Vitrectomy outcomes in eyes with diabetic macular edema and vitreomacular traction

Fluocinolone Acetonide Implant for Uveitis: Dissecting Responder and Non-Responder Outcomes at a Tertiary Center

Macular edema (ME) remains a primary cause of visual deterioration in uveitis. Visual acuity (VA) can often be maintained using corticosteroid depot systems. This study evaluated the efficacy of a fluocinolone acetonide (FAc) intravitreal implant (ILUVIEN®) in treating non-infectious uveitis using real-world data. This retrospective analysis included 135 eyes subdivided into responders and non-responders. Central retinal thickness (CRT), VA, and intraocular pressure (IOP) were followed over time. A significant decrease in CRT and an increase in VA were observed in all eyes throughout the follow-up period (p < 0.01). An IOP increase (p = 0.028) necessitated treatment in 43% of eyes by Month 6. Non-responders were older (p = 0.004) and had been treated with more dexamethasone (DEX) implants (p = 0.04); 89.3% had a defect in the external limiting membrane (ELM) and inner/outer segment (IS/OS) zone (p < 0.001). Immunomodulatory therapy had no impact on treatment response. Pars plana vitrectomy (PPV) patients had a mean CRT reduction of 47.55 µm and a reduced effect by Month 24 (p = 0.046) versus non-PPV patients. We conclude that the FAc implant achieves long-term control of CRT and improves VA. Increases in IOP were manageable. Eyes with a previous PPV showed milder results. Data showed a correlation between older age, a damaged ELM and IS/OS zone, frequent DEX inserts, and poorer outcome measures.

Sodium-glucose co-transporter 2 inhibitor therapy reduces the administration frequency of anti-vascular endothelial growth factor agents in patients with diabetic macular oedema with a history of anti-vascular endothelial growth factor agent use: A cohort study using the Japanese health insurance claims database

AIM

We assessed the effectiveness of sodium-glucose co-transporter 2 inhibitors (SGLT2is) in reducing the administration frequency of anti-vascular endothelial growth factor (VEGF) agents in patients with diabetic macular oedema (DMO) using a health insurance claims database.

MATERIALS AND METHODS

This retrospective cohort study analysed health insurance claims data covering 11 million Japanese patients between 2005 and 2019. We analysed the frequency and duration of intravitreal injection of anti-VEGF agents after initiating SGLT2is or other antidiabetic drugs.

RESULTS

Among 2412 matched patients with DMO, the incidence rates of anti-VEGF agent injections were 230.1 per 1000 person-year in SGLT2i users and 228.4 times per 1000 person-year in non-users, respectively, and the risk ratio for events was unchanged in both groups. Sub-analysis of each baseline characteristic of the patients showed that SGLT2is were particularly effective in patients with a history of anti-VEGF agent use [p = .027, hazard ratio (HR): 0.44, 95% confidence interval (CI): 0.22-0.91]. SGLT2is reduced the risk for the first (p = .023, HR: 0.45, 95% CI: 0.22-0.91) and second (p = .021, HR: 0.39, 95% CI: 0.17-0.89) anti-VEGF agent injections.

CONCLUSIONS

There was no difference in the risk ratio for the addition of anti-VEGF therapy between the two treatment groups. However, the use of SGLT2is reduced the frequency of anti-VEGF agent administration in patients with DMO requiring anti-VEGF therapy. Therefore, SGLT2i therapy may be a novel, non-invasive, low-cost adjunctive therapy for DMO requiring anti-VEGF therapy.

Optical coherence tomography in the management of diabetic macular oedema

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.

Central Serous Chorioretinopathy. A Review

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.

From randomised controlled trials to real-world data: Clinical evidence to guide management of diabetic macular oedema

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.

Microinvasive pars plana vitrectomy combined with internal limiting membrane peeling versus anti-VEGF intravitreal injection for treatment-naïve diabetic macular edema (VVV-DME study): study protocol for a randomized controlled trial

BACKGROUND

Diabetic macular edema (DME) is the main cause of vision loss in diabetic patients. Currently, anti-vascular endothelial growth factor (VEGF) intravitreal injection stands as the first-line therapy for DME. However, some patients exhibit insufficient response to anti-VEGF agents and often require multiple injections, imposing psychological and economic burdens. While microinvasive pars plana vitrectomy (PPV) has been shown to be safe and effective in treating refractory DME, scant research has explored its application to treatment-naïve DME. The purpose of this study is to determine whether early PPV combined with internal limiting membrane (ILM) peeling can lessen the therapeutic burden of DME patients, prevent vision loss, and maintain long-term stabilization of diabetic retinopathy.

METHODS

This is a single-center, prospective, parallel-group, non-inferiority randomized controlled trial involving 102 DME participants. Participants will be randomly assigned to either the study group (PPV combined with ILM peeling) or the control group (conbercept intravitreal injection (IVC)) at a 1:1 ratio, with a scheduled follow-up at 12 months post-operation. Comparative analysis of results between the two groups will be conducted at months 1, 3, 6, and 12 after the intervention. The primary outcomes involve evaluating the changes in central subfield thickness (CST) and best corrected visual acuity (BCVA). The secondary outcomes include assessment of optical coherence tomography (OCT) and OCT angiography (OCTA) biomarkers, re-treatment and adverse events rates, diabetic retinopathy (DR) development, cost-effectiveness analysis, and vision-related quality of life (VRQL).

DISCUSSION

Some patients do not respond well to anti-VEGF drugs and repeated intravitreal injections increase the treatment burden for patients. The VVV study aims to explore whether PPV combined with ILM peeling could become an initial treatment option for treatment-naïve DME patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05728476. Registered on 15 February 2023.

Aflibercept for long-term treatment of diabetic macular edema and proliferative diabetic retinopathy: a meta-analysis

Purpose

This meta-analysis compared the long-term (12 months or 24 months) efficacy and safety of intravitreal aflibercept injection (IAI) for diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR).

Methods

We selected 16 randomized controlled trials (RCTs) performed after 2015 that had a minimum of 12 months and up to 24 months of treatment and conducted a meta-analysis with Review Manager version 5.3. Visual acuity (VA), central subfield thickness (CST) and adverse events were the outcomes selected for evaluation from the eligible studies.

Results

Based on 16 RCTs, we evaluated a total of 7125 patients. For PDR and severe DME with poor baseline vision, after a minimum of 12 months and up to 24 months of treatment, the aflibercept treatment group obtained better VA improvement than the focal/grid laser photocoagulation treatment group (MD=13.30; 95%CI: 13.01~13.58; P<0.001) or other treatments (ranibizumab, focal/grid laser photocoagulation, PRP, et al.) group (MD=1.10; 95%CI: 1.05~1.16; P<0.001). In addition, the aflibercept treatment group got higher CST reduction than the focal/grid laser photocoagulation treatment (MD=-33.76; 95%CI: -45.53 ~ -21.99; P<0.001) or other treatments (ranibizumab, focal/grid laser photocoagulation, et al.) group (MD=-33.76; 95%CI: -45.53 ~ -21.99; P<0.001). There was no significant difference in the overall incidence of ocular and non-ocular adverse events in each treatment group.

Conclusions

This meta-analysis showed that the advantages of IAI are obvious in the management of DME and PDR with poor baseline vision for long-term observation (a minimum of 12 months and up to 24 months) with both VA improvement and CST reduction. Applied IAI separately trended to be more effective than panretinal photocoagulation separately in VA improvement for PDR. More parameters should be required to assess functional and anatomic outcomes.

Pathological Neurovascular Unit Mapping onto Multimodal Imaging in Diabetic Macular Edema

Diabetic retinopathy is a form of diabetic microangiopathy, and vascular hyperpermeability in the macula leads to retinal thickening and concomitant reduction of visual acuity in diabetic macular edema (DME). In this review, we discuss multimodal fundus imaging, comparing the pathogenesis and interventions. Clinicians diagnose DME using two major criteria, clinically significant macular edema by fundus examination and center-involving diabetic macular edema using optical coherence tomography (OCT), to determine the appropriate treatment. In addition to fundus photography, fluorescein angiography (FA) is a classical modality to evaluate morphological and functional changes in retinal capillaries, e.g., microaneurysms, capillary nonperfusion, and fluorescein leakage. Recently, optical coherence tomography angiography (OCTA) has allowed us to evaluate the three-dimensional structure of the retinal vasculature and newly demonstrated that lamellar capillary nonperfusion in the deep layer is associated with retinal edema. The clinical application of OCT has accelerated our understanding of various neuronal damages in DME. Retinal thickness measured by OCT enables us to quantitatively assess therapeutic effects. Sectional OCT images depict the deformation of neural tissues, e.g., cystoid macular edema, serous retinal detachment, and sponge-like retinal swelling. The disorganization of retinal inner layers (DRIL) and foveal photoreceptor damage, biomarkers of neurodegeneration, are associated with visual impairment. Fundus autofluorescence derives from the retinal pigment epithelium (RPE) and its qualitative and quantitative changes suggest that the RPE damage contributes to the neuronal changes in DME. These clinical findings on multimodal imaging help to elucidate the pathology in the neurovascular units and lead to the next generation of clinical and translational research in DME.

Evaluating the effect of vitreomacular interface abnormalities on anti-vascular endothelial growth factor treatment outcomes in diabetic macular edema by optical coherence tomography: a systematic review and meta-analysis

PURPOSE

To evaluate the effect of vitreomacular interface (VMI) configuration on treatment outcomes after intravitreal anti-vascular endothelial growth factor (anti-VEGF) therapy for diabetic macular edema (DME) using optical coherence tomography (OCT).

METHODS

A systematic literature search was performed on PubMed, Embase, web of science and clinicaltrials.gov. The primary outcome parameters were central macular thickness (CMT), best-corrected visual acuity (BCVA) and mean injection numbers. We performed this meta-analysis by Review Manager (RevMan) 5.4.1.

RESULTS

The impact of epiretinal membrane (ERM), vitreomacular traction (VMT) and vitreomacular adhesion (VMA) on the treatment outcomes were analyzed separately. 9 clinical studies involving 699 eyes were eligible for the meta-analysis for evaluating the effect of ERM/VMT on efficacy. And 7 studies with 610 eyes were included to access whether VMA affected the response to anti-VEGF therapy in patients with DME. The ERM/VMT group had poorer CMT reductions than the control group at 1 month ([MD] 52.91mm, P<0.00001), while no significant difference at 3 months ([MD] 43.95 mm, P=0.22) and over 12 months ([MD] 30.51 mm, P=0.45). No statistically significant difference in the mean BCVA change at 1 month ([MD] -0.03 Log MAR, P=0.79), whereas ERM/VMT group had poor visual acuity gains at 3 months ([MD] 0.08 Log MAR, P=0.003), and a tendency of poor vision improvement over 12 months follow-up ([MD] 0.07 Log MAR, P=0.11). There was no significant difference in the visual and anatomical results over 3 months in DME patients with or without VMA ([MD] -21.92 mm, P = 0.09; [MD] 1.79 letters, P=0.22). Besides, VMI configuration was not found to affect mean injection numbers.

CONCLUSION

The limited evidence suggested that ERM/VMT was associated with worse CMT reduction at 1 month, poor BCVA gain at 3 months and a tendency of limited vision improvement over 12 months follow-up in DME patients treated with anti-VEGF agents. And VMA may not adversely affect the anatomic and functional outcomes. However, the results of this meta-analysis should be interpreted with caution because of the heterogeneity among study designs.

Mid-term safety and effectiveness of macular peeling one month after intravitreal dexamethasone implant for tractional diabetic macular edema

Macular peeling combined or followed by intravitreal dexamethasone implant (DEX-i) was recommended as an efficacy approach for tractional diabetic macular edema (tDME). Knowing the synergistic effect of cataract surgery and DEX-i one month earlier in eyes with DME, we compared Epiretinal Membrane/Inner Limiting Membrane (ERM/ILM) peeling preceded by DEX-i one month before versus ERM/ILM peeling alone for the treatment of tDME. A retrospective study on patients affected by tDME who underwent ERM/ILM peeling one month after DEX-i (n = 11; Group A) or ERM/ILM peeling alone (n = 10; Group B) was performed. Longitudinal comparison of best-correct visual acuity (BCVA), central retinal thickness (CRT), and intraocular pressure (IOP) between the time of surgery (T₀) and each time point (months 1,3,5,6) within and among the groups were assessed. To evaluate the repeated measurements of BCVA, CRT, and IOP, a linear mixed-effects model was used. In Group A, DEX-i significantly improved mean BCVA and CRT (P < 0.001) just after 1 month (T₀). After ERM/ILM peeling, mean BCVA and CRT significantly improved from month 1 in Group A and month 3 in Group B. Mixed model revealed a significant difference in BCVA (P ≤ 0.0001) and CRT (P ≤ 0.02) at different time-points among the groups with better results in Group A. Neither complications nor uncontrolled IOP increase was detected. ERM/ILM peeling confirmed its effectiveness in treating tDME. DEX-i performed one month before surgery seemed to be a safe approach and ensured a greater and faster recovery considering functional and tomographic parameters.

Real-World Outcomes of Anti-VEGF Therapy in Diabetic Macular Oedema: Barriers to Treatment Success and Implications for Low/Lower-Middle-Income Countries

Diabetic macular oedema (DMO) is the leading cause of vision loss associated with diabetic eye disease. The exponential increase in the diabetic population and thus, of DMO is an impetus for optimizing the management of DMO. One major challenge in DMO management is the discrepancy between treatment outcomes seen in clinical trials and the real world. Contrary to the homogeneity, better patient motivation and shorter study durations seen in randomised control trials, routine clinical practice is fraught with more diverse populations, undertreatment and variable compliance with long-term therapy. Under both circumstances, this review aims to compare efficacy outcomes and adverse events of DMO therapies within the scope of anti-vascular endothelial growth factor (anti-VEGF) medications, specifically the commonly used ones-bevacizumab, ranibizumab and aflibercept. Impediments and methods to achieve better treatment outcomes in the real world will be addressed to achieve better outcomes. Low- to lower-middle-income countries are faced with even more barriers which range from paucity of data on epidemiology and treatment response to scarce human and financial resources to poorer national level attention and then basic issues like transportation. Additionally, to address the lack of a global consensus in DMO treatment, this review generates and recommends, for clinical and research purposes, an up-to-date consensus algorithm for DMO management universally. Underpinned by results from clinical trials and recent guidelines, this therapeutic flowchart can be utilised in various resource settings including low- and lower-middle-income countries where affordability is a major deterrent to treatment access.

Role of Vitrectomy in Nontractional Refractory Diabetic Macular Edema

Background: Currently, the gold standard of diabetic macular edema (DME) treatment is anti-vascular endothelial growth factor (VEGF) injections, although a percentage of patients do not respond optimally. Vitrectomy with or without internal limiting membrane (ILM) peeling is a well-established treatment for DME cases with a tractional component while its role for nontractional cases is unclear.The aim of this study is to evaluate the role of vitrectomy with or without ILM peeling in nontractional refractory DME.Methods: We performed a retrospective review of twenty-eight eyes with nontractional refractory DME treated with vitrectomy at San Giuseppe Hospital, Milan, between 2016 and 2018. All surgeries were performed by a single experienced vitreoretinal surgeon. In 43.4% of cases, the ILM was peeled. Best corrected visual acuity and optical coherence tomography (OCT) scans were assessed preoperatively and at 6, 12, and 24 months post-vitrectomy. Results: The mean central macular thickness improved from 413.1 ± 84.4 to 291.3 ± 57.6 μm at two years (p < 0.0001). The mean logarithm of the minimum angle of resolution logMAR best-corrected visual acuity (BCVA) improved after two years, from 0.6 ± 0.2 to 0.2 ± 0.1 (p < 0.0001). We found no difference between ILM peeling vs. no ILM peeling group in terms of anatomical (p = 0.8) and visual outcome (p = 0.3). Eyes with DME and subfoveal serous retinal detachment (SRD) at baseline had better visual outcomes at the final visit (p = 0.001). Conclusions:We demonstrated anatomical and visual improvement of patients who underwent vitrectomy for nontractional refractory DME with and without ILM peeling. Improvement was greater in patients presenting subretinal fluid preoperatively.

Diabetic Retinopathy – Diagnostics and Treatment Guidelines

Diabetic retinopathy is one of the most common complications of diabetes mellitus and represents a serious health, social and economic problem. With the expected increase in the number of patients with diabetes, it is becoming the leading cause of severe vision loss in the working-age population.  The presented guidelines summarize the current knowledge about this disease in order to standardize and update the procedures for the diagnosis, classification and treatment of diabetic retinopathy.

Vitrectomy with ILM peeling in diabetic macular edema in one eye vs. intravitreal anti-VEGF injections in the second eye: a comparative study

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.

Evaluating the preventive effect of metoclopramide and aminophylline on pain after deep vitrectomy

BACKGROUND

Deep vitrectomy is one of the most frequently performed ophthalmic procedures. Postoperative pain is a common complaint among patients. Consequently, we investigated whether metoclopramide and aminophylline could decrease pain intensity following deep vitrectomy.

METHODS

This double-blinded clinical trial study that was approved by the Ethical Committee of Isfahan University of Medical Sciences (IR.MUI.REC.1396.3.217) (Thesis Reg. number: 396217) and registered at the Iranian Registry of Clinical Trials (IRCT) (Reg. number: IRCT20170716035104N5, available at https://www.irct.ir/trial/59146) aimed to evaluate 105 patients who were candidates for deep vitrectomy. They were randomly assigned into three groups: metoclopramide (received 0.1 mg/kg diluted in 10 ml of normal saline), aminophylline (received 4 mg/kg diluted in 10 ml of normal saline), and placebo (received 10 ml of normal saline). Postoperative pain was evaluated in all groups.

RESULTS

The postoperative pain levels of the three groups differed significantly from the start of the recovery to 30 minutes, 60 minutes, 2 hours, and 4 hours postoperatively, with metoclopramide and aminophylline groups experiencing less postoperative pain than the placebo group. Moreover, there was a significant difference between the groups regarding patient satisfaction (P<0.05).

CONCLUSION

Both metoclopramide and aminophylline significantly reduce postoperative pain after deep vitrectomy, although metoclopramide has a greater effect.

Pars plana vitrectomy for tractional diabetic macular edema with or without internal limiting membrane peeling

Background

The effectiveness of internal limiting membrane (ILM) peeling in the surgical treatment of tractional diabetic macular edema (DME), although widely examined, remains controversial. This study aimed to assess the efficacy of pars plana vitrectomy (PPV) in the management of tractional DME and to highlight any benefits of additional ILM peeling.

Methods

This was an open-label, prospective, comparative, and interventional study that enrolled 50 eyes with tractional DME that underwent PPV and allocated each to one of two groups: group A consisted of 25 eyes that had no ILM peeling and group B consisted of 25 eyes that underwent ILM peeling. Postoperative assessments of best-corrected distance visual acuity (BCDVA) in the logarithm of minimal angle of resolution (logMAR) notation and central macular thickness (CMT) were performed at 1, 3, and 6 months postoperatively.

Results

At baseline, the two groups were comparable in terms of sex ratios, phakic status, insulin use, coexistence of hypertension, and mean (standard deviation [SD]) age, BCDVA, CMT, duration of diabetes mellitus, and glycosylated hemoglobin (HbA1c) levels. In group A, the mean (SD) BCDVA improved significantly from 0.89 (0.12) logMAR preoperatively to 0.64 (0.24) logMAR (P < 0.001), and the mean (SD) CMT declined significantly from 471.28 (80.83) µm to 228.20 (26.45) µm (P < 0.001), at the 6-month postoperative assessment. Likewise, in group B, the mean (SD) BCDVA improved significantly from 0.83 (0.10) logMAR preoperatively to 0.58 (0.24) logMAR (P < 0.001), and the mean (SD) CMT decreased significantly from 496.84 (89.82) µm to 226.20 (18.04) µm (P < 0.001), after 6 months. There were no significant differences between groups A and B in the changes in BCDVA (Delta BCDVA) or CMT (Delta CMT) at 1, 3, and 6 months postoperatively with respect to the baseline values (all P > 0.05). Postoperative complications were comparable between the two groups. A significant negative correlation was detected between the preoperative HbA1c level and BCDVA improvement in all participants (r = - 0.82; P < 0.001).

Conclusions

PPV is an effective treatment for tractional DME. Additional ILM peeling was not significantly associated with functional and anatomical benefits over a short period. Long-term glycemic control plays a role in vision gain after vitrectomy in patients with diabetes. Further long-term studies are required to verify our findings.

Ophthalmic imaging in diabetic retinopathy: A review

Retinal imaging has been a key tool in the diagnosis, evaluation, management and documentation of diabetic retinopathy (DR) and diabetic macular oedema (DMO) for many decades. Imaging technologies have rapidly evolved over the last few decades, yielding images with higher resolution and contrast with less time, effort and invasiveness. While many retinal imaging technologies provide detailed insight into retinal structure such as colour reflectance photography and optical coherence tomography (OCT), others such as fluorescein or OCT angiography and oximetry provide dynamic and functional information. Many other novel imaging technologies are in development and are poised to further enhance our evaluation of patients with DR.

The Role of Intravitreal Corticosteroids in the Treatment of DME: Predictive OCT Biomarkers

This work aims to summarize predictive biomarkers to guide treatment choice in DME. Intravitreal anti-VEGF is considered the gold standard treatment for centers involving DME, while intravitreal steroid treatment has been established as a second-line treatment in DME. However, more than 1/3 of the patients do not adequately respond to anti-VEGF treatment despite up to 4-weekly injections. Not surprisingly, insufficient response to anti-VEGF therapy has been linked to low-normal VEGF levels in the serum and aqueous humor. These patients may well benefit from an early switch to intravitreal steroid treatment. In these patients, morphological biomarkers visible in OCT may predict treatment response and guide treatment decisions. Namely, the presence of a large amount of retinal and choroidal hyperreflective foci, disruption of the outer retinal layers and other signs of chronicity such as intraretinal cysts extending into the outer retina and a lower choroidal vascular index are all signs suggestive of a favorable treatment response of steroids compared to anti-VEGF. This paper summarizes predictive biomarkers in DME in order to assist individual treatment decisions in DME. These markers will help to identify DME patients who may benefit from primary dexamethasone treatment or an early switch.

Current and Novel Therapeutic Approaches for Treatment of Diabetic Macular Edema

Diabetic macular edema (DME) is a major ocular complication of diabetes mellitus (DM), leading to significant visual impairment. DME's pathogenesis is multifactorial. Focal edema tends to occur when primary metabolic abnormalities lead to a persistent hyperglycemic state, causing the development of microaneurysms, often with extravascular lipoprotein in a circinate pattern around the focal leakage. On the other hand, diffusion edema is due to a generalized breakdown of the inner blood-retinal barrier, leading to profuse early leakage from the entire capillary bed of the posterior pole with the subsequent extravasation of fluid into the extracellular space. The pathogenesis of DME occurs through the interaction of multiple molecular mediators, including the overexpression of several growth factors, including vascular endothelial growth factor (VEGF), insulin-like growth factor-1, angiopoietin-1, and -2, stromal-derived factor-1, fibroblast growth factor-2, and tumor necrosis factor. Synergistically, these growth factors mediate angiogenesis, protease production, endothelial cell proliferation, and migration. Treatment for DME generally involves primary management of DM, laser photocoagulation, and pharmacotherapeutics targeting mediators, namely, the anti-VEGF pathway. The emergence of anti-VEGF therapies has resulted in significant clinical improvements compared to laser therapy alone. However, multiple factors influencing the visual outcome after anti-VEGF treatment and the presence of anti-VEGF non-responders have necessitated the development of new pharmacotherapies. In this review, we explore the pathophysiology of DME and current management strategies. In addition, we provide a comprehensive analysis of emerging therapeutic approaches to the treatment of DME.

Intraocular Pressure Changes After Intravitreal Fluocinolone Acetonide Implant: Results from Four European Countries

INTRODUCTION

The 0.19 mg fluocinolone acetonide (FAc) intravitreal implant delivers a continuous intravitreal corticosteroid dose for the treatment of refractory diabetic macular oedema (DMO). The aim of this study was to assess the impact of an FAc intravitreal implant on intraocular pressure (IOP).

METHODS

We retrospectively collected anonymised data on the patients' characteristics, DMO treatment, and IOP and IOP-lowering treatments before and after the FAc intravitreal implant between September 2013 and March 2020 in several European centres.

RESULTS

A total of 221 eyes from 179 patients were included. The mean follow-up duration was 13.4 (± 12.5, range 2.4-33.5) months. Overall, 194 eyes (88.2%) had received an intravitreal dexamethasone injection before the FAc intravitreal implant. For 25 eyes (11.3%) there was a history of glaucoma, and 52 eyes (23.5%) had previous IOP-lowering treatment. Mean IOP before injection was 14.7 (3.4) mmHg and increased to 16.9 (3.7) mmHg 12 months after injection (P < 0.0001). During follow-up, 55 eyes (24.9%) required the addition or initiation of topical IOP-lowering medication, only one patient (0.5%) had laser trabeculoplasty and one patient (0.5%) a minimally invasive glaucoma surgery, and no patient required incisional IOP-lowering surgery.

CONCLUSION

The FAc intravitreal implant led to substantial IOP elevation. This elevation was monitored most of the time with addition or initiation of topical IOP-lowering medication.

Sodium-Glucose Co-Transporter 2 Inhibitors Reduce Macular Edema in Patients with Diabetes mellitus

Purpose: To determine the efficacy of systemic sodium-glucose co-transporter 2 inhibitors (SGLT2i) on diabetic macular edema (DME). Methods: The medical records of patients with DME with a central retinal thickness (CRT) ≥320 µm in men and 305 µm in women, more than 6 months after the initiation of diabetes mellitus treatment, were reviewed. The CRT and best-corrected visual acuity (BCVA) were evaluated before and after the initiation of systemic SGLT2i and non-SGLT2i treatments. Results: There were 24 eyes of 19 patients with DME that were treatment naïve or had not received treatments for the DME within four months before the initiation of SGLT2i. In these patients, the BCVA had a 0.31 ± 0.39 logarithm of the minimum angle of resolution (logMAR) units at the baseline, and it did not improve significantly at 0.26 ± 0.29 logMAR units after the initiation of SGLT2i (p = 0.56). However, the SGLT2i treatment significantly reduced the CRT from 423.3 ± 79.8 µm to 379.6 ± 69.5 µm (p = 0.0001). In the same evaluation of 19 eyes of 14 patients with DME that were initiated with non-SGLT2i agents, there was no significant difference between the baseline BCVA and the BCVA after the initiation of non-SGLT2i (p = 0.47). The CRT increased significantly after the initiation of non-SGLT2i (p = 0.0011). In three eyes in which the SGLT2i treatments were administered at the time of anti-vascular endothelial growth factor (VEGF) treatments, the anti-VEGF treatment alone had only a limited effect on the DME, but the reduction in the DME was enhanced after the addition of SGLT2i. Conclusions: These findings indicate that systemic SGLT2i can reduce DMEs, and they suggest that SGLT2i may be an additional treatment option to anti-VEGF treatments for eyes with DMEs.

Systemic and vitreous biomarkers - new insights in diabetic retinopathy

PURPOSE

Diabetic retinopathy (DR) is a microvascular inflammatory and neurodegenerative disease. The purpose of this study was to analyze the relationship between DR severity and the levels of potential biomarkers in the serum and/or vitreous.

METHODS

A prospective, consecutive, controlled, observational study was performed between June 2018 and January 2020. Blood and vitreous samples were collected on the day of vitrectomy in patients without diabetes and in patients with diabetes with epiretinal membrane, macular edema, and indication for vitrectomy.

RESULTS

Transthyretin (TTR) was the only blood biomarker with levels statistically higher in patients with diabetes (p = 0.037). However, no correlation with DR severity was observed. Erythropoietin (EPO) was the only blood biomarker whose levels were associated with DR severity (p = 0.036). In vitreous samples, levels of EPO (p = 0.011), interleukin (IL)-6 (p < 0.001), IL-8 (p < 0.001), IL-17 (p = 0.022), monokine induced by interferon-γ (MIG) (p < 0.001), and interferon gamma-induced protein 10 (IP-10) (p = 0.005) were significantly higher in patients with diabetes. Additionally, in vitreous, IL-6, IL-8, MIG, and IPL-10 levels were also higher in more severe DR cases (p < 0.05).

CONCLUSIONS

Among the studied biomarkers, vitreous IL-6, IL-8, MIG, and IP-10 were the ones whose levels had the strongest coherent relationship with DR severity prediction and, thus, have the best potential post-vitrectomy prognostic value.

Factors associated with diabetic macular edema in patients with proliferative diabetic retinopathy

PURPOSE

To identify factors associated with diabetic macular edema (DME) and to characterize the types of DME present in eyes with proliferative diabetic retinopathy (PDR).

METHODS

Observational, retrospective case series of PDR patients reviewed for demographic information, general medical history, ophthalmologic history, optical coherence tomography (OCT), and fluorescein angiogram image characteristics. DME and vitreomacular interface (VMI) status were determined using OCT images. DME was defined as center-involving DME (CI-DME) and noncenter-involving DME (NCI-DME). VMI was defined as vitreomacular adhesion (VMA), vitreomacular traction (VMT), or macular posterior vitreous detachment (PVD).

RESULTS

A total of 293 eyes of 210 screened patients with PDR were included. Of the eyes, 194/293 (66.2%) had DME, and 99/293 (33.8%) had no DME; in univariable analysis, there were no significant differences in VMI status (p = 0.4) or epiretinal membrane (ERM, p = 0.1) between them. Of 194 eyes with DME, 90/194 (46.4%) had CI-DME, and 104/194 (53.6%) had NCI-DME. In univariable analysis, CI-DME eyes were significantly more likely than NCI-DME eyes to have a PVD (p = 0.029) and ERM (p < 0.001). In multivariable analysis, the presence of younger age (p = 0.028) and presence of ERM (p = 0.001) were significantly more likely to be observed in eyes with CI-DME.

CONCLUSION

In this exploratory study focused on diabetic patients with PDR, we determined that VMI status did not have a significant association with DME in general, but VMI status, younger age, and presence of ERM may be associated with CI-DME.

Epiretinal Membrane Peeling in Eyes with Retinal Vein Occlusion: Visual and Morphologic Outcomes

Introduction

To evaluate the anatomical and functional outcomes of pars plana vitrectomy (PPV) and epiretinal membrane (ERM) peeling in patients with retinal vein occlusion (RVO) and secondary ERM.

Methods

Retrospective, multicenter study including patients with RVO and ERM who underwent PPV and ERM peeling with or without phacoemulsification. Demographic, clinical, surgical, and optical coherence tomography (OCT) features were recorded at the time of ERM peeling (baseline). Best-corrected visual acuity (BCVA) and central macular thickness (CMT) were longitudinally collected up to 36 months after surgery. Clinical factors associated with BCVA and CMT and disappearance of macular edema during follow-up were investigated.

Results

Twenty-one eyes of 21 patients with a median follow-up of 18 months were included. The BCVA improved significantly after ERM peeling (baseline vs. 24 months, p = 0.01). Absence of the external liming membrane/ellipsoid zone on OCT was associated with worse visual outcomes (regression estimate [95% confidence interval, CI] = 0.93 [0.39–1.48] logMAR, p = 0.004). Eyes with disorganization of the inner retinal layers at baseline had higher CMT values at each visit (regression estimate [95% CI] = 114.1 [78.9–219.4] μm, p = 0.004). Older age at the time of RVO (p = 0.03) and branch RVO (p = 0.04) were risk factors for persistent macular edema after ERM removal.

Conclusion

PPV and ERM removal provided encouraging functional and morphological results in eyes with RVO, with disappearance of macular edema in most eyes. The integrity of the outer retina and preservation of inner retinal segmentation were associated with better visual and anatomical outcomes after ERM removal, respectively.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40123-022-00461-7.

Vitreous microparticles contain apoptotic signals suggesting a diabetic vitreopathy

AIM

To evaluate differences in microparticle profiles in vitreous samples between diabetic and non-diabetic eyes undergoing vitrectomy.

METHODS

Un-masked cross-sectional series of 34 eyes undergoing vitrectomy. Vitreous specimens were collected and processed to evaluate for membrane integrity (DAPI), apoptosis (Annexin-V), and endothelial-cell origin (V-Cadherin). A BD LSR II flow cytometer was used for analysis and standardized sub-micron-sized beads were used for size comparison.

RESULTS

Thirty-four specimens underwent analysis. Greater levels of Annexin-V were found on microparticles from specimens in which blood had entered the vitreous (n=12) compared to those without blood (n=22; 52.3%±30.7% vs 19.6%±27.2%, P=0.002). Patients with diabetes having surgery with hemorrhage (n=7) had greater expression of Annexin-V than those without hemorrhage (n=8; 62.1%±31.7% vs 18.9%±20.9%, P=0.009). However, in patients with non-diabetic vitreous hemorrhage, the level of Annexin-V expression was not significantly different compared to other disease processes (38.6%±25.7%, n=5 vs 20.0%±30.9%, n=14, P=0.087).

CONCLUSION

Increased expression of the apoptotic marker, Annexin-V is detected on vitreous microparticles in diabetes-related vitreous hemorrhage. When evaluating vitreous hemorrhage in patients without diabetes, the apoptotic signal is not significantly different. Vitrectomy in patients with diabetes, and improvement in visual outcomes, may be related to the removal of a serum-derived, pro-apoptotic vitreous. Further investigation is warranted in order to identify the molecular characteristics of microparticles that regulate disease.

Vitrectomized versus non-vitrectomized eyes in diabetic macular edema response to ranibizumab-retinal layers thickness as prognostic biomarkers

To evaluate the role of the vitreous in the management of diabetic macular edema with ranibizumab intravitreal injections in a pro re nata regimen. Prospective study of 50 consecutive eyes with diabetic macular edema treated with ranibizumab and 12 months of follow-up. Primary endpoint: to assess differences between non-vitrectomized and vitrectomized eyes in the number injections needed to control the edema. Secondary endpoints: comparison of groups regarding best corrected visual acuity, central foveal thickness and thickness of seven retinal layers. 46 eyes from 38 patients, 10 vitrectomized and 36 non-vitrectomized, completed the follow-up. At month 12, the two groups achieved an equivalent anatomical outcome and needed a similar number of ranibizumab intravitreal injections. In vitrectomized eyes final visual acuity was worse when baseline retinal nerve fiber layers in the central foveal subfield were thicker, showing a strong correlation (r = − 0.942, p < 0.001). A similar, albeit moderate correlation was observed in non-vitrectomized eyes (r = − 0.504, p = 0.002). A decrease of retinal nerve fiber layers inner ring thickness was correlated with a better final visual acuity only in vitrectomized eyes (r = 0.734, p = 0.016). The effect of diabetic macular edema seems to be worse in vitrectomized eyes, with a thinner inner retina reservoir.

Clinicaltrials.govNCT04387604.

Intravitreal Tissue Plasminogen Activator Injection for Treatment-Resistant Diabetic Macular Edema of the Vitrectomized Eye

Diabetic macular edema (DME) is the main cause of visual loss in patients with diabetic retinopathy. DME has been treated using intravitreal anti-vascular endothelial growth factor (VEGF) drugs, steroids, laser photocoagulation, vitreoretinal surgery, and their combinations. These modalities are generally effective in preserving vision, but they sometimes produce only limited responses in patients with persistent or refractory DME. The levels of various inflammatory factors, including cytokines, chemokines, and extracellular matrices, as well as VEGF in the vitreous fluid, are increased in patients with DME. Excessive fibrinogen/fibrin levels in the vitreous fluid or fibrin deposition in the retina also contribute to DME pathogenesis. Tissue plasminogen activator (t-PA) promotes the degradation of fibrinogen or fibrin. Intravitreal t-PA injection is a commonly used treatment for subretinal hemorrhage secondary to age-related macular degeneration. Intravitreal t-PA injections have previously been used to restore vision by inducing posterior vitreous detachment in patients with DME. Herein, we describe the visual outcomes of intravitreal t-PA injection in a 78-year-old woman with treatment-resistant DME in her vitrectomized eye after several previous treatments. Before the injection, her best-corrected visual acuity (BCVA) was 0.7 logMAR and central foveal retinal thickness (CRT) was 735 μm. At 1 month after the injection, her BCVA was 0.8 logMAR and CRT was 558 μm, and 3 months later, her BCVA was 0.8 logMAR and CRT was 207 μm. Her BCVA was sustained, and CRT showed gradual improvements. These findings suggested the effectiveness of intravitreal t-PA injections for DME in the vitrectomized eye.

Potential bias of preoperative intravitreal anti-VEGF injection for complications of proliferative diabetic retinopathy

PURPOSE

Intravitreal anti-VEGF injection (IVI) is administered before vitrectomy to assist management of proliferative diabetic retinopathy (PDR)-related complications. In the clinical setting, retinal surgeons determine the use of preoperative IVI based on individual criteria. In this study, we investigated factors related to the potential bias of retinal surgeons in using IVI prior to vitrectomy for PDR-related complications, and evaluated the real-world outcomes of surgeon-determined preoperative IVI.

METHODS

Medical records of 409 eyes of 409 patients who underwent 25-gauge vitrectomy for PDR complications at seven Japanese centers (22 surgeons) were retrospectively reviewed. Ocular factors, demographic and general clinical factors, surgical procedures, and postoperative complications were compared between IVI group (patients who received preoperative IVI; 87 eyes, 21.3%) and non-IVI group (patients who did not receive preoperative IVI; 322 eyes, 78.7%). In addition, baseline HbA1c in IVI group and non-IVI group was compared between eyes with and without postoperative complications.

RESULTS

At baseline, IVI group was younger (P<0.001), had shorter duration of diabetes treatment (P = 0.045), and higher frequencies of neovascular glaucoma [NVG] (P<0.001) and tractional retinal detachment [TRD] (P<0.001) compared to non-IVI group. Although IVI group had higher frequencies of intraoperative retinal break and tamponade procedure, there were no significant differences in postoperative complications and additional treatments between two groups. Baseline HbA1c levels were also not correlated with postoperative complications of VH, NVG, and RD both in IVI group and non-IVI group. Logistic regression analysis identified age (P<0.001, odds ratio [OR] 0.95), presence of NVG (P<0.001, OR 20.2), and presence of TRD (P = 0.0014, OR 2.44) as preoperative factors in favor of IVI.

CONCLUSIONS

In this multicenter real-world clinical study, younger age and presence of NVG and TRD were identified as potential biases in using IVI before vitrectomy for PDR complications. Eyes that received preoperative IVI had more intraoperative retinal breaks requiring tamponade than eyes not receiving IVI, but postoperative outcome was not different between the two groups.

Pars Plana Vitrectomy with Internal Limiting Membrane Peeling for Treatment-Naïve Diabetic Macular Edema: A Prospective, Uncontrolled Pilot Study

Purpose

To report the outcomes in subjects undergoing pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling for the management of treatment-naïve diabetic macular edema (DME).

Methods

Ten treatment-naïve subjects with non-proliferative diabetic retinopathy prospectively underwent PPV with ILM peeling for the treatment of DME at a single university-affiliated institution. The preoperative features, intraoperative details and postoperative outcomes were collected and analyzed.

Results

All 10 subjects underwent PPV with ILM peeling without significant intraoperative or postoperative complications at 6 months follow-up. Visual acuity improved from a baseline of 0.74 (95% CI: 0.48–1.0) logMAR (Snellen 20/110) to 0.46 (95% CI: 0.3–0.62) logMAR (Snellen 20/58) at 6 months follow-up (p=0.045). Optical coherence tomography central macular thickness reduced from a baseline of 456 (95% CI: 394.7–516.4) microns to 316.8 (95% CI: 275.9–357.7) microns at 6 months follow-up (p < 0.001).

Conclusion

This pilot study suggests that PPV with ILM peeling may be a viable treatment option for the management of treatment naïve DME in subjects with non-proliferative diabetic retinopathy. Development of a randomized controlled trial may be justified to validate the results of this study.

Clinicaltrials.gov Identifier #

NCT03660345.

One-Year Outcome of Aflibercept Intravitreal Injection in Vitrectomized Eyes with Diabetic Macular Edema

Aim

To evaluate the efficacy of intravitreal Aflibercept injection (IAI) for vitrectomized eyes with diabetic macular edema (DME) at one year.

Methods

This is a prospective, non-comparative, multicenter observational study including diabetic patients whose HbA1c is < 9%, with visual acuity between 20/400 to 20/40 due to DME, who have undergone vitrectomy since at least 3 months before the first aflibercept injection. Treatment protocol included 5 monthly aflibercept injection followed by a ProReNata regimen during the first year. Visual acuity, OCT findings and number of IAI were assessed at 6 months and one year.

Results

Forty-six eyes were included. Indications for vitrectomy were epiretinal membrane (58.7%), intravitreal hemorrhage (26.1%), and vitreomacular traction (8.7%), retinal detachment (4.3%), and other cause (4.3%). Median duration of macular edema was 3 years. Median interval between vitrectomy and first visit was 9 months. Thirty eyes were non-naïve and received previously thermal laser (44.3%), intravitreal injection of triamcinolone (26.7%), of ranibizumab (70%), of dexamethasone implant (36.7%), or bevacizumab (6.7%). Data was available for 35 eyes at 1 year. Visual gain was significant, +6 letters (p <0.001) and central subfield thickness (CST) decreased significantly (−108μm, p < 0.001) at 1 year. Mean number of injections was 9.3 and mean interval injection was 5.8 weeks.

Conclusion

These results suggest that IAI may be beneficial in vitrectomized eyes with refractory DME which require frequent injections to obtain visual and anatomical improvement.

Clinical Trial Registration

http://www.clinicaltrials.gov, registration Number NCT02874859.

En face image-based classification of diabetic macular edema using swept source optical coherence tomography

This retrospective study was performed to classify diabetic macular edema (DME) based on the localization and area of the fluid and to investigate the relationship of the classification with visual acuity (VA). The fluid was visualized using en face optical coherence tomography (OCT) images constructed using swept-source OCT. A total of 128 eyes with DME were included. The retina was segmented into: Segment 1, mainly comprising the inner nuclear layer and outer plexiform layer, including Henle’s fiber layer; and Segment 2, mainly comprising the outer nuclear layer. DME was classified as: foveal cystoid space at Segment 1 and no fluid at Segment 2 (n = 24), parafoveal cystoid space at Segment 1 and no fluid at Segment 2 (n = 25), parafoveal cystoid space at Segment 1 and diffuse fluid at Segment 2 (n = 16), diffuse fluid at both segments (n = 37), and diffuse fluid at both segments with subretinal fluid (n = 26). Eyes with diffuse fluid at Segment 2 showed significantly poorer VA, higher ellipsoid zone disruption rates, and greater central subfield thickness than did those without fluid at Segment 2 (P < 0.001 for all). These results indicate the importance of the localization and area of the fluid for VA in DME.

Optical Coherence Tomography Biomarkers in Bilateral Diabetic Macular Edema Patients with Asymmetric anti-VEGF Response

Background: This study aimed to identify optical coherence tomography (OCT) biomarkers for predicting response to anti-VEGF treatment in diabetic macular edema (DME)Methods: Bilateral DME patients with asymmetric response to a loading dose of anti-VEGF (ranibizumab/aflibercept) treatment were retrospectively studied. The morphologic response criterion was central subfield thickness (CST) ≤300 µm; asymmetric response was defined as ≥10% difference in CST reduction between the eyes. The functional response criterion was an increase in logMAR acuity of ≥3 lines, with an increase below this threshold in the fellow eye considered asymmetric response. Relationships between final morphologic and functional responses to anti-VEGF therapy and baseline values of the following OCT-derived biomarkers were evaluated: DME subtype, CST, vitreoretinal interface anomalies, disorganization of the inner retinal layers (DRIL), external limiting membrane (ELM) disruption, ellipsoid zone (EZ) disruption, and subretinal fluid (SRF).Results: After a loading dose of anti-VEGF, 31 eyes that met both morphologic and functional response criteria were classified as responders (RR) and 27 eyes that did not respond morphologically or functionally based on the defined criteria were classified as resistant (RT). Eyes that showed only functional (n = 5) or morphological response (n = 1) were excluded due to their small number. The presence of SRF or simple epiretinal membrane (ERM) was not associated with any difference in treatment responses (p > .05), while tractional ERM, extensive DRIL (≥500 µm), and ELM and EZ disruptions in the fovea-centered 1000-µm zone were important OCT biomarkers in predicting resistance (p < .001). A multilayer perceptron model ranked predictive power as 100% for ELM disruption, 51.7% for tractional ERM, 25.4% for DRIL, and 24.5% for EZ disruption.Conclusion: Extensive ELM disruption was the strongest OCT biomarker to predict anti-VEGF resistance, followed by tractional ERM. EZ disruption and DRIL had relatively lower predictive value.

Diabetic macular edema

Diabetic retinopathy (DR) is a leading cause of preventable blindness world-wide. Diabetic macular edema (DME) is the most common cause of moderate vision loss in patients with diabetes. Although treatments for DME have improved significantly over the past decades, the burden of this disease remains high for patients and the healthcare system alike. The role of the primary care provider is critical in the prevention and prompt referral for management of DME.

Evaluation of Macular Changes in the Long Term after Pars Plana Vitrectomy with Internal Limiting Membrane Peeling for Diabetic Macular Edema

AIM

To evaluate long-term macular changes following pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling for diabetic macular edema (DME).

METHODS

Forty eligible eyes of 37 patients were included in this retrospective study. Best corrected visual acuity (BCVA), central macular thickness (CMT), and 5-mm macular volume (5-MV) were examined preoperatively, postoperatively after 1, 2, 3, 6, 12, and 24 months, and at a final visit. Response to surgical treatment was considered as recurrence, reincrease, or recovery of DME based on macular changes.

RESULTS

Mean follow-up time was 51.1 ± 19.0 months after surgery. Recurrence (n = 5) and reincrease (n = 17) of DME was observed in 22 eyes (55%) and additional treatments were applied. Recovery of DME was observed in 18 eyes (45%). Preoperative and final-visit mean BCVA (logMAR) was 1.08 ± 0.37 and 0.93 ± 0.45, respectively (p = 0.02). Preoperative and final-visit mean CMT was 514.74 ± 155.65 and 281.87 ± 112.58 µm, respectively (p < 0.001). The 5-MV significantly decreased following surgery (from 8.18 ± 1.57 to 6.52 ± 1.39 mm3; p < 0.001). DME was present in 12 eyes (30%) at the final visit.

CONCLUSION

Although PPV with ILM peeling had efficacy in DME management, this effect tended to decrease over time, such that a considerable number of patients required additional treatment.

Three-year outcomes of vitrectomy combined with intraoperative dexamethasone implantation for non-tractional refractory diabetic macular edema

This retrospective, consecutive interventional study investigated the long-term clinical outcomes of combined vitrectomy with intraoperative dexamethasone implants for non-tractional refractory diabetic macular edema (DME). The study included 43 eyes from 39 participants with DME that had continued for more than 6 months despite repeated non-surgical treatment. Postoperative changes in best-corrected visual acuity (BCVA) and central macular thickness (CMT) were evaluated over 3 years. A Kaplan-Meier curve was obtained for any additional non-surgical treatment, and the average number of non-surgical treatments required for DME before and after surgery was compared. Other postsurgical complications were also investigated. The logMAR BCVA improved from 0.526 ± 0.417 (20/67) preoperatively to 0.294 ± 0.374 (20/39) 3 years postoperatively (p < 0.001, generalized estimating equation). The CMT improved from 478 ± 122 μm preoperatively to 314 ± 90 μm 3 years postoperatively (p < 0.001, generalized estimating equation). Additional non-surgical treatment was not required for 29 (67%) eyes. The average number of annual non-surgical treatments decreased from 5.04 times preoperatively to 0.34 times postoperatively. Seventeen (40%) eyes developed temporary ocular hypertension after surgery, which normalized after antihypertensive eye drop instillation. In conclusion, vitrectomy combined with intraoperative dexamethasone implantation provides satisfactory long-term clinical outcomes for non-tractional refractory DME while reducing the number of intraocular injections for DME.

Pars Plana Vitrectomy versus Intravitreal Injection of Ranibizumab in the Treatment of Diabetic Macular Edema Associated with Vitreomacular Interface Abnormalities

Purpose

To compare the efficacy of pars plana vitrectomy (PPV) versus intravitreal injection (IVI) of ranibizumab (RBZ) in the treatment of diabetic macular edema (DME) associated with vitreomacular interface abnormalities (VMIA).

Methods

The records of patients presenting with DME and VMIA throughout 2016 to 2018 were retrospectively analyzed. The patients were divided into 2 groups: group I received IVIs of RBZ and group II underwent PPV with internal limiting membrane peeling. The main outcome measures were the change in the LogMAR corrected distance visual acuity (CDVA) and central subfield thickness (CSFT) on optical coherence tomography over 6 months.

Results

At 6 months, mean CDVA improved by 0.22 ± 0.21 in group I patients (p < 0.001), while in group II, it improved only by 0.09 ± 0.22 (p < 0.115). Fifty-five percent of group I and 60% of group II patients had stable CDVA (within 2 lines from baseline) at 6 months. Significant improvement in vision (gain of 2 or more lines) was seen in 45% and 30%, respectively. Worsening of vision (loss of 2 or more lines) was seen only in 2 patients in group II, but none in group I. The mean CSFT improved significantly in both groups (by 162 µ and 216 µ, respectively; p < 0.001). The mean CSFT at 6 months was similar in both groups (354 µ and 311 µ, respectively; p=0.172).

Conclusions

Both treatments resulted in anatomical improvement of DME with concurrent VMIA. Visual improvement was more pronounced in the IVI group, although this may have been affected by other confounding factors.

Review of clinical studies and recommendation for a therapeutic flow chart for diabetic macular edema

Diabetic macular edema (DME), characterized by exudative fluid accumulation in the macula, is the most common form of sight-threatening retinopathy in patients with diabetes. The management of DME has changed considerably in recent years, especially following the development of intravitreal anti-vascular endothelial growth factor therapy which has emerged as a first-line therapy for center-involved DME. Laser treatment, intravitreal steroid therapy, and vitrectomy are also important treatment options for DME. We believe that it is important to choose the most appropriate treatment option for DME based on the clinical evidences, in addition to the careful consideration of individual patients' general or ocular condition, DME characteristics, patients' motivation, and compliance to the treatment in real-world clinical practice. In this review, we have summarized important clinical evidences for the main treatments for DME, presented an expert review for these evidences, and proposed a recommended therapeutic flow chart for DME. We hope that our review of the clinical evidences and the recommended therapeutic flow chart for DME will contribute to better treatment outcome for DME.

Safety and Efficacy of Ranibizumab and Luseogliflozin Combination Therapy in Patients with Diabetic Macular Edema: Protocol for a Multicenter, Open-Label Randomized Controlled Trial

INTRODUCTION

Diabetic macular edema (DME) threatens daily life activities such as reading and driving and reduces the patients' quality-of-life. Recently, anti-vascular endothelial growth factor (VEGF) agents have become a first-line therapy in DME. However, therapy with anti-VEGF agents has several problems: repeated invasive injections are required; medical costs are high; and a certain proportion of patients with DME are resistant to treatment with anti-VEGF agents. While sodium-glucose co-transporter 2 (SGLT2) inhibitors have been widely used for the treatment of type 2 diabetes mellitus (T2DM), the effects of a combination therapy with anti-VEGF agent and SGLT2 inhibitor on DME are not yet known.

METHODS

This study enrolls subjects with T2DM and DME, randomizes them into either a study agent treatment group (treated with ranibizumab as anti-VEGF agent and luseogliflozin as SGLT2 inhibitor) or a control group (treated with ranibizumab and glimepiride), and observes the subjects for 52 weeks after initiation of treatment. Planned outcomes: The primary endpoint is intergroup difference in the number of intravitreal anti-VEGF injections to the study eye from baseline to week 48. Secondary and exploratory endpoints include safety and ophthalmologic and internal medical clinical parameters.

REGISTRATION

This study is registered at the University Hospital Medical Information Network Clinical Trial Registry (UMIN000033961) and Japan Registry of Clinical Trials (jRCTs031180210).

The Evolving Treatment of Diabetic Retinopathy

Purpose

To review the current therapeutic options for the management of diabetic retinopathy (DR) and diabetic macular edema (DME) and examine the evidence for integration of laser and pharmacotherapy.

Methods

A review of the PubMed database was performed using the search terms diabetic retinopathy, diabetic macular edema, neovascularization, laser photocoagulation, intravitreal injection, vascular endothelial growth factor (VEGF), vitrectomy, pars plana vitreous surgery, antiangiogenic therapy. With additional cross-referencing, this yielded 835 publications of which 301 were selected based on content and relevance.

Results

Many recent studies have evaluated the pharmacological, laser and surgical therapeutic strategies for the treatment and prevention of DR and DME. Several newer diagnostic systems such as optical coherence tomography (OCT), microperimetry, and multifocal electroretinography (mfERG) are also assisting in further refinements in the staging and classification of DR and DME. Pharmacological therapies for both DR and DME include both systemic and ocular agents. Systemic agents that promote intensive glycemic control, control of dyslipidemia and antagonists of the renin-angiotensin system demonstrate beneficial effects for both DR and DME. Ocular therapies include anti-VEGF agents, corticosteroids and nonsteroidal anti-inflammatory drugs. Laser therapy, both as panretinal and focal or grid applications continue to be employed in management of DR and DME. Refinements in laser devices have yielded more tissue-sparing (subthreshold) modes in which many of the benefits of conventional continuous wave (CW) lasers can be obtained without the adverse side effects. Recent attempts to lessen the burden of anti-VEGF injections by integrating laser therapy have met with mixed results. Increasingly, vitreoretinal surgical techniques are employed for less advanced stages of DR and DME. The development and use of smaller gauge instrumentation and advanced anesthesia agents have been associated with a trend toward earlier surgical intervention for diabetic retinopathy. Several novel drug delivery strategies are currently being examined with the goal of decreasing the therapeutic burden of monthly intravitreal injections. These fall into one of the five categories: non-biodegradable polymeric drug delivery systems, biodegradable polymeric drug delivery systems, nanoparticle-based drug delivery systems, ocular injection devices and with sustained release refillable devices. At present, there remains no one single strategy for the management of the particular stages of DR and DME as there are many options that have not been rigorously tested through large, randomized, controlled clinical trials.

Conclusion

Pharmacotherapy, both ocular and systemic, will be the primary mode of intervention in the management of DR and DME in many cases when cost and treatment burden are less constrained. Conventional laser therapy has become a secondary intervention in these instances, but remains a first-line option when cost and treatment burden are more constrained. Results with subthreshold laser appear promising but will require more rigorous study to establish its role as adjunctive therapy. Evidence to support an optimal integration of the various treatment options is lacking. Central to the widespread adoption of any therapeutic regimen for DR and DME is substantiation of safety, efficacy, and cost-effectiveness by a body of sound clinical trials.

Posterior vitreous detachment in patients with diabetes mellitus

PURPOSE

To compare the progression of posterior vitreous detachment (PVD) during aging among eyes of diabetics with diabetic retinopathy (DR), eyes of diabetics without DR, and eyes of nondiabetics.

STUDY DESIGN

Prospective cross-sectional study.

METHODS

One-hundred thirty-three diabetic eyes with DR (DR group), 254 diabetic eyes without DR (non-DR group), and 577 nondiabetic eyes (nondiabetic group) were divided into four age categories: 1) 40-49 years, 2) 50-59 years, 3) 60-69 years, and 4) 70-79 years. The PVD state was examined using swept source-optical coherence tomography and classified into five stages: 0 (non PVD), 1 (paramacular PVD), 2 (perifoveal PVD), 3 (vitreofoveal separation), and 4 (complete PVD).

RESULTS

The PVD stage significantly progressed in the DR, non-DR, and nondiabetic groups (p <0.0001). At 40-49 and 50-59 years, the PVD stage did not differ significantly among the three groups. At 60-69 and 70-79 years, the PVD stage was significantly less progressed in the DR than the non-DR and nondiabetic groups (p ≤0.0027), and did not differ significantly between the non-DR and nondiabetic groups. At 70-79 years, complete PVD was detected in 40.6% of eyes in the DR group, 69.6% in the non-DR group, and 73.5% of eyes in the nondiabetic group.

CONCLUSION

PVD progresses later in diabetic eyes with DR than in diabetic eyes without DR and nondiabetics eyes at 60 and 70 years of age, suggesting a stronger vitreomacular adhesion in diabetics with DR.

Revisiting pars plana vitrectomy in the primary treatment of diabetic macular edema in the era of pharmacological treatment

Diabetic macular edema (DME) is the most common cause of moderate visual loss in diabetic patients. The current treatment of choice for center-involved DME is anti-vascular endothelial growth factor (VEGF) treatment. Most patients that undergo pharmacological inhibition with anti-VEGF agents need multiple monitoring visits that include optical coherence tomography imaging and multiple injections. Despite this intensive treatment, up to 60% of eyes will have persistent DME after six consecutive monthly injections of an anti-VEGF. Its sustainability over the long term has been questioned. Pars plana vitrectomy (PPV) by increasing the vitreous cavity oxygenation, relieving vitreomacular traction, and removing cytokines from the vitreous cavity may cause long-term resolution of DME without the aforementioned concerns in selected cases. Eyes with vitreomacular traction clearly benefit from PPV as the primary treatment. The role of PPV for eyes with DME without tractional elements is less clear and needs to be explored further.

Predictive factors of outcome of selective retina therapy for diabetic macular edema

PURPOSE

To investigate the predictive factors of clinical outcome of selective retina therapy (SRT) for diabetic macular edema (DME).

METHODS

This retrospective study included 22 eyes of 22 patients (15 males and 7 females), who were treated with SRT for DME at the Department of Ophthalmology of Osaka City University Hospital and observed at least 6 months after the treatment. The mean age was 64 years (range 40-81). Thirteen of the 22 eyes (59%) had a treatment history other than SRT before. SRT laser (527 nm, 1.7 µs, 100 Hz) was used for treatment. Changes in the best-corrected visual acuity (BCVA) (logMAR) and central macular thickness (CMT) in optical coherence tomography were examined at baseline, 3-month follow-up, and 6-month follow-up. Factors associated with the rate of change in CMT at 3 and 6 months after SRT were examined.

RESULTS

The mean BCVA (logMAR) was 0.26 ± 0.31, 0.22 ± 0.27 and 0.23 ± 0.29 at baseline, 3 months and 6 months, respectively (p = 0.15 at 3 months, 0.40 at 6 months; compared to baseline). The mean CMT was 502 ± 163, 493 ± 204, and 416 ± 185 μm at baseline, 3 months, and 6 months, respectively (p = 0.69 at 3 months, 0.01 at 6 months; compared to baseline). The multivariate analysis found a significant negative association with previous macular photocoagulation (p = 0.03) at 3 months and a positive association with a history of insulin use (p = 0.02) and previous panretinal photocoagulation (p = 0.03) at 6 months after SRT.

CONCLUSION

The CMT was significantly decreased at 6 months after SRT in DME. The history of insulin use and panretinal photocoagulation may positively and the history of macular photocoagulation may negatively affect the outcome of SRT, which must be considered when determining the therapeutic indications for SRT.

Outcomes of 25-Gauge Vitrectomy for Tractional and Nontractional Diabetic Macular Edema with Proliferative Diabetic Retinopathy

The benefit of pars plana vitrectomy with internal limiting membrane peeling for tractional macular edema and diffuse nontractional macular edema in diabetic retinopathy has been reported. Although these studies had included various stages, use of conventional 20-gauge vitrectomy system, small number of cases, single-center study, and lack of retinal structure measurements were limitations. We compared one-year outcomes of 25-gauge vitrectomy for refractory diabetic macular edema with or without the tractional proliferative membrane in proliferative diabetic retinopathy (PDR) eyes and examined the prognostic factors for postoperative visual acuity. A total of consecutive 116 PDR eyes of 116 patients that underwent 25-gauge vitrectomy for tractional macular edema (TME group: 56 eyes) or nontractional macular edema (nTME group: 60 eyes) at six centers were retrospectively reviewed. Visual acuity (VA), central macular thickness (CMT), complications, and postoperative treatments before and 12 months after vitrectomy were compared. Mean VA improved significantly in each group (both P < 0.01), and mean CMT decreased significantly in each group (both P < 0.01). Thirteen eyes underwent additional vitrectomy, six eyes developed neovascular glaucoma, six eyes received intravitreal anti-VEGF injection, and thirteen eyes received subtenon triamcinolone acetonide injection. Multiple linear regression analysis showed that baseline VA and CMT in the TME group and kidney function in the nTME group were the predictable factors of the 12-month postoperative VA. Twenty-five-gauge vitrectomy effectively improved VA and macular structure both in TME and nTME groups. Baseline VA, CMT, and kidney function are important factors affecting postoperative VA.

Characteristics of diabetic macular edema patients with serous retinal detachment

To determine characteristics of diabetic macular edema patients with serous retinal detachment (SRD).We classified naïve diabetic macular edema (DME) patients with or without SRD, and compared their baseline characteristics; intravitreal bevacizumab (IVB) responsiveness; aqueous concentrations of IL (interleukin)-1β, -2, -8, -10, -17, placental growth factor (PlGF), and vascular endothelial growth factor (VEGF). In addition, factors associated with the existence of SRD were identified.Of the 64 DME patients, 14 had SRD. The average levels of aqueous VEGF and PlGF were significantly higher in the SRD group than in the control group (P = .022 and P = .041, respectively). The best-corrected visual acuity (BCVA) and central subfield thickness (CST) did not differ significantly between the 2 groups at baseline or after 3 consecutive monthly IVBs. In multivariate logistic regression analysis, the level of aqueous VEGF was the only factor associated with the existence of SRD (odds ratio: 1.03; P = .038).Rather than aqueous inflammatory cytokines, levels of aqueous VEGFs were associated with the occurrence of SRD in DME patients. In terms of prognosis, the existence of SRD was not related with BCVA or CST changes.

Submacular Injection of Ranibizumab as a New Surgical Treatment for Refractory Diabetic Macular Edema

Purpose

In this study, we describe a new surgical technique for the treatment of refractory DME. The technique consists of vitrectomy with ILM peeling with a subretinal injection of ranibizumab.

Methods

This is a prospective interventional noncomparative study including patients with refractory DME. Included patients were subjected to the new surgical technique of pars plana vitrectomy with subretinal injection of ranibizumab.

Results

The study included 19 eyes with refractory macular edema, in which this novel technique was attempted. There were 10 males and 9 females. The age of the patients ranged from 17 to 67 years with a mean of 55.58 ± 13.242 years. The duration of diabetes before enrollment in the study ranged from 7 to 25 years with a mean of 16.3 years. Preoperatively, the mean CMT of the eyes ranged from 352 to 883 microns with mean ± SD of 498.58 ± 152.16 microns. Postoperatively, this improved significantly to 373.5 ± 100.3, 355.9 ± 89.8, and 365.74 ± 120.12 microns at 1, 3, and 6 months, respectively (p ≤ 0.001 for all).

Conclusion

This novel surgical procedure of vitrectomy with ILM peeling with a subretinal injection of ranibizumab is effective in cases of refractory DME. The study has been registered in Contact ClinicalTrials.gov PRS Identifier: NCT03975088.