- Doctoral School of Biomedical Sciences, University of Oradea, 410087 Oradea, Romania; (F.B.); (C.M.V.); (D.M.T.); (A.-F.R.)
| | - Simona Gabriela Bungau
- Doctoral School of Biomedical Sciences, University of Oradea, 410087 Oradea, Romania; (F.B.); (C.M.V.); (D.M.T.); (A.-F.R.)
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania;
| | - Mihaela Alexandra Bogdan
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania;
| | - Cosmin Mihai Vesa
- Doctoral School of Biomedical Sciences, University of Oradea, 410087 Oradea, Romania; (F.B.); (C.M.V.); (D.M.T.); (A.-F.R.)
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
| | - Ada Radu
- Ducfarm Pharmacy, 410514 Oradea, Romania;
| | - Alexandra Georgiana Tarce
- Medicine Program of Study, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania;
| | - Anamaria Lavinia Purza
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania;
| | - Delia Mirela Tit
- Doctoral School of Biomedical Sciences, University of Oradea, 410087 Oradea, Romania; (F.B.); (C.M.V.); (D.M.T.); (A.-F.R.)
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania;
| | - Cristian Bustea
- Department of Surgery, Oradea County Emergency Clinical Hospital, 410169 Oradea, Romania;
| | - Andrei-Flavius Radu
- Doctoral School of Biomedical Sciences, University of Oradea, 410087 Oradea, Romania; (F.B.); (C.M.V.); (D.M.T.); (A.-F.R.)
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
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Nozaki M, Ando R, Kimura T, Kato F, Yasukawa T. The Role of Laser Photocoagulation in Treating Diabetic Macular Edema in the Era of Intravitreal Drug Administration: A Descriptive Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1319. [PMID: 37512130 PMCID: PMC10385537 DOI: 10.3390/medicina59071319] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 07/11/2023] [Accepted: 07/15/2023] [Indexed: 07/30/2023]
Abstract
Background and Objectives: This study aimed to elucidate the role of laser photocoagulation therapy in the treatment of diabetic macular edema (DME) as an alternative to, or in conjunction with, the first-line treatment, anti-vascular endothelial growth factor (VEGF). Materials and Methods: A comprehensive literature search to identify studies that evaluated the efficacy of laser photocoagulation therapy in the management of DME was performed. The relevant findings of the efficacy of focal/grid laser therapy from data in randomized, controlled trials were synthesized, and the potential of new laser technologies, such as navigated laser systems, pattern scan lasers, and subthreshold lasers, was explored. The usefulness of multimodal imaging-guided laser therapy was also evaluated, with a focus on the potential contribution to anti-VEGF therapy. Results: Focal laser photocoagulation targeting microaneurysms remains an effective therapeutic approach to chronic refractory edema, despite the widespread use of anti-VEGF therapy. To achieve the best possible treatment outcomes, precise identification of microaneurysms is essential. This requires the use of multimodal imaging-guided, highly accurate, minimally invasive coagulation techniques. Subthreshold laser therapy can also reduce the frequency of anti-VEGF injections and minimize treatment burden. Conclusions: Further studies are needed to determine the optimal timing and settings for laser photocoagulation therapy and the potential of new laser technologies in the management of DME. Nevertheless, laser photocoagulation therapy plays an important role in the management of DME, in conjunction with anti-VEGF therapy.
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Affiliation(s)
- Miho Nozaki
- Department of Ophthalmology, Laser Eye Center, Nagoya City University East Medical Center, Nagoya 464-8547, Japan
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Japan
| | - Ryota Ando
- Department of Ophthalmology, Laser Eye Center, Nagoya City University East Medical Center, Nagoya 464-8547, Japan
| | - Toshiya Kimura
- Department of Ophthalmology, Laser Eye Center, Nagoya City University East Medical Center, Nagoya 464-8547, Japan
| | - Fusae Kato
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Japan
- Department of Ophthalmology, Toyota Kosei Hospital, Toyota 470-0396, Japan
| | - Tsutomu Yasukawa
- Department of Ophthalmology and Visual Science, Nagoya City University Graduate School of Medical Sciences, Nagoya 467-8601, Japan
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11
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Tatsumi T. Current Treatments for Diabetic Macular Edema. Int J Mol Sci 2023; 24:ijms24119591. [PMID: 37298544 DOI: 10.3390/ijms24119591] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Abstract
Diabetic retinopathy is a major retinal disorder and a leading cause of blindness. Diabetic macular edema (DME) is an ocular complication in patients with diabetes, and it can impair vision significantly. DME is a disorder of the neurovascular system, and it causes obstructions of the retinal capillaries, damage of the blood vessels, and hyperpermeability due to the expression and action of vascular endothelial growth factor (VEGF). These changes result in hemorrhages and leakages of the serous components of blood that result in failures of the neurovascular units (NVUs). Persistent edema of the retina around the macula causes damage to the neural cells that constitute the NVUs resulting in diabetic neuropathy of the retina and a reduction in vision quality. The macular edema and NVU disorders can be monitored by optical coherence tomography (OCT). Neuronal cell death and axonal degeneration are irreversible, and their development can result in permanent visual loss. Treating the edema before these changes are detected in the OCT images is necessary for neuroprotection and maintenance of good vision. This review describes the effective treatments for the macular edema that are therefore neuroprotective.
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Affiliation(s)
- Tomoaki Tatsumi
- Department of Ophthalmology and Visual Science, Chiba University Graduate School of Medicine, Inohana 1-8-1, Chuo-ku, Chiba 260-8670, Japan
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12
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Zavorkova M, Nekolova J, Prochazkova L, Cermakova E, Jiraskova N. Diabetic macular edema treatment with subthreshold micropulse laser - five-year long monitoring. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2023; 167:74-79. [PMID: 36622063 DOI: 10.5507/bp.2022.055] [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: 09/29/2022] [Accepted: 12/19/2022] [Indexed: 01/10/2023] Open
Abstract
AIM The objective of this study was to evaluate the efficacy of diabetic macular edema (DME) therapy using subthreshold micropulse laser (SMPL) with a wavelength of 577 nm during a long-term monitoring period of 5 years. METHODS The cohort included the total number of 52 eyes of 34 patients with DME. All underwent the standard laser treatment for the diabetic retinopathy outside the macula and DME treatment with SMPL. Subsequent check-ups were followed every 3 months in the first year of treatment, and every 4 to 6 months in the following years. The treatment was combined neither with focal macular laser nor with anti-VEGF therapy. RESULTS The mean central retinal thickness (CRT) was 345.9 µm SD 122.6 µm at the beginning of the monitoring. At the end of the follow-up period five years after treatment it was 256.4 µm SD 98.4 µm. The mean CRT decreased by 89.5 µm SD 153.6 µm during 5 years. At the beginning of the monitoring, before treatment with SMPL, the best corrected visual acuity (BCVA) was 70.0, SD 10.1 ETDRS letters. One year after therapy, BCVA was 72, SD 10.0 letters, two years later it was 71.4, SD 10.4 letters and decreased to 66.9, SD 12.1 letters after 5 years. The mean BCVA decreased by merely 3.1, SD 10.9 letters during 5 years. CONCLUSION Based on our long-term observations, the DME treatment with SMPL appears to be an effective method for reducing DME and protecting BCVA against rapid worsening.
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Affiliation(s)
- Martina Zavorkova
- Department of Ophthalmology, Faculty of Health Studies, Jan Evangelista Purkyne University and Department of Ophthalmology, Masaryk Hospital, Usti nad Labem, Krajska zdravotni a.s., Usti nad Labem, Czech Republic.,Department of Ophthalmology, Faculty of Medicine in Hradec Kralove, Charles University and Department of Ophthalmology, University Hospital Hradec Kralove, Czech Republic
| | - Jana Nekolova
- Department of Ophthalmology, Faculty of Medicine in Hradec Kralove, Charles University and Department of Ophthalmology, University Hospital Hradec Kralove, Czech Republic
| | - Lidmila Prochazkova
- Department of Ophthalmology, Faculty of Health Studies, Jan Evangelista Purkyne University and Department of Ophthalmology, Masaryk Hospital, Usti nad Labem, Krajska zdravotni a.s., Usti nad Labem, Czech Republic
| | - Eva Cermakova
- Department of Medical Biophysics, Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Nada Jiraskova
- Department of Ophthalmology, Faculty of Medicine in Hradec Kralove, Charles University and Department of Ophthalmology, University Hospital Hradec Kralove, Czech Republic
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13
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Subthreshold Micropulse Laser for Diabetic Macular Edema: A Review. J Clin Med 2022; 12:jcm12010274. [PMID: 36615074 PMCID: PMC9821545 DOI: 10.3390/jcm12010274] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 12/18/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022] Open
Abstract
Diabetic macular edema (DME) is one of the main causes of visual impairment in patients of working age. DME occurs in 4% of patients at all stages of diabetic retinopathy. Using a subthreshold micropulse laser is an alternative or adjuvant treatment of DME. Micropulse technology demonstrates a high safety profile by selectively targeting the retinal pigment epithelium. There are no standardized protocols for micropulse treatment, however, a 577 nm laser application over the entire macula using a 200 μm retinal spot, 200 ms pulse duration, 400 mW power, and 5% duty cycle is a cost-effective, noninvasive, and safe therapy in mild and moderate macular edemas with retinal thickness below 400 μm. Micropulse lasers, as an addition to the current gold-standard treatment for DME, i.e., anti-vascular endothelial growth factor (anti-VEGF), stabilize the anatomic and functional retinal parameters 3 months after the procedure and reduce the number of required injections per year. This paper discusses the published literature on the safety and application of subthreshold micropulse lasers in DME and compares them with intravitreal anti-VEGF or steroid therapies and conventional grid laser photocoagulation. Only English peer-reviewed articles reporting research within the years 2010-2022 were included.
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14
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Toto L, D’Aloisio R, Quarta A, Libertini D, D’Onofrio G, De Nicola C, Romano A, Mastropasqua R. Intravitreal Dexamethasone Implant (IDI) Alone and Combined with Navigated 577 nm Subthreshold Micropulse Laser (SML) for Diabetic Macular Oedema. J Clin Med 2022; 11:jcm11175200. [PMID: 36079129 PMCID: PMC9457485 DOI: 10.3390/jcm11175200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 08/27/2022] [Accepted: 08/29/2022] [Indexed: 11/23/2022] Open
Abstract
Background: The anatomical and functional changes after intravitreal dexamethasone implant (IDI) alone and combined with navigated subthreshold micropulse laser (NSML) in diabetic macular oedema (DMO) were compared. Methods: Patients with a clinically confirmed diagnosis of non-proliferative diabetic retinopathy (NPDR) and DMO were enrolled in this prospective study and were randomly assigned to two different treatment groups: thirty patients were treated with IDI (IDI group), and the other 30 patients received IDI combined with NSML treatment (combined IDI/NSML group). All patients during a 6-month follow-up underwent best corrected visual acuity (BCVA) evaluation and spectral domain optical coherence tomography (SD OCT). The main outcome measures were: BCVA, central macular thickness (CMT); (3) choroidal vascularity index (CVI), subfoveal choroidal thickness (SCHT); and time to retreatment between IDI at baseline and the second implant in both groups. Results: BCVA, CMT, and SCHT significantly decreased starting from the 1-month follow-up and CVI from 3 months in both groups. The between-group differences were significantly different from 1-month follow-up for BCVA, from 5-month follow-up for CMT and SCHT, and from 4-month follow-up for CVI. The Needed to Treat analysis indicated that six patients would have to be treated with SML after IDI in order for just one person to receive a benefit. Conclusions: the combined treatment showed good anatomical and functional outcomes for the treatment of DMO. In addition, IDI/SML seems to reduce injection frequency over time, improving patients’ quality of life and reducing the socio-economic burden.
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15
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Tatsumi T, Takatsuna Y, Oshitari T, Kaiho T, Kawasaki Y, Shiko Y, Sugawara T, Baba T, Yamamoto S. Randomized clinical trial comparing intravitreal aflibercept combined with subthreshold laser to intravitreal aflibercept monotherapy for diabetic macular edema. Sci Rep 2022; 12:10672. [PMID: 35739147 PMCID: PMC9226173 DOI: 10.1038/s41598-022-14444-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 06/07/2022] [Indexed: 11/25/2022] Open
Abstract
To compare the efficacy and safety of intravitreal aflibercept with three loading doses + pro re nata regimen combined with subthreshold laser application to that of IVA monotherapy on eyes with diabetic macular edema. This was a phase 4 clinical trial with a prospective, randomized, and parallel investigator-driven protocol. Patients with DME were randomly assigned to the IVA monotherapy group (n = 25) or the IVA + SL combination therapy group (n = 26). The main outcome measures were the number of IVA injections and the changes in the best-corrected visual acuity (BCVA) and the central retinal thickness (CRT) at the final evaluation at 96 weeks. The mean number of IVA injections in the monotherapy group was 5.86 ± 2.43 and it was 6.05 ± 2.73 in the IVA + SL group at 96 weeks, and this difference was not significant (P = 0.83). The differences in the mean changes of the CRT (P = 0.17) and the BCVA (P = 0.31) were also not significant between the two groups throughout the follow-up period. We conclude that adjunct of SL to anti-VEGF therapy does not reduce the number of necessary intravitreal injections.
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Affiliation(s)
- Tomoaki Tatsumi
- Department of Ophthalmology and Visual Science, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan.
| | - Yoko Takatsuna
- Department of Ophthalmology and Visual Science, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan. .,Department of Ophthalmology, Chiba Rosai Hospital, 2-16, Tatsumidaihigashi, Ichihara, Chiba, 290-0003, Japan.
| | - Toshiyuki Oshitari
- Department of Ophthalmology and Visual Science, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan.,Department of Ophthalmology, International University of Health and Welfare School of Medicine, 4-3, Kozunomori, Narita, Chiba, 286-8686, Japan
| | - Tomomi Kaiho
- Department of Ophthalmology and Visual Science, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan
| | - Yohei Kawasaki
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan.,Faculty of Nursing, Japanese Red Cross College of Nursing, 4-1-3, Hiroo, Shibuya-ku, Tokyo, 150-0012, Japan
| | - Yuki Shiko
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Takeshi Sugawara
- Department of Ophthalmology and Visual Science, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan.,Chiba University Hospital Translational Research and Development Center, 1-8-1, Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan
| | - Takayuki Baba
- Department of Ophthalmology and Visual Science, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan
| | - Shuichi Yamamoto
- Department of Ophthalmology and Visual Science, Chiba University Graduate School of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba, Chiba, 260-8670, Japan
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16
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Dascalu AM, Rizzo M, Rizvi AA, Stoian AP, Iancu RC, Stana D, Tudosie MS, Serban D. Safety and outcomes of intravitreal aflibercept in diabetic macular edema - a systematic review. Curr Pharm Des 2022; 28:1758-1768. [PMID: 35469564 DOI: 10.2174/1381612828666220425101030] [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: 07/26/2021] [Accepted: 02/16/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Recent evidence on the role of vascular endothelial growth factor (VEGF) in the pathogenesis of ischemia and microvascular hyperpermeability leading to macular edema has brought anti-VEGF intravitreal therapy into the limelight. OBJECTIVE We performed a systematic literature review focusing on the outcomes and safety of the intravitreal use of aflibercept in diabetic macular edema. METHODS The studies documented cases with at least three consecutive intravitreal injections of aflibercept (IVA) repeated monthly with a follow-up period of at least one year. The outcomes were evaluated in terms of reported functional and anatomical improvement of the macula, as reflected by changes in visual acuity and macular thickness measured by Optical Coherence Tomography (OCT). In addition, for safety assessment, all reported local and general adverse effects were analyzed. RESULTS All studies showed an overall significant anatomical and functional improvement. In patients with the 5 IVA monthly at the beginning of the therapy, the visual gain at 52 weeks varied widely between 5 and 18.9 EDRS letters, with a mean value of 9.48 letters. The higher gain was obtained in treatment naïve patients, with worse VA and increased CST at baseline. The lower gain was obtained in patients previously treated with anti-VEGF. Anti-Platelet Trialists' Collaboration-defined arterial thromboembolic events were not statistically different between the aflibercept group and the laser group. CONCLUSIONS Intravitreal aflibercept therapy provides significant improvement in visual acuity and a good safety profile. Randomized studies are needed to document the optimal frequency of intravitreal injections for optimal treatment.
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Affiliation(s)
- Ana Maria Dascalu
- Faculty of Medicine, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Ophthalmology Department, Emergency University Hospital
| | - Manfredi Rizzo
- Department of Diabetes, Nutrition and Metabolic Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Division of Endocrinology, Diabetes and Metabolism, University of South Carolina School of Medicine Columbia, SC, USA.,Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Italy
| | - Ali A Rizvi
- Division of Endocrinology, Diabetes and Metabolism, University of South Carolina School of Medicine Columbia, SC, USA.,Department of Medicine, University of Central Florida College of Medicine, Orlando, FL, USA
| | - Anca Pantea Stoian
- Department of Diabetes, Nutrition and Metabolic Diseases, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Raluca Claudia Iancu
- Faculty of Medicine, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Ophthalmology Department, Emergency University Hospital
| | - Daniela Stana
- Ophthalmology Department, Emergency University Hospital
| | - Mihai Silviu Tudosie
- Faculty of Medicine, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Dragos Serban
- Faculty of Medicine, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
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17
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Santhakumaran S, Salimi A, Brunetti V, Galic J. Efficacy and safety of aflibercept therapy for diabetic macular edema: A systematic review and meta-analysis. J Curr Ophthalmol 2022; 34:133-147. [PMID: 36147265 PMCID: PMC9486998 DOI: 10.4103/joco.joco_308_21] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 04/24/2022] [Accepted: 04/28/2022] [Indexed: 11/05/2022] Open
Abstract
Purpose: To assess the real-world efficacy and safety of aflibercept for the treatment of diabetic macular edema (DME). Methods: A systematic search was conducted across multiple databases. Articles were included if participants had DME and received aflibercept treatment for a minimum of 52 ± 4 weeks. Primary outcomes included changes in best-corrected visual acuity (BCVA) and central macular thickness (CMT). A risk of bias assessment of studies was completed, pooled estimates were obtained, and a meta-regression was performed. Information on adverse events was collected. Results: The search yielded 2112 articles, of which 30 were included. Aflibercept was more effective than laser photocoagulation functionally (12-month BCVA-weighted mean difference [WMD] = 10.77 letters, P < 0.001; 24 months = 8.12 letters, P < 0.001) and anatomically (12-month CMT WMD = –114.12 μm, P < 0.001; 24 months = –90.4 μm, P = 0.004). Compared to bevacizumab, aflibercept was noninferior at improving BCVA at 12 months (WMD = 1.71 letters, P = 0.34) and 24 months (WMD = 1.58 letters, P = 0.083). One study found that aflibercept was more effective than bevacizumab anatomically at 1 and 2 years (P < 0.001 at 12 and 24 months). Compared to ranibizumab, aflibercept rendered a greater improvement in BCVA at 1 year (WMD = 1.76 letters, P = 0.001), but not 2 years (WMD = 1.66 letters, P = 0.072). CMT was not significantly different between both therapies at 12 months (WMD = −14.30 μm, P = 0.282) and 24 months (P = 0.08). One study reported greater functional improvement with aflibercept compared with dexamethasone (P = 0.004), but inferiority in reducing CMT (P < 0.001). Meta-regression analysis demonstrated that dosing schedule was found to impact outcomes at 12 and 24 months, while study design and sample size did not impact outcomes at 12 months. There were minimal safety concerns using aflibercept therapy. Conclusions: Aflibercept is a safe and effective therapy option for DME in the clinical setting, performing superiorly to laser photocoagulation. Evidence regarding comparisons with bevacizumab, ranibizumab, and dexamethasone is mixed and limited.
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18
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El Matri L, Chebil A, El Matri K, Falfoul Y, Chebbi Z. Subthreshold micropulse laser adjuvant to bevacizumab versus bevacizumab monotherapy in treating diabetic macular edema: one- year- follow-up. Ther Adv Ophthalmol 2021; 13:25158414211040887. [PMID: 34497974 PMCID: PMC8419546 DOI: 10.1177/25158414211040887] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 08/03/2021] [Indexed: 11/15/2022] Open
Abstract
Purpose To compare the therapeutic impact of combining intravitreal injections of bevacizumab (IVB) with micropulse laser (MPL) in central diffuse diabetic macular edema (DME) versus IVB monotherapy during 12 months follow-up. Methods We conducted a retrospective comparative study of 98 treatment-naive eyes (63 patients) with central diffuse DME. The first group of patients (IVB + MPL group, n = 49) was treated with 3 monthly IVB followed by MPL within 1 week after the third injection. Patients were then followed and treated on a pro re nata (PRN) basis, with MPL retreatment if necessary. The changes in best-corrected visual acuity (BCVA), central macular thickness (CMT), number of IVB injections and MPL sessions were evaluated at 4, 8, and 12 months. A control group of diabetic patients with treatment-naive DME was treated with standard protocol of 3 monthly IVB as monotherapy then followed on a PRN basis (IVB group, n = 49). Statistic comparaison of BCVA, CMT, and IVB number variation was interpreted at 12 months between both groups. Results In IVB + MPL group, baseline BCVA improvement was not significant at 4 and 8 months (p = 0.90, p = 0.08), and was statistically significant (p = 0.01) at 12 months. Mean CMT significantly decreased at 4, 8, and 12 months (p < 0.01) in IVB + MPL group. The difference in BCVA (p = 0.091) and CMT (p = 0.082) variation at 12 months between both groups was not significant but the number of injections was significantly lower in IVB + MPL group (4.1 ± 1.5 injections) compared to IVB group (7.2 ± 1.3 injections) (p < 0.005). Conclusion Combining intravitreal injections of bevacizumab and MPL in the treatment of DME is effective and safe. This protocol may decrease the number of IVB and its frequency. It offers the advantage of lasting therapeutic response with fewer recurrences.
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Affiliation(s)
- Leila El Matri
- Department B, Institut Hedi Rais d'ophtalmologie de Tunis, Tunis, Tunisia
| | - Ahmed Chebil
- Department B, Institut Hedi Rais d'ophtalmologie de Tunis, Tunis, Tunisia
| | - Khaled El Matri
- Department B, Institut Hedi Rais d'ophtalmologie de Tunis, Boulevard 9 avril 1938, 1006 Tunis, Tunisia
| | - Yousra Falfoul
- Department B, Institut Hedi Rais d'ophtalmologie de Tunis, Tunis, Tunisia
| | - Zouheir Chebbi
- Department B, Institut Hedi Rais d'ophtalmologie de Tunis, Tunis, Tunisia
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19
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Subthreshold Micropulse Laser Modulates Retinal Neuroinflammatory Biomarkers in Diabetic Macular Edema. J Clin Med 2021; 10:jcm10143134. [PMID: 34300297 PMCID: PMC8304624 DOI: 10.3390/jcm10143134] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/05/2021] [Accepted: 07/14/2021] [Indexed: 01/03/2023] Open
Abstract
Subthreshold micropulse laser treatment has become a recognized option in the therapeutic approach to diabetic macular edema. However, some yet undefined elements pertaining to its mechanism of action and most effective treatment method still limit its clinical diffusion. We reviewed the current literature on subthreshold micropulse laser treatment, particularly focusing on its effects on the modulation of retinal neuroinflammation. Subthreshold micropulse laser treatment seems to determine a long-term normalization of specific retinal neuroinflammatory metabolic pathways, contributing to the restoration of retinal homeostasis and the curtailing of local inflammatory processes. Optimized and standardized parameters ensure effective and safe treatment.
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20
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Lai FHP, Chan RPS, Lai ACH, Tsang S, Woo TTY, Lam RF, Yuen CYF. Comparison of two-year treatment outcomes between subthreshold micropulse (577 nm) laser and aflibercept for diabetic macular edema. Jpn J Ophthalmol 2021; 65:680-688. [PMID: 34125326 DOI: 10.1007/s10384-021-00846-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 05/06/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE To compare two-year treatment outcomes of subthreshold micropulse (577 nm) laser and aflibercept for diabetic macular edema (DME). STUDY DESIGN Retrospective case-control study. METHODS A total 164 eyes in 164 DME patients treated with either micropulse laser (86 eyes) or intravitreal aflibercept monotherapy (78 eyes) were recruited. Main outcome measures included at least five Early Treatment Diabetic Retinopathy Study (ETDRS) letters' improvement from baseline at 6, 12 and 24 months. RESULTS Rescue aflibercept was initiated in 24% of eyes in micropulse laser group. At 6-month visit the aflibercept group achieved a higher percentage of eyes with at least 5-letter visual acuity improvement than micropulse laser group (56% vs 38%, P = 0.044), however, this was not the case at 12-month (45% vs 49%, P = 0.584) and 24-month visits (49% vs 57%, P = 0.227). At 6-month visit the aflibercept group achieved a higher percentage of eyes with at least 10% improvement of central macular thickness (73% vs 49%, P = 0.005), but this was not the case at 12-month (73% vs 70%, P = 0.995) and 24-month visits (85% vs 84%, P = 0.872). CONCLUSION Aflibercept achieved faster and higher rates of anatomical and functional improvement than micropulse laser in DME patients. Long term efficacy of treatment did not result in significant differences between aflibercept monotherapy and micropulse laser in DME patients. Primary treatment of micropulse laser with deferred rescue aflibercept might be the treatment option without reducing the chance of visual improvement in DME eyes.
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Affiliation(s)
- Frank Hiu Ping Lai
- Department of Ophthalmology, Caritas Medical Centre, 111 Wing Hong Street, Sham Shui Po, Hong Kong.
| | - Rose P S Chan
- Department of Ophthalmology, Caritas Medical Centre, 111 Wing Hong Street, Sham Shui Po, Hong Kong
| | - Anthony C H Lai
- Department of Ophthalmology, Caritas Medical Centre, 111 Wing Hong Street, Sham Shui Po, Hong Kong
| | - Susanna Tsang
- Department of Ophthalmology, Caritas Medical Centre, 111 Wing Hong Street, Sham Shui Po, Hong Kong
| | - Tiffany T Y Woo
- Department of Ophthalmology, Caritas Medical Centre, 111 Wing Hong Street, Sham Shui Po, Hong Kong
| | - Robert F Lam
- Department of Ophthalmology, Caritas Medical Centre, 111 Wing Hong Street, Sham Shui Po, Hong Kong
| | - Can Y F Yuen
- Department of Ophthalmology, Caritas Medical Centre, 111 Wing Hong Street, Sham Shui Po, Hong Kong
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21
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Wallsh JO, Gallemore RP. Anti-VEGF-Resistant Retinal Diseases: A Review of the Latest Treatment Options. Cells 2021; 10:cells10051049. [PMID: 33946803 PMCID: PMC8145407 DOI: 10.3390/cells10051049] [Citation(s) in RCA: 64] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 02/07/2023] Open
Abstract
Anti-vascular endothelial growth factor (anti-VEGF) therapy currently plays a central role in the treatment of numerous retinal diseases, most notably exudative age-related macular degeneration (eAMD), diabetic retinopathy and retinal vein occlusions. While offering significant functional and anatomic benefits in most patients, there exists a subset of 15–40% of eyes that fail to respond or only partially respond. For these cases, various treatment options have been explored with a range of outcomes. These options include steroid injections, laser treatment (both thermal therapy for retinal vascular diseases and photodynamic therapy for eAMD), abbreviated anti-VEGF treatment intervals, switching anti-VEGF agents and topical medications. In this article, we review the effectiveness of these treatment options along with a discussion of the current research into future directions for anti-VEGF-resistant eyes.
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Affiliation(s)
- Josh O. Wallsh
- Department of Ophthalmology, Albany Medical College, Albany, NY 12208, USA;
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22
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Veritti D, Sarao V, Soppelsa V, Lanzetta P. Managing Diabetic Macular Edema in Clinical Practice: Systematic Review and Meta-Analysis of Current Strategies and Treatment Options. Clin Ophthalmol 2021; 15:375-385. [PMID: 33551641 PMCID: PMC7856351 DOI: 10.2147/opth.s236423] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 01/22/2021] [Indexed: 12/15/2022] Open
Abstract
Purpose This meta-analysis aims to summarize 12-month best-corrected visual acuity (BCVA) outcomes in response to anti-vascular endothelial growth factor (VEGF) therapy and dexamethasone implant for the treatment of diabetic macular edema (DME) and to identify factors affecting treatment response using evidence generated from meta-regression. Methods A systematic review of electronic databases was conducted to identify randomized controlled trials (RCTs) and real-life/observational studies that reported 12-month changes in BCVA in patients with DME on anti-VEGF or dexamethasone implant treatment in monotherapy. Study factors that were analyzed are baseline patient characteristics, study type, drug employed, number of injections and 12-month change in BCVA. Data were pooled in a random-effects meta-analysis with BCVA change as the main outcome. Meta-regression was conducted to assess the impact of multiple covariates. Results One-hundred-five heterogeneous study populations (45,032 eyes) were identified and included in the analysis. The use of anti-VEGFs and dexamethasone implant induced an overall increase of +8.13 ETDRS letters in BCVA at 12 months of follow-up. Meta-regression provided evidence that mean BCVA change using anti-VEGFs was not statistically higher for RCTs (p=0.35) compared to observational studies. Dexamethasone implant showed a trend for better results in observational studies over RCTs. Populations following a fixed aflibercept regimen performed better than those following a reactive treatment regimen. Mean BCVA gain was higher in younger populations (p<0.001), with lower baseline BCVA (p<0.0001) and longer diabetes duration (p<0.0001), receiving a higher number of injections (p<0.0001). Conclusion Intravitreal therapy with anti-VEGFs or dexamethasone implant produces a significant improvement in BCVA at 12 months in patients with DME. Meta-regression identified the modifiable covariates that can be targeted in order to maximize functional results.
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Affiliation(s)
- Daniele Veritti
- Department of Medicine - Ophthalmology, University of Udine, Udine, Italy
| | - Valentina Sarao
- Department of Medicine - Ophthalmology, University of Udine, Udine, Italy.,Istituto Europeo di Microchirurgia Oculare (IEMO), Udine, Italy
| | - Valentina Soppelsa
- Department of Medicine - Ophthalmology, University of Udine, Udine, Italy
| | - Paolo Lanzetta
- Department of Medicine - Ophthalmology, University of Udine, Udine, Italy.,Istituto Europeo di Microchirurgia Oculare (IEMO), Udine, Italy
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Li AS, Veerappan M, Mittal V, Do DV. Anti-VEGF agents in the management of diabetic macular edema. EXPERT REVIEW OF OPHTHALMOLOGY 2020. [DOI: 10.1080/17469899.2020.1806713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Angela S. Li
- Stanford University School of Medicine, Stanford University, Palo Alto, CA, USA
- Department of Ophthalmology, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Malini Veerappan
- Stanford University School of Medicine, Stanford University, Palo Alto, CA, USA
- Department of Ophthalmology, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Vaishali Mittal
- Stanford University School of Medicine, Stanford University, Palo Alto, CA, USA
- Department of Ophthalmology, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Diana V. Do
- Stanford University School of Medicine, Stanford University, Palo Alto, CA, USA
- Department of Ophthalmology, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
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Zas M, Cotic M, Wu M, Wu A, Wu L. Macular laser photocoagulation in the management of diabetic macular edema: Still relevant in 2020? Taiwan J Ophthalmol 2020; 10:87-94. [PMID: 32874835 PMCID: PMC7442095 DOI: 10.4103/tjo.tjo_16_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 03/30/2020] [Indexed: 11/13/2022] Open
Abstract
Macular laser photocoagulation (MLP) is inferior to intravitreal vascular endothelial growth factor (VEGF) inhibitors in the treatment of center-involved diabetic macular edema (DME). Ultra-widefield fluorescein angiography-guided laser photocoagulation to presumed ischemic areas of the peripheral retina or MLP do not reduce the treatment burden nor improve the visual outcomes of eyes treated with anti-VEGF drugs. Destruction of retinal tissue is not necessary to induce a therapeutic response in DME. Modern lasers are capable of producing invisible laser "burns" that do not destroy the targeted tissue using micropulse subthreshold (ST) mode where the laser's duty cycle is modified or alternatively selective retinal therapy (SRT) where ultrashort pulses of continuous wave laser selectively target the RPE. The best results with micropulse ST laser are obtained in eyes with a central macular thickness ≤400 μm. Eyes need to be treated in a continuous manner with no spaces between burns in the edematous area. Micropulse ST-MLP downregulates inflammatory biomarkers produced by activated microglial cells and Müller cells. Micropulse ST-MLP may reduce the anti-VEGF injection burden in DME. In SRT, the diseased RPE is targeted and heated with the laser with the hope that the adjacent RPE migrates and proliferates into these areas to heal the diseased RPE. There is much less experience with SRT, but the results are promising and deserve further study.
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Affiliation(s)
- Marcelo Zas
- Department of Ophthalmology, Jose de San Martin Clinics Hospital, Universidad de Buenos Aires, Buenos Aires, Argentina, USA
| | - Mariano Cotic
- Department of Ophthalmology, Jose de San Martin Clinics Hospital, Universidad de Buenos Aires, Buenos Aires, Argentina, USA
| | - Max Wu
- Department of Ophthalmology, Jose de San Martin Clinics Hospital, College of Engineering, Cornell University, Ithaca, NY, USA
- Macula, Vitreous and Retina Associates of Costa Rica, San José, Costa Rica, USA
| | - Andres Wu
- Macula, Vitreous and Retina Associates of Costa Rica, San José, Costa Rica, USA
| | - Lihteh Wu
- Macula, Vitreous and Retina Associates of Costa Rica, San José, Costa Rica, USA
- Macula, Vitreous and Retina Associates of Costa Rica, Illinois Eye and Ear Infirmary, University of Illinois, Chicago, IL, USA
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