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Virgili G, Curran K, Lucenteforte E, Peto T, Parravano M. Anti-vascular endothelial growth factor for diabetic macular oedema: a network meta-analysis. Cochrane Database Syst Rev 2023; 2023:CD007419. [PMID: 38275741 PMCID: PMC10294542 DOI: 10.1002/14651858.cd007419.pub7] [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] [Indexed: 01/27/2024]
Abstract
Background Diabetic macular oedema (DMO) is a common complication of diabetic retinopathy. Antiangiogenic therapy with anti-vascular endothelial growth factor (anti-VEGF) can reduce oedema, improve vision, and prevent further visual loss. These drugs have replaced laser photocoagulation as the standard of care for people with DMO. In the previous update of this review, we found moderate-quality evidence that, at 12 months, aflibercept was slightly more effective than ranibizumab and bevacizumab for improving vision in people with DMO, although the difference may have been clinically insignificant (less than 0.1 logarithm of the minimum angle of resolution (logMAR), or five Early Treatment Diabetic Retinopathy Study (ETDRS) letters, or one ETDRS line). Objectives The objective of this updated review was to compare the effectiveness and safety of the different anti-VEGF drugs in RCTs at longer followup (24 months). Search methods We searched various electronic databases on 8 July 2022. Selection criteria We included randomised controlled trials (RCTs) that compared any anti-angiogenic drug with an anti-VEGF mechanism of action versus another anti-VEGF drug, another treatment, sham, or no treatment in people with DMO. Data collection and analysis We used standard Cochrane methods for pairwise meta-analysis and we augmented this evidence using network meta-analysis (NMA) methods. We used the Stata 'network' meta-analysis package for all analyses. We used the CINeMA (Confidence in Network Meta-Analysis) web application to grade the certainty of the evidence. Main results We included 23 studies (13 with industry funding) that enrolled 3513 people with DMO (median central retinal thickness (CRT) 460 microns, interquartile range (IQR) 424 to 482) and moderate vision loss (median best-corrected visual acuity (BCVA) 0.48 logMAR, IQR 0.42 to 0.55. One study that investigated ranibizumab versus sham and one study that mainly enrolled people with subclinical DMO and normal BCVA were not suitable for inclusion in the efficacy NMA. Consistent with the previous update of this review, we used ranibizumab as the reference drug for efficacy, and control (including laser, observation, and sham) as the reference for systemic safety. Eight trials provided data on the primary outcome (change in BCVA at 24 months, in logMAR: lower is better). We found no evidence of a difference between the following interventions and ranibizumab alone: aflibercept (mean difference (MD) -0.05 logMAR, 95% confidence interval (CI) -0.12 to 0.02; moderate certainty); bevacizumab (MD -0.01 logMAR, 95% CI -0.13 to 0.10; low certainty), brolucizumab (MD 0.00 logMAR, 95% CI -0.08 to 0.07; low certainty), ranibizumab plus deferred laser (MD 0.00 logMAR, 95% CI -0.11 to 0.10; low certainty), and ranibizumab plus prompt laser (MD 0.03 logMAR, 95% CI -0.04 to 0.09; very low certainty). We also analysed BCVA change at 12 months, finding moderate-certainty evidence of increased efficacy with brolucizumab (MD -0.07 logMAR, 95%CI -0.10 to -0.03 logMAR), faricimab (MD -0.08 logMAR, 95% CI -0.12 to -0.05), and aflibercept (MD -0.07 logMAR, 95 % CI -0.10 to -0.04) compared to ranibizumab alone, but the difference could be clinically insignificant. Compared to ranibizumab alone, NMA of six trials showed no evidence of a difference with aflibercept (moderate certainty), bevacizumab (low certainty), or ranibizumab with prompt (very low certainty) or deferred laser (low certainty) regarding improvement by three or more ETDRS lines at 24 months. There was moderate-certainty evidence of greater CRT reduction at 24 months with brolucizumab (MD -23 microns, 95% CI -65 to -1 9) and aflibercept (MD -26 microns, 95% CI -53 to 0.9) compared to ranibizumab. There was moderate-certainty evidence of lesser CRT reduction with bevacizumab (MD 28 microns, 95% CI 0 to 56), ranibizumab plus deferred laser (MD 63 microns, 95% CI 18 to 109), and ranibizumab plus prompt laser (MD 72 microns, 95% CI 25 to 119) compared with ranibizumab alone. Regarding all-cause mortality at the longest available follow-up (20 trials), we found no evidence of increased risk of death for any drug compared to control, although effects were in the direction of an increase, and clinically relevant increases could not be ruled out. The certainty of this evidence was low for bevacizumab (risk ratio (RR) 2.10, 95% CI 0.75 to 5.88), brolucizumab (RR 2.92, 95% CI 0.68 to 12.58), faricimab (RR 1.91, 95% CI 0.45 to 8.00), ranibizumab (RR 1.26, 95% CI 0.68 to 2.34), and very low for conbercept (RR 0.33, 95% CI 0.01 to 8.81) and aflibercept (RR 1.48, 95% CI 0.79 to 2.77). Estimates for Antiplatelet Trialists Collaboration arterial thromboembolic events at 24 months did not suggest an increase with any drug compared to control, but the NMA was overall incoherent and the evidence was of low or very low certainty. Ocular adverse events were rare and poorly reported and could not be assessed in NMAs. Authors' conclusions There is limited evidence of the comparative efficacy and safety of anti-VEGF drugs beyond one year of follow-up. We found no clinically important differences in visual outcomes at 24 months in people with DMO, although there were differences in CRT change. We found no evidence that any drug increases all-cause mortality compared to control, but estimates were very imprecise. Evidence from RCTs may not apply to real-world practice, where people in need of antiangiogenic treatment are often under-treated, and the individuals exposed to these drugs may be less healthy than trial participants.
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Key Words
- Angiogenesis Inhibitors [adverse effects, *therapeutic use]
- Aptamers, Nucleotide [adverse effects, therapeutic use]
- Bevacizumab [adverse effects, therapeutic use]
- Diabetic Retinopathy [*complications]
- Laser Coagulation [methods]
- Macular Edema [*drug therapy, etiology, surgery]
- Network Meta-Analysis
- Quality of Life
- Randomized Controlled Trials as Topic
- Ranibizumab [adverse effects, therapeutic use]
- Receptors, Vascular Endothelial Growth Factor [therapeutic use]
- Recombinant Fusion Proteins [adverse effects, therapeutic use]
- Triamcinolone [adverse effects, therapeutic use]
- Vascular Endothelial Growth Factor A [*antagonists & inhibitors]
- Visual Acuity [*drug effects, physiology]
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Affiliation(s)
- Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | | | - Ersilia Lucenteforte
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Tunde Peto
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Mariacristina Parravano
- Ophthalmology, Fondazione G.B. Bietti per lo studio e la ricerca in Oftalmolologia-IRCCS, Rome, Italy
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Stefansson E, Loftsson T, Larsen M, Papp A, Kaarniranta K, Munk MR, Dugel P, Tadayoni R. Topical treatment of diabetic macular edema using dexamethasone ophthalmic suspension: A randomized, double-masked, vehicle-controlled study. Acta Ophthalmol 2023; 101:22-33. [PMID: 35848336 DOI: 10.1111/aos.15215] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/23/2022] [Accepted: 06/26/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE To evaluate topical dexamethasone ophthalmic suspension OCS-01 (Oculis SA, Lausanne, Switzerland) in diabetic macular edema (DME). METHODS This was a multicenter, double-masked, parallel-group, randomized, Phase 2 study. Patients aged 18-85 years with DME of <3 years duration, ETDRS central subfield thickness ≥ 310 μm by SD-OCT, and ETDRS letter score ≤ 73 and ≥ 24 in the study eye were randomized 2:1 to OCS-01 or matching vehicle, 1 drop 3 times/day for 12 weeks. Efficacy was evaluated as change from baseline to Week 12 of ETDRS letter score and central macular thickness (CMT). The primary analysis used a linear model with baseline ETDRS letters as a covariate, and missing data imputed using multiple imputation pattern mixture model techniques. Active treatment was considered superior to vehicle if the one-sided p-value was <0.15 and the difference in mean change from baseline in ETDRS letters was >0. RESULTS Mean CMT showed a greater decrease from baseline with OCS-01 (N = 99) than vehicle (N = 45) at Week 12 (-53.6 vs -16.8 μm, p = 0.0115), with significant differences favouring OCS-01 from Weeks 2 to 12. OCS-01 was well-tolerated, and increased intraocular pressure was the most common adverse event. Mean change in ETDRS letter score from baseline to Week 12 met the p was +2.6 letters with topical OCS-01 and 1 letter with vehicle (p = 0.125). In a post-hoc analysis, there was a greater difference in patients with baseline BCVA ≤65 letters, the OCS-01 group improved 3.8 letters compared with 0.9 letters with vehicle. CONCLUSION Topical OCS-01 was significantly more effective than vehicle in improving central macular thickness in patients with DME. Visual improvement was better in eyes with lower baseline vision.
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Affiliation(s)
| | | | - Michael Larsen
- Eye Department, Rigshospitalet - Glostrup, Copenhagen, Denmark
| | - András Papp
- Department of Ophthalmology, Semmelweis University, Budapest, Hungary
| | - Kai Kaarniranta
- University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - Marion R Munk
- Inselspital, University Hospital Bern, Bern, Switzerland.,Bern Photographic Reading Center, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Pravin Dugel
- Keck School of Medicine, USC Roski Eye Institute, Los Angeles, California, USA
| | - Ramin Tadayoni
- Service d'Ophtalmologie Paris, Hopital Lariboisière, Paris, France
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Zaher Addeen S, Shaddoud I. Combined phacoemulsification surgery and intravitreal triamcinolone injection versus stand-alone surgery in patients with type 2 diabetes: a prospective randomized trial. BMC Ophthalmol 2022; 22:445. [PMCID: PMC9675215 DOI: 10.1186/s12886-022-02676-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 11/07/2022] [Indexed: 11/21/2022] Open
Abstract
Background We would assess the efficacy of intravitreal injection of triamcinolone acetonide IVTA combined with standard phacoemulsification on the central subfield macular thickness (CSMT), the progression of diabetic retinopathy (DR), and the corrected distant visual acuity (CDVA) in type 2 diabetic patients. Methods In this prospective single-blinded randomized clinical trial we recruited patients with type 2 diabetes who were eligible for cataract surgery. The patients were randomly assigned to two groups. The case group received an intravitreal IVTA at the end of phacoemulsification, and the control group had routine surgery. CSMT, progression of DR, CDVA, IOP, and adverse events including endophthalmitis were compared between the groups preoperatively and at 1, 3, and 6 months postoperatively. Results Among a total of 66 patients that were treated within the study period, 50 patients were included in the final analysis. The case group comprised 21 eyes, and the control group included 29 eyes. Regression models and corrected ANOVA test for repeated measures showed a significant reduction in CSMT at 3 and 6 months postoperatively, which was most significant when the preoperative CSMT was ≥300 μm, with a cut-off value of 347.3 μm in the case group (p < 0.000). DR progression was halted in the case group at 6 months with 52.38% of patients having their DR classified as moderate (P = 0.012). CDVA was significantly improved from baseline 6/60 (logMAR 1.0) pre-op to 6/6 (logMAR 0.00) at 6 months post-op in the case group, and from baseline 6/120 (logMAR 1.3) pre-op to 6/12 (logMAR 0.3) at 6 months post-op in the control group. The gain in visual acuity was significantly higher in the case group at all study points (p < 0.001). No significant rise in IOP was observed at any study point in both groups (p = 0.23 > 0.05). No endophthalmitis was recorded. Conclusions Diabetic patients benefit significantly from cataract surgery. This study supports IVTA injection at the end of phacoemulsification in diabetic patients. Triamcinolone is an affordable (which is of particular importance in low-income countries as per our setting), and relatively safe “phaco-enhancer”. Trial registration NCT05413330. Initial release 10/06/2022. Unique Protocol ID: UDMS-Opthal-01-2022.
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Affiliation(s)
- Sarah Zaher Addeen
- grid.8192.20000 0001 2353 3326Department of ophthalmology, Al Mouassat University Hospital, Damascus University, Damascus, Syria
| | - Iyad Shaddoud
- grid.8192.20000 0001 2353 3326Department of ophthalmology, Al Mouassat University Hospital, Damascus University, Damascus, Syria
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Dinh RH, Moushmoush O, Kolyvas P, Jacobsen BA, Mathai M, Sanghavi K, Levinson JD, Do BK. Describing Adverse Events Associated with Bilateral Same-Day Intravitreal Dexamethasone Implants. Ophthalmic Surg Lasers Imaging Retina 2022; 53:612-618. [PMID: 36378615 DOI: 10.3928/23258160-20221018-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND OBJECTIVES To explore the incidence of adverse events after bilateral same-day intravitreal 0.7-mg dexamethasone implant (SDIDI) injections. MATERIALS AND METHODS We performed an IRB approved, single-center, retrospective review of patients receiving bilateral SDIDI injections from January 1, 2016 to October 31, 2021 and reviewed adverse events that occurred within 3 months of injection. RESULTS A total of 206 bilateral (412 eyes) SDIDI injections were performed in 59 patients. Ocular hypertension or the addition of intraocular pressure (IOP) lowering drops occurred in 121 (29.4%) eyes after IDI. Two (0.5%) eyes required glaucoma drainage surgeries. Of the 117 phakic eyes, 32 (27.4%) had progression of cataract or cataract extraction. There were two (0.5%) episodes of vitreous hemorrhage and one (0.2%) retinal tear with retinal detachment. There were no cases of endophthalmitis. CONCLUSION Serious complication rates after bilateral same-day IDI injections appears low. Increased IOP that requires intervention can occur. [Ophthalmic Surg Lasers Imaging Retina 2022;53:612-618.].
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Kwon JW, Park YG. CLINICAL FEATURES OF INTRAVITREAL DEXAMETHASONE IMPLANTATION IN VITRECTOMIZED EYES OF PATIENTS WITH DIABETIC MACULAR EDEMA. Retina 2022; 42:782-788. [PMID: 34907121 DOI: 10.1097/iae.0000000000003380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To identify the clinical outcomes of intravitreal dexamethasone implantation (IVD) in previously vitrectomized eyes of patients with diabetic macular edema. METHOD We performed a retrospective observational study. We recorded central subfield thickness, best-corrected visual acuity, and intraocular pressure up to 12 months after IVD implant placement. We compared the duration of IVD action, intraocular pressure trends, and the prevalence of ocular hypertension after the first IVD treatment of nonvitrectomized and vitrectomized eyes. We also compared the central subfield thickness, best-corrected visual acuity, number of IVD treatments, and prevalence of ocular hypertension between the 2 groups after 12 months. RESULTS We found no significant between-group differences in the central subfield thickness, best-corrected visual acuity, or the prevalence of ocular hypertension during treatment. However, the duration of action of the first IVD treatment was significantly shorter in vitrectomized eyes, and these eyes required more IVD treatments during the 12-month follow-up period. The maximal average intraocular pressure was observed at 2 months after the first IVD treatment in the nonvitrectomized group, but 1 month after the first IVD treatment in the vitrectomized group. CONCLUSION These findings suggest that the IVD pharmacokinetics and pharmacodynamics differ between vitrectomized and nonvitrectomized eyes. Nevertheless, given the relatively long-lasting effectiveness of the treatment and the good clinical results, consecutive IVD treatments may be beneficial for patients with diabetic macular edema with previously vitrectomized eyes.
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Affiliation(s)
- Jin-Woo Kwon
- Department of Ophthalmology, St. Vincent's Hospital, College of Medicine, the Catholic University of Korea, Seoul, Korea; and
| | - Young-Gun Park
- Department of Ophthalmology, Seoul St. Mary's Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea
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6
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Pesonen M, Kankaanpää E, Vottonen P. Cost-effectiveness of dexamethasone and triamcinolone for the treatment of diabetic macular oedema in Finland: A Markov-model. Acta Ophthalmol 2021; 99:e1146-e1153. [PMID: 33421332 PMCID: PMC8597173 DOI: 10.1111/aos.14745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 11/23/2020] [Accepted: 11/29/2020] [Indexed: 01/20/2023]
Abstract
PURPOSE Diabetic macular oedema (DMO), a complication of diabetes, causes vision loss and blindness. Corticosteroids are usually used as a second-line treatment. The aim of this study was to analyse the cost-effectiveness of dexamethasone implants compared to cheaper and more frequently applied triamcinolone injections. METHODS Markov-modelling, which incorporated both eyes, was used for economic evaluation. The model consisted of five health states based on visual acuity, illustrating the progression of DMO. A cycle length of five months was chosen for dexamethasone and four months for triamcinolone. Time horizons of two and five years were applied. Transition probabilities and health state utilities were sourced from previous studies. The perspective used in this analysis was the hospital perspective. The health care costs were acquired from Kuopio University Hospital in Finland. RESULTS In this cost-effectiveness analysis, the incremental cost-effectiveness ratio ICER with 3% discount rate was €56 591/QALY for a two-year follow-up and -€1 110 942/QALY for a five-year follow-up. In order to consider dexamethasone as cost-effective over a 2-year time horizon, the WTP needs to be around €55 000/QALY. Over the five-year follow-up, triamcinolone is clearly a dominant treatment. Sensitivity analyses support the cost-effectiveness of dexamethasone over a 2-year time horizon. CONCLUSIONS Since the sensitivity analyses support the results, dexamethasone would be a cost-effective treatment during the first two years with WTP threshold around €55 000/QALY, and triamcinolone would be a convenient treatment after that. This recommendation is in line with the guidelines of EURETINA.
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Affiliation(s)
| | | | - Pasi Vottonen
- Suomen Terveystalo Oy and University of Eastern FinlandKuopioFinland
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7
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Statement of the German Ophthalmological Society, the German Retina Society, and the Professional Association of Ophthalmologists in Germany on treatment of diabetic macular edema : Dated August 2019. Ophthalmologe 2021; 118:40-67. [PMID: 33033871 DOI: 10.1007/s00347-020-01244-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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8
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Luís ME, Sampaio F, Costa J, Cabral D, Teixeira C, Ferreira JT. Dril Influences Short-term Visual Outcome after Intravitreal Corticosteroid Injection for Refractory Diabetic Macular Edema. Curr Eye Res 2021; 46:1378-1386. [PMID: 33463388 DOI: 10.1080/02713683.2021.1878540] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Purpose: Intravitreal injections (IVI) of anti-vascular endothelial growth factor (anti-VEGF) are considered the gold standard for diabetic macular edema (DME). Despite adequate anti-VEGF treatments, many patients present persistent DME. The aim of this study is to identify systemic, ocular and anatomical characteristics influencing functional and anatomical outcomes in refractory DME patients treated with IVI of corticosteroid.Materials and Methods: Retrospective multicenter hospital-based cohort study including type 2 diabetic adult patients with refractory DME that switched from intravitreal anti-VEGF to intravitreal corticosteroid between January 2017 and September 2018. Sociodemographic, clinical data, DME and treatment characteristics were collected at baseline (visit before switch), as well as spectral domain OCT features.Results: A total of 101 eyes were included. The median number of anti-VEGF injections before switch was 5.0 (min-max: 4.0-9.0) and the median anti-VEGF treatment duration before switch was 33.2 (min-max: 19.5-50.3) months. More than half of the patients (56; 54.9%) were diagnosed with diffuse DME. At baseline, 80 (88%) patients had cystoid DME, 55 (62.5%) patients had disorganization of retinal inner layers (DRIL) and 16 (17.6%) had subretinal fluid. Dexamethasone was the corticosteroid more commonly used (71.4%), followed by triamcinolone (24.4%) and fluocinolone (4.2%). Regarding best corrected visual acuity (BCVA), post-switch results showed no statistically significant improvement at three-month follow-up (p = .048/0.096), but the mean central macular thickness (CMT) decreased significantly from 486.3 (SD = 159) µm to 369.3 (SD = 129) µm at three-month follow-up (p < .001). DRIL was the tomographic characteristic able to influence significantly both CMT and BCVA final results (p = .02 and 0.012, respectively).Conclusions: Subfoveal DRIL on structural OCT was the DME factor influencing significantly clinical and imaging outcomes in refractory DME patients treated with intravitreal corticosteroid. Portuguese care trend towards DME shows preference for the use of dexamethasone implant after therapeutic failure with ranibizumab or bevacizumab injection.
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Affiliation(s)
- Maria Elisa Luís
- Ophthalmology Department, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Filipa Sampaio
- Ophthalmology Department, Hospital Pedro Hispano, Unidade Local de Saúde de Matosinhos, Matosinhos, Portugal
| | - José Costa
- Ophthalmology Department, Hospital de Braga, Braga, Portugal Association for Innovation and Biomedical Research on Light (AIBILI), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Diogo Cabral
- Ophthalmology Department, Instituto de Oftalmologia Dr. Gama Pinto CEDOC - NOVA Medical School - Faculdade de Ciências Médicas da Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Carla Teixeira
- Ophthalmology Department, Hospital Pedro Hispano, Unidade Local de Saúde de Matosinhos, Matosinhos, Portugal
| | - Joana Tavares Ferreira
- Ophthalmology Department, Hospital CUF Cascais, Lisbon, Portugal.,Ophthalmology Department, Hospital CUF Descobertas, Lisbon, Portugal.,Neuro-Ophthalmology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal.,Centro de Estudos das Ciências da Visão, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal.,Escola Superior de Tecnologia da Saúde de Lisboa Do Instituto Politécnico de Lisboa, Lisbon, Portugal
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9
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Risk factors for ocular hypertension after intravitreal dexamethasone implantation in diabetic macular edema. Sci Rep 2020; 10:13736. [PMID: 32792579 PMCID: PMC7426405 DOI: 10.1038/s41598-020-70833-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 08/05/2020] [Indexed: 11/09/2022] Open
Abstract
We designed a retrospective observational study to identify factors associated with ocular hypertension [OHTN, defined as intraocular pressure (IOP) > 25 mmHg] after intravitreal dexamethasone (IVD) implantation in diabetic macular edema (DME) patients. We measured IOP monthly after placement of an IVD implant, and identified the trend of IOP, incidence of OHTN, and its associated systemic or ocular factors. On average, IOP was highest at 2 months after IVD implantation. Of 84 DME patients who received an IVD implant, 3 (3.57%) presented with an IOP ≥ 25 mmHg at 1 month after implantation, 6 (7.14%) at 2 months, and 2 (2.38%) at 3 months. Compared with the non-OHTN group, the OHTN group had significantly shorter axial lengths and were younger. Logistic regression analysis revealed that axial length < 23.00 mm and age < 57 years were associated with OHTN occurrence. Patients whose IOP was elevated > 30% or ≥ 20 mmHg at 1 month post-implantation, subsequently developed OHTN with statistical significance. In conclusion, shorter axial length and younger age were associated with OHTN occurrence after IVD implantation. Additionally, identifying levels or trends in IOP at 1 month after the IVD procedure may be helpful in predicting subsequent OHTN occurrence.
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Nithianandan H, Kuriyan AE, Venincasa MJ, Sridhar J. <p>Analysis of Funding Source and Spin in the Reporting of Studies of Intravitreal Corticosteroid Therapy for Diabetic Macular Edema: A Systematic Review</p>. Clin Ophthalmol 2020; 14:2383-2395. [PMID: 32903959 PMCID: PMC7445525 DOI: 10.2147/opth.s262085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 07/28/2020] [Indexed: 01/05/2023] Open
Affiliation(s)
- Harrish Nithianandan
- Department of Ophthalmology & Visual Sciences, McGill University, Montreal, Quebec, Canada
| | - Ajay E Kuriyan
- Retina Service, Wills Eye Hospital, Philadelphia, PA, USA
| | - Michael J Venincasa
- Department of Ophthalmology, Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Jayanth Sridhar
- Department of Ophthalmology, Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
- Correspondence: Jayanth Sridhar Email
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Stellungnahme der DOG, der RG und des BVA zur Therapie des diabetischen Makulaödems. Ophthalmologe 2020; 117:218-247. [DOI: 10.1007/s00347-019-01015-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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12
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Maniadakis N, Konstantakopoulou E. Cost Effectiveness of Treatments for Diabetic Retinopathy: A Systematic Literature Review. PHARMACOECONOMICS 2019; 37:995-1010. [PMID: 31012025 DOI: 10.1007/s40273-019-00800-w] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Diabetic retinopathy (DR) affects approximately one-third of people diagnosed with diabetes, can be sight-threatening, and generates significant human and economic burden. Over the last 2 decades, newer therapies have emerged, offering significant clinical benefits, however at a cost. Given the scarcity of available budgets, the cost effectiveness of these newer treatments is of vital importance to policy makers. METHODS A systematic review was conducted in the PubMed, EMBASE, Cochrane, HEED and CRD databases to find and evaluate economic evaluations assessing the cost effectiveness of alterative DR treatments. Studies were assessed for their eligibility, findings and quality, and are presented in this systematic review. RESULTS Of the 5254 studies retrieved from the literature search, 17 were included in this review. For patients with proliferative DR, when early pars plana vitrectomy was compared with pan-retinal laser photocoagulation, similar cost per quality-adjusted life-year (QALY) was observed between the two. Treatment with either intravitreal ranibizumab (IVR) or intravitreal bevacizumab (IVB) falls within acceptable cost-effectiveness thresholds in the diabetic macular oedema (DMO) population; however, in the non-DMO population, the marginal benefit of IVR or IVB in relation to the marginal cost relative to laser does not justify their use. Among the anti-vascular endothelial growth factor (VEGF) therapies, IVB appears more attractive from an economic point of view due to its lower cost. For patients with DMO, studies indicate that a combination therapy of IVR or IVB with laser and, to a lesser degree, as monotherapy, are cost effective relative to laser monotherapy; IVR plus laser is cost effective relative to laser plus triamcinolone; and laser combined with triamcinolone injections is reportedly more cost effective over IVR for pseudophakic eyes only. Moreover, fluocinolone implants appear cost effective compared with sham implants, or when treating refractory DMO. IVR administered either pro re nata (PRN) or as 'treat and extend' dominated intravitreal aflibercept (IVA) in a few studies. On the other hand, IVR monotherapy or with laser (as well as IVA) does not compare favourably relative to IVB monotherapy or with laser. CONCLUSIONS Interpretation of cost-effectiveness data should be treated with caution in this case; details of the therapeutic regimen, such as dosage and frequency, and clinical efficacy of the treatments should be considered in relation to policy-making decisions. Given the scarcity of resources, the ever-increasing significance of health technology assessment, and the substantial differences in the methodologies of the studies presented in this review, there is a pressing need for more advanced and standardised approaches to assessing the effectiveness and cost effectiveness of the emerging anti-VEGF pharmacotherapies for the treatment of DMO.
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Affiliation(s)
- Nikolaos Maniadakis
- Department of Health Services Organization, National School of Public Health, Athens, Greece
| | - Evgenia Konstantakopoulou
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, 162 City Road, London, EC1V 2PD, UK.
- Institute of Ophthalmology, University College London, London, UK.
- Division of Optics and Optometry, Department of Biomedical Sciences, University of West Attica, Athens, Greece.
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Urbančič M, Gardašević Topčić I. Dexamethasone implant in the management of diabetic macular edema from clinician's perspective. Clin Ophthalmol 2019; 13:829-840. [PMID: 31190726 PMCID: PMC6526171 DOI: 10.2147/opth.s206769] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 04/04/2019] [Indexed: 12/17/2022] Open
Abstract
The aim of this article is to provide an overview of characteristics and principles of use of dexamethasone implant in patients with diabetic macular edema (DME). The condensed information about patient selection, dosing, and postinjection management is provided to make the clinician’s decisions easier in real-life practice. DME is a common complication of diabetes and the leading cause of visual loss in the working-age population. Inflammation plays an important role in the pathogenesis of DME. The breakdown of the blood–retinal barrier involves the expression of inflammatory cytokines and growth factors, including vascular endothelial growth factor (VEGF). Steroids have proved to be effective in the treatment of DME by blocking the production of VEGF and other inflammatory cytokines, by inhibiting leukostasis, and by enhancing the barrier function of vascular endothelial cell tight junctions. Dexamethasone intravitreal implant has demonstrated efficacy in the treatment of DME resistant to anti-VEGF therapy and in vitrectomized eyes. Data from clinical trials suggest that dexamethasone implant can be considered as first-line treatment in pseudophakic eyes. Dexamethasone implant is also the first-line therapy in patients not suited for anti-VEGF therapy, pregnant women, and patients unable to return for frequent monitoring. It has been shown that the maximum effect of dexamethasone implant on visual gain and retinal thickness occurs approximately 2 months after injection. Various treatment regimens are used in real-life situations, and reported reinjection intervals were usually <6 months. The number of retreatments needed decreased over time. Treatment algorithms should be personalized. Postinjection management and follow-up should consider potential adverse events such as intraocular pressure elevation and cataract.
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Affiliation(s)
- Mojca Urbančič
- Eye Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
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Virgili G, Parravano M, Evans JR, Gordon I, Lucenteforte E. Anti-vascular endothelial growth factor for diabetic macular oedema: a network meta-analysis. Cochrane Database Syst Rev 2018; 10:CD007419. [PMID: 30325017 PMCID: PMC6517135 DOI: 10.1002/14651858.cd007419.pub6] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Diabetic macular oedema (DMO) is a common complication of diabetic retinopathy. Antiangiogenic therapy with anti-vascular endothelial growth factor (anti-VEGF) can reduce oedema, improve vision and prevent further visual loss. These drugs have replaced laser photocoagulation as the standard of care for people with DMO. OBJECTIVES The 2014 update of this review found high-quality evidence of benefit with anti-VEGF modalities, compared to laser photocoagulation, for the treatment of DMO. The objective of this updated review is to compare the effectiveness and safety of the different anti-VEGF drugs using network meta-analysis methods. SEARCH METHODS We searched various electronic databases on 26 April 2017. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared any anti-angiogenic drug with an anti-VEGF mechanism of action versus another anti-VEGF drug, another treatment, sham or no treatment in people with DMO. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods for pair-wise meta-analysis and we augmented this evidence using network meta-analysis methods. We focused on the relative efficacy and safety of the three most commonly used drugs as interventions of direct interest for practice: aflibercept and ranibizumab, used on-label; and off-label bevacizumab.We collected data on three efficacy outcomes (gain of 15 or more Early Treatment Diabetic Retinopathy Study (ETDRS) letters; mean change in best-corrected visual acuity (BCVA); mean change in central retinal thickness (CRT)), three safety outcomes (all severe systemic adverse events (SSAEs); all-cause death; arterial thromboembolic events) and quality of life.We used Stata 'network' meta-analysis package for all analyses. We investigated the risk of bias of mixed comparisons based on the variance contribution of each study, having assigned an overall risk of bias to each study. MAIN RESULTS Twenty-four studies included 6007 participants with DMO and moderate vision loss, of which two studies randomised 265 eyes of 230 participants and one was a cross-over study on 56 participants (62 eyes) that was treated as a parallel-arm trial. Data were collected on drugs of direct interest from three studies on aflibercept (975 eyes), eight studies on bevacizumab (515 eyes), and 14 studies on ranibizumab (1518 eyes). As treatments of indirect interest or legacy treatment we included three studies on pegaptanib (541 eyes), five studies on ranibizumab plus prompt laser (557 eyes), one study on ranibizumab plus deferred laser (188 eyes), 13 studies on laser photocoagulation (936 eyes) and six studies on sham treatment (793 eyes).Aflibercept, bevacizumab and ranibizumab were all more effective than laser for improving vision by 3 or more lines after one year (high-certainty evidence). Approximately one in 10 people improve vision with laser, and about three in 10 people improve with anti-VEGF treatment: risk ratio (RR) versus laser 3.66 (95% confidence interval (CI) 2.79 to 4.79) for aflibercept; RR 2.47 (95% CI 1.81 to 3.37) for bevacizumab; RR 2.76 (95% CI 2.12 to 3.59) for ranibizumab. On average there was no change in visual acuity (VA) with laser after one year, compared with a gain of 1 or 2 lines with anti-VEGF treatment: laser versus aflibercept mean difference (MD) -0.20 (95% CI -0.22 to -0.17) logMAR; versus bevacizumab MD -0.12 (95% CI -0.15 to -0.09) logMAR; versus ranibizumab MD -0.12 (95% CI -0.14 to -0.10) logMAR. The certainty of the evidence was high for the comparison of aflibercept and ranibizumab with laser and moderate for bevacizumab comparison with laser due to inconsistency between the indirect and direct evidence.People receiving ranibizumab were less likely to gain 3 or more lines of VA at one year compared with aflibercept: RR 0.75 (95% CI 0.60 to 0.94), moderate-certainty evidence. For every 1000 people treated with aflibercept, 92 fewer would gain 3 or more lines of VA at one year if treated with ranibizumab (22 to 148 fewer). On average people receiving ranibizumab had worse VA at one year (MD 0.08 logMAR units, 95% CI 0.05 to 0.11), moderate-certainty evidence; and higher CRT (MD 39 µm, 95% CI 2 µm to 76 µm; low-certainty evidence). Ranibizumab and bevacizumab were comparable with respect to aflibercept and did not differ in terms of VA: RR of gain of 3 or more lines of VA at one year 1.11 (95% CI 0.87 to 1.43), moderate-certainty evidence, and difference in change in VA was 0.00 (95% CI -0.02 to 0.03) logMAR, moderate-certainty evidence. CRT reduction favoured ranibizumab by -29 µm (95% CI -58 µm to -1 µm, low-certainty evidence). There was no evidence of overall statistical inconsistency in our analyses.The previous version of this review found moderate-certainty evidence of good safety of antiangiogenic drugs versus control. This update used data at the longest available follow-up (one or two years) and found that aflibercept, ranibizumab and bevacizumab do not differ regarding systemic serious adverse events (SSAEs) (moderate- or high-certainty evidence). However, risk of bias was variable, loop inconsistency could be found and estimates were not precise enough on relative safety regarding less frequent events such as arterial thromboembolic events or death (low- or very low-certainty evidence).Two-year data were available and reported in only four RCTs in this review. Most industry-sponsored studies were open-label after one year. One large publicly-funded study compared the three drugs at two years and found no difference. AUTHORS' CONCLUSIONS Anti-VEGF drugs are effective at improving vision in people with DMO with three to four in every 10 people likely to experience an improvement of 3 or more lines VA at one year. Aflibercept may confer some advantage over ranibizumab and bevacizumab in people with DMO at one year in visual and anatomic terms but it is unclear whether this applies to the long-term. There is a need for more evidence on the long-term (greater than two years) comparative effects of these anti-VEGF agents. Evidence from RCTs may not apply to real-world practice, where people in need of antiangiogenic treatment are often under-treated and under-monitored.We found no signals of differences in overall safety between the three antiangiogenic drugs that are currently available to treat DMO, but our estimates are imprecise for cardiovascular events and death.
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Affiliation(s)
- Gianni Virgili
- University of FlorenceDepartment of Translational Surgery and Medicine, Eye ClinicLargo Brambilla, 3FlorenceItaly50134
| | - Mariacristina Parravano
- Fondazione G.B. Bietti per lo studio e la ricerca in Oftalmolologia‐IRCCSOphthalmologyVia Livenza n 3RomeItaly00198
| | - Jennifer R Evans
- London School of Hygiene & Tropical MedicineCochrane Eyes and Vision, ICEHKeppel StreetLondonUKWC1E 7HT
| | - Iris Gordon
- London School of Hygiene & Tropical MedicineCochrane Eyes and Vision, ICEHKeppel StreetLondonUKWC1E 7HT
| | - Ersilia Lucenteforte
- University of FlorenceDepartment of Neurosciences, Psychology, Drug Research and Children’s Healthviale Gaetano Pieraccini, 6FlorenceItaly50139
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Bastakis GG, Dimopoulos D, Stavrakakis A, Pappas G. Long-term efficacy and duration of action of dexamethasone implant, in vitrectomised and non-vitrectomised eyes with persistent diabetic macular oedema. Eye (Lond) 2018; 33:411-418. [PMID: 30302004 DOI: 10.1038/s41433-018-0219-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 08/04/2018] [Accepted: 08/16/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To evaluate the efficacy and duration of action of an intravitreal (dexamethasone (Ozurdex)) implant in vitrectomised and non-vitrectomised eyes with persistent diabetic macular oedema (DMO). METHODS We retrospectively analysed the records for 18 eyes that had or had not been vitrectomised but required an intravitreal dexamethasone implant for DMO after a poor response to anti-vascular endothelial growth factor. Optical coherence tomography and visual acuity (VA) examinations were performed before and 1, 3 and 6 months after implantation. The six months following implantation constituted one treatment round; up to three rounds were studied. RESULTS Ten of 18 eyes had undergone vitrectomy. Best-corrected visual acuity (BCVA) and central macular thickness (CMT) were significantly improved by months 1-3 after implantation of the Ozurdex device in all rounds of treatment. The BCVA and CMT deteriorated gradually after month 3 through to month 6 post implantation. There were no statistically significant differences between the vitrectomised and non-vitrectomised groups at any time point. When the implantation interval was <6 weeks from the end of each treatment round, the improvement in BCVA and CMT was obvious even after 18 months of treatment. CONCLUSIONS Vitrectomy did not have a negative effect on the duration of action or efficacy of the Ozurdex implant in patients with persistent DMO. The implant started working from the first month after implantation regardless of whether vitrectomy had or had not been performed. The maximum functional and anatomic improvement was achieved in the first 3 months post implantation in all treatment rounds.
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Affiliation(s)
- George G Bastakis
- Ophthalmology Clinic, Medical Retina & Vitreoretinal Surgery Department, Venizeleio Hospital of Crete, Knossos avenue 44, Crete, 71409,, Heraklion, Greece
| | - Dimitris Dimopoulos
- Ophthalmology Clinic, Medical Retina & Vitreoretinal Surgery Department, Venizeleio Hospital of Crete, Knossos avenue 44, Crete, 71409,, Heraklion, Greece
| | - Anastasios Stavrakakis
- Ophthalmology Clinic, Medical Retina & Vitreoretinal Surgery Department, Venizeleio Hospital of Crete, Knossos avenue 44, Crete, 71409,, Heraklion, Greece
| | - George Pappas
- Ophthalmology Clinic, Medical Retina & Vitreoretinal Surgery Department, Venizeleio Hospital of Crete, Knossos avenue 44, Crete, 71409,, Heraklion, Greece.
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16
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Intravitreal Steroid Implants in the Management of Retinal Disease and Uveitis. Int Ophthalmol Clin 2018; 56:127-49. [PMID: 27575764 DOI: 10.1097/iio.0000000000000132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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17
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Moon SW, Sun Y, Warther D, Huffman K, Freeman WR, Sailor MJ, Cheng L. New model of proliferative vitreoretinopathy in rabbit for drug delivery and pharmacodynamic studies. Drug Deliv 2018; 25:600-610. [PMID: 29461171 PMCID: PMC6058613 DOI: 10.1080/10717544.2018.1440664] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Blinding retinal diseases become more epidemic as the population ages. These diseases, such as diabetic retinopathy and macular edema, are of chronic nature and require protracted drug presence at the disease site. A sustained intravitreal porous silicon delivery system with dexamethasone (pSiO2-COO-DEX) was evaluated in a new rabbit model of proliferative vitreoretinopathy (PVR) in a real treatment design. In contrast to the pretreatment design model, pSiO2-COO-DEX was intravitreally injected into the eyes with active inflammation. Subretinal injection of vascular endothelial growth factor (VEGF) and Matrigel induced a late-onset vitreoretinal inflammation that gradually developed into PVR. This method mimics the human disease better than PVR induced by either intravitreal cell injection or trauma. The pSiO2-COO-DEX intervened eyes had minimal PVR, while balanced saline solution or free dexamethasone intervened eyes had significantly more PVR formation. In addition, adding VEGF to the Matrigel for subretinal injection induced greater inflammation and retinal neovascularization in comparison to only Matrigel injected under the medullary ray. Clinical and pathological examinations, including fundus fluorescein angiography and optical coherence tomography, confirmed these changes. In the current study, neither subretinal injection of Matrigel or subretinal injection of VEGF and Matrigel induced choroidal neovascularization. However, the current PVR model demonstrates a chronic course with moderate severity, which may be useful for drug screening studies.
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Affiliation(s)
- Sang Woong Moon
- a Department of Ophthalmology , Jacobs Retina Center at Shiley Eye Institute, University of California San Diego , La Jolla , CA , USA.,b Department of Ophthalmology, College of Medicine , Kyung Hee University , Seoul , Republic of Korea
| | - Yaoyao Sun
- a Department of Ophthalmology , Jacobs Retina Center at Shiley Eye Institute, University of California San Diego , La Jolla , CA , USA.,c Department of Ophthalmology , Ophthalmology & Optometry Center, Peking University People's Hospital , Beijing , China
| | - David Warther
- d Department of Chemistry and Biochemistry , University of California San Diego , La Jolla , CA , USA
| | - Kristyn Huffman
- a Department of Ophthalmology , Jacobs Retina Center at Shiley Eye Institute, University of California San Diego , La Jolla , CA , USA
| | - William R Freeman
- a Department of Ophthalmology , Jacobs Retina Center at Shiley Eye Institute, University of California San Diego , La Jolla , CA , USA
| | - Michael J Sailor
- d Department of Chemistry and Biochemistry , University of California San Diego , La Jolla , CA , USA
| | - Lingyun Cheng
- a Department of Ophthalmology , Jacobs Retina Center at Shiley Eye Institute, University of California San Diego , La Jolla , CA , USA
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Khan Z, Kuriakose RK, Khan M, Chin EK, Almeida DRP. Efficacy of the Intravitreal Sustained-Release Dexamethasone Implant for Diabetic Macular Edema Refractory to Anti-Vascular Endothelial Growth Factor Therapy: Meta-Analysis and Clinical Implications. Ophthalmic Surg Lasers Imaging Retina 2017; 48:160-166. [PMID: 28195619 DOI: 10.3928/23258160-20170130-10] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 12/12/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVE To assess the effect on best-corrected visual acuity (BCVA) and efficacy of the intravitreal sustained-release 0.7 mg dexamethasone implant (Ozurdex; Allergan, Irvine, CA) in patients with recalcitrant diabetic macular edema (DME). PATIENTS AND METHODS Meta-analysis utilizing the MOOSE framework and a random effects model. Studies included adults undergoing treatment with Ozurdex for DME. The methodologic quality of each study was assessed using the MINORS and the Cochrane Collaboration Risk of Bias for randomized studies. RESULTS A total of 3,859 patients among 15 studies were included in the final analysis. The mean difference in BCVA was a gain of four lines or 20 Early Treatment of Diabetic Retinopathy Study letters with Ozurdex at a mean follow-up period of 6 months. CONCLUSIONS Treatment with Ozurdex is associated with significant mean improvement in visual acuity. Clinicians should have a multimodality approach to treating DME and be aware of this treatment option in those who have a suboptimal response to anti-VEGF therapy. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:160-166.].
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Virgili G, Parravano M, Evans JR, Gordon I, Lucenteforte E. Anti-vascular endothelial growth factor for diabetic macular oedema: a network meta-analysis. Cochrane Database Syst Rev 2017; 6:CD007419. [PMID: 28639415 PMCID: PMC6481463 DOI: 10.1002/14651858.cd007419.pub5] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Diabetic macular oedema (DMO) is a common complication of diabetic retinopathy. Antiangiogenic therapy with anti-vascular endothelial growth factor (anti-VEGF) modalities can reduce oedema and thereby improve vision and prevent further visual loss. These drugs have replaced laser photocoagulation as the standard of care for people with DMO. OBJECTIVES The 2014 update of this review found high-quality evidence of benefit with antiangiogenic therapy with anti-VEGF modalities, compared to laser photocoagulation, for the treatment of DMO.The objective of this updated review is to compare the effectiveness and safety of the different anti-VEGF drugs in preserving and improving vision and quality of life using network meta-analysis methods. SEARCH METHODS We searched various electronic databases on 26 April 2017. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared any anti-angiogenic drug with an anti-VEGF mechanism of action versus another anti-VEGF drug, another treatment, sham or no treatment in people with DMO. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods for pair-wise meta-analysis and we augmented this evidence using network meta-analysis methods. We focused on the relative efficacy and safety of the three most commonly used drugs as interventions of direct interest for practice: aflibercept and ranibizumab, used on-label; and off-label bevacizumab.We collected data on three efficacy outcomes (gain of 15 or more Early Treatment Diabetic Retinopathy Study (ETDRS) letters; mean change in best-corrected visual acuity (BCVA); mean change in central retinal thickness (CRT)), three safety outcomes (all severe systemic adverse events (SSAEs); all-cause death; arterial thromboembolic events) and quality of life.We used Stata 'network' meta-analysis package for all analyses. We investigated the risk of bias of mixed comparisons based on the variance contribution of each study, having assigned an overall risk of bias to each study. MAIN RESULTS Twenty-four studies included 6007 participants with DMO and moderate vision loss, of which two studies randomised 265 eyes of 230 participants and one was a cross-over study on 56 participants (62 eyes) that was treated as a parallel-arm trial. Data were collected on drugs of direct interest from three studies on aflibercept (975 eyes), eight studies on bevacizumab (515 eyes), and 14 studies on ranibizumab (1518 eyes). As treatments of indirect interest or legacy treatment we included three studies on pegaptanib (541 eyes), five studies on ranibizumab plus prompt laser (557 eyes), one study on ranibizumab plus deferred laser (188 eyes), 13 studies on laser photocoagulation (936 eyes) and six studies on sham treatment (793 eyes).Aflibercept, bevacizumab and ranibizumab were all more effective than laser for improving vision by 3 or more lines after one year (high-certainty evidence). Approximately one in 10 people improve vision with laser, and about three in 10 people improve with anti-VEGF treatment: risk ratio (RR) versus laser 3.66 (95% confidence interval (CI) 2.79 to 4.79) for aflibercept; RR 2.47 (95% CI 1.81 to 3.37) for bevacizumab; RR 2.76 (95% CI 2.12 to 3.59) for ranibizumab. On average there was no change in visual acuity (VA) with laser after one year, compared with a gain of 1 or 2 lines with anti-VEGF treatment: laser versus aflibercept mean difference (MD) -0.20 (95% CI -0.22 to -0.17) logMAR; versus bevacizumab MD -0.12 (95% CI -0.15 to -0.09) logMAR; versus ranibizumab MD -0.12 (95% CI -0.14 to -0.10) logMAR. The certainty of the evidence was high for the comparison of aflibercept and ranibizumab with laser and moderate for bevacizumab comparison with laser due to inconsistency between the indirect and direct evidence.People receiving ranibizumab were less likely to gain 3 or more lines of VA at one year compared with aflibercept: RR 0.75 (95% CI 0.60 to 0.94), moderate-certainty evidence. For every 1000 people treated with aflibercept, 92 fewer would gain 3 or more lines of VA at one year if treated with ranibizumab (22 to 148 fewer). On average people receiving ranibizumab had worse VA at one year (MD 0.08 logMAR units, 95% CI 0.05 to 0.11), moderate-certainty evidence; and higher CRT (MD 39 µm, 95% CI 2 µm to 76 µm; low-certainty evidence). Ranibizumab and bevacizumab were comparable with respect to aflibercept and did not differ in terms of VA: RR of gain of 3 or more lines of VA at one year 1.11 (95% CI 0.87 to 1.43), moderate-certainty evidence, and difference in change in VA was 0.00 (95% CI -0.02 to 0.03) logMAR, moderate-certainty evidence. CRT reduction favoured ranibizumab by -29 µm (95% CI -58 µm to -1 µm, low-certainty evidence). There was no evidence of overall statistical inconsistency in our analyses.The previous version of this review found moderate-certainty evidence of good safety of antiangiogenic drugs versus control. This update used data at the longest available follow-up (one or two years) and found that aflibercept, ranibizumab and bevacizumab do not differ regarding systemic serious adverse events (SSAEs) (moderate- or high-certainty evidence). However, risk of bias was variable, loop inconsistency could be found and estimates were not precise enough on relative safety regarding less frequent events such as arterial thromboembolic events or death (low- or very low-certainty evidence).Two-year data were available and reported in only four RCTs in this review. Most industry-sponsored studies were open-label after one year. One large publicly-funded study compared the three drugs at two years and found no difference. AUTHORS' CONCLUSIONS Anti-VEGF drugs are effective at improving vision in people with DMO with three to four in every 10 people likely to experience an improvement of 3 or more lines VA at one year. There is moderate-certainty evidence that aflibercept confers some advantage over ranibizumab and bevacizumab in people with DMO at one year in visual and anatomic terms. Relative effects among anti-VEGF drugs at two years are less well known, since most studies were short term. Evidence from RCTs may not apply to real-world practice, where people in need of antiangiogenic treatment are often under-treated and under-monitored.We found no signals of differences in overall safety between the three antiangiogenic drugs that are currently available to treat DMO, but our estimates are imprecise for cardiovascular events and death.
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Key Words
- humans
- angiogenesis inhibitors
- angiogenesis inhibitors/therapeutic use
- antibodies, monoclonal
- antibodies, monoclonal/therapeutic use
- antibodies, monoclonal, humanized
- antibodies, monoclonal, humanized/therapeutic use
- aptamers, nucleotide
- aptamers, nucleotide/therapeutic use
- bevacizumab
- diabetic retinopathy
- diabetic retinopathy/complications
- laser coagulation
- laser coagulation/methods
- macular edema
- macular edema/drug therapy
- macular edema/surgery
- randomized controlled trials as topic
- ranibizumab
- receptors, vascular endothelial growth factor
- receptors, vascular endothelial growth factor/therapeutic use
- recombinant fusion proteins
- recombinant fusion proteins/therapeutic use
- triamcinolone
- triamcinolone/therapeutic use
- vascular endothelial growth factor a
- vascular endothelial growth factor a/antagonists & inhibitors
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Affiliation(s)
- Gianni Virgili
- University of FlorenceDepartment of Translational Surgery and Medicine, Eye ClinicLargo Brambilla, 3FlorenceItaly50134
| | - Mariacristina Parravano
- Fondazione G.B. Bietti per lo studio e la ricerca in Oftalmolologia‐IRCCSOphthalmologyVia Livenza n 3RomeItaly00198
| | - Jennifer R Evans
- London School of Hygiene & Tropical MedicineCochrane Eyes and Vision, ICEHKeppel StreetLondonUKWC1E 7HT
| | - Iris Gordon
- London School of Hygiene & Tropical MedicineCochrane Eyes and Vision, ICEHKeppel StreetLondonUKWC1E 7HT
| | - Ersilia Lucenteforte
- University of FlorenceDepartment of Neurosciences, Psychology, Drug Research and Children’s Healthviale Gaetano Pieraccini, 6FlorenceItaly50139
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20
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Cheung GCM, Yoon YH, Chen LJ, Chen SJ, George TM, Lai TYY, Park KH, Tahija SG, Uy HS, Wong TY. Diabetic macular oedema: evidence-based treatment recommendations for Asian countries. Clin Exp Ophthalmol 2017; 46:75-86. [DOI: 10.1111/ceo.12999] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 05/24/2017] [Accepted: 05/25/2017] [Indexed: 01/06/2023]
Affiliation(s)
- Gemmy CM Cheung
- Singapore National Eye Centre, Duke-NUS Medical School; National University of Singapore; Singapore
| | - Young Hee Yoon
- Department of Ophthalmology, Asan Medical Center; University of Ulsan College of Medicine; Seoul Korea
| | | | - Shih Jen Chen
- Department of Ophthalmology, Taipei Veterans General Hospital, School of Medicine; National Yang Ming University; Taipei Taiwan
| | - Tara M George
- Sunway Medical Centre, Eye Centre; Petaling Jaya Malaysia
| | - Timothy YY Lai
- Department of Ophthalmology and Visual Sciences; The Chinese University of Hong Kong; Kowloon Hong Kong
| | - Kyu Hyung Park
- Department of Ophthalmology, Seoul National University Bundang Hospital; Seoul National University College of Medicine; Seongnam Korea
| | | | - Harvey S Uy
- Department of Ophthalmology and Visual Sciences; University of the Philippines, Philippine General Hospital; Manila Philippines
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Identification of time point to best define 'sub-optimal response' following intravitreal ranibizumab therapy for diabetic macular edema based on real-life data. Eye (Lond) 2017. [PMID: 28622321 DOI: 10.1038/eye.2017.111] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PurposeTo determine the average time-point at which it is best to define 'sub-optimal response' after ranibizumab treatment for diabetic macular edema (DME) based on the data obtained from real-life clinical practice.MethodsIn this retrospective observational study, 322 consecutive treatment naïve eyes with DME were treated with three loading doses of intravitreal ranibizumab followed by re-treatment based on decision of the treating physician on a case-by-case basis. The demographic data, clinic-based visual acuity measurements and central subfield thickness (CST) assessed on spectral domain optical coherence tomography (OCT) were evaluated at baseline (month 0), 1, 2, 3, 6, and 12 months.ResultsOn an average, the improvement in visual acuity and CST was first seen after the loading dose. However, the maximal response in terms of proportion of patients with improvement in visual acuity and/ or CST in this cohort was observed at 12 months. Patients who presented with low visual acuity at baseline (<37 ETDRS letters) were unlikely to attain driving vision with ranibizumab therapy.ConclusionsOn an average, a 'sub-optimal response' after ranibizumab therapy is best defined at month 12 as patients may continue to improve with treatment.
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Abstract
Diabetic macular oedema (DMO) results from alterations of several biochemical pathways in diabetic eyes. Centre-involving DMO is an important cause of visual loss in diabetes. Anti-vascular endothelial growth factor agents are now the mainstay of centre-involving DMO treatment. Oedema that does not achieve optimal response to these agents occurs in a sizeable proportion of eyes and is called refractory or persistent DMO. Management of refractory DMO is challenging. In this paper, the pathophysiology of DMO, and the definitions used in various studies are summarised. Therapeutic options for refractory DMO management including corticosteroids, laser, combination therapies, and surgery are explored. Novel agents on the horizon for DMO control that are being investigated at present are discussed as well. A literature review was performed and a summary of the research studies for each of the agents is provided in order to guide the reader regarding the existing evidence for their application in DMO. Importance of early recognition of disease and prompt treatment to achieve best visual outcome is discussed. Utility of optical coherence tomography to guide disease diagnosis and monitoring is highlighted. An algorithmic approach for DMO management is described. Finally, the impact that personalized medicine and genetics might have on DMO management is assessed.
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Efficacité précoce de l’implant de dexaméthasone (OZURDEX ® ) évaluée en vraie vie dans le traitement de l’œdème maculaire diabétique. J Fr Ophtalmol 2017; 40:408-413. [DOI: 10.1016/j.jfo.2016.10.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 08/01/2016] [Accepted: 10/14/2016] [Indexed: 11/17/2022]
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Report of 12-months efficacy and safety of intravitreal fluocinolone acetonide implant for the treatment of chronic diabetic macular oedema: a real-world result in the United Kingdom. Eye (Lond) 2017; 31:650-656. [PMID: 28106887 PMCID: PMC5396008 DOI: 10.1038/eye.2016.301] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 11/20/2016] [Indexed: 01/06/2023] Open
Abstract
Purpose To report the 12-months visual and anatomical outcomes of chronic diabetic macular oedema (DMO) treated with ILUVIEN in a real-world clinical practice in a single tertiary referral centre. Method Retrospective data collection and analysis of consecutive 28 eyes of 23 diabetic patients received ILUVIEN implant for refractory DMO. Standard assessment included visual acuity (VA), central retinal thickness (CRT), slit-lamp biomicroscopy, and Goldmann tonometry for intraocular pressure (IOP) at 1, 6, and 12 months. Results Baseline mean VA was 47 (SD 18) letters improved to 55 (SD 17) letters (P=0.004) at 12 months. VA was improved in 16 eyes (57%), stabilised in 9 eyes (32%), and decreased in 3 eyes (11%). Seven eyes (25%) gained ≥15 letters, and 10 eyes (36%) gained >10 letters from baseline. The percentage of eyes achieved driving vision (≥70 Early Treatment Diabetic Retinopathy Study letters) was doubled from baseline 18 to 36% at 6 months and 32% at 12 months. Mean CRT decreased by 198 μm from baseline 494 μm (SD 191) to 296 μm (SD 121) at 12 months (P<0.001). Two eyes received additional anti-vascular endothelial growth factor injections after 10 months. Complications: Raised IOP in three eyes (11%) controlled with IOP-lowering drops, vitreous haemorrhage in one eye and one endophthalmitis (1 year vision improved to 6/24). Conclusion Our real-world results show that the visual and the anatomical improvements achieved by a single ILUVIEN implant injection were maintained up to 12 months with minimal adjunctive therapy. IOP monitoring remains essential in ILUVIEN patients, although our study shows a relatively low risk of IOP elevation post ILUVIEN injection, even in existing controlled ocular hypertension. Our results demonstrate that ILUVIEN is an effective long-term option in treating chronic refractory DMO.
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Meireles A, Goldsmith C, El-Ghrably I, Erginay A, Habib M, Pessoa B, Coelho J, Patel T, Tadayoni R, Massin P, Atorf J, Augustin AJ. Efficacy of 0.2 μg/day fluocinolone acetonide implant (ILUVIEN) in eyes with diabetic macular edema and prior vitrectomy. Eye (Lond) 2017; 31:684-690. [PMID: 28085139 PMCID: PMC5437318 DOI: 10.1038/eye.2016.303] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 11/15/2016] [Indexed: 11/17/2022] Open
Abstract
Purpose Limited data are available on the efficacy of the 0.2 μg/day fluocinolone acetonide (FAc) implant in eyes with prior vitrectomy. Here, we present a collection of 26 vitrectomized eyes treated with the 0.2 μg/day FAc implant. Methods Retrospective study involving six centers from four European countries analyzing the safety and efficacy data from patients (26 eyes from 25 patients) with DME and a prior vitrectomy that had been treated with one 0.2 μg/day FAc implant. Results Prior intravitreal therapies included anti-VEGF (mean, 3.8 injections) and steroids (mean, 1.9 injections). Pars plana vitrectomy (PPV) was performed in these eyes primarily for abnormalities of vitreoretinal interface, followed by proliferative diabetic retinopathy and vitreous hemorrhage. The 0.2 μg/day FAc implant was injected 24.2 months, on average, after PPV and the mean duration of follow-up after injection was 255 days (range, 90 to 759 days). The mean change in BCVA was +11.7 ETDRS letters (range, −19 to +40 letters; P<0.0004) and the mean change in central foveal thickness (CFT) was −233.5 μm (range, −678 to 274 μm; P<0.0001). The mean change in IOP from baseline at the last visit was +1.4 mm Hg (range, −9 to +8 mm Hg; P=0.0090). Eight eyes initiated or continued IOP lowering medications. Conclusions These data suggest the 0.2 μg/day FAc implant is effective in vitrectomized patients with an acceptable safety profile. Further studies are still required to confirm the current findings and to assess the effect of the 0.2 μg/day FAc implant over a longer period of follow-up.
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Affiliation(s)
- A Meireles
- Unit of Ophthalmology, CHP-Hospital Santo António, Porto, Portugal.,Unit of Ophthalmology, Universidade do Porto-Instituto Ciências Biomédicas Abel Salazar, Porto, Portugal
| | - C Goldsmith
- Unit of Ophthalmology, James Paget University Hospital, Great Yarmouth, UK
| | - I El-Ghrably
- Unit of Ophthalmology, James Cook University Hospital, Middlesbrough, UK
| | - A Erginay
- Unit of Ophthalmology, Lariboisiere University hospital, Paris, France
| | - M Habib
- Unit of Ophthalmology, Sunderland Eye Hospital, Sunderland, UK
| | - B Pessoa
- Unit of Ophthalmology, CHP-Hospital Santo António, Porto, Portugal
| | - J Coelho
- Unit of Ophthalmology, CHP-Hospital Santo António, Porto, Portugal
| | - T Patel
- Unit of Ophthalmology, James Paget University Hospital, Great Yarmouth, UK
| | - R Tadayoni
- Unit of Ophthalmology, Lariboisiere University hospital, Paris, France
| | - P Massin
- Unit of Ophthalmology, Lariboisiere University hospital, Paris, France
| | - J Atorf
- Department of Ophthalmology, Staedtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - A J Augustin
- Department of Ophthalmology, Staedtisches Klinikum Karlsruhe, Karlsruhe, Germany
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Ramu J, Chatziralli I, Yang Y, Menon G, Bailey C, Eckstein M, Hykin P, Sivaprasad S. Health-related quality of life, visual function and treatment satisfaction following intravitreal dexamethasone implant for diabetic macular edema. Patient Prefer Adherence 2017; 11:579-586. [PMID: 28360511 PMCID: PMC5364019 DOI: 10.2147/ppa.s132859] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The aim of this study was to explore and describe quantitatively patient-reported outcome measures (PROMs), ie, health-related quality of life (QoL), visual function and treatment satisfaction, in patients with diabetic macular edema (DME) receiving two different regimens of Ozurdex (intravitreal dexamethasone implant). METHODS In this multicenter, prospective study, 100 patients with center-involving refractory DME were randomized 1:1 to either five monthly fixed dosing or optical coherence tomography (OCT)-guided pro re nata (PRN) regimen of dexamethasone intravitreal implant therapy. The primary outcome was the difference between arms in change in PROMs and health-related QoL from baseline to 12 months, as measured by the Retinopathy-Dependent Quality of Life (RetDQoL) questionnaire, Visual Function Questionnaire-25 (VFQ-25) and Retinopathy Treatment Satisfaction Questionnaire (RetTSQ). RESULTS There was no statistically significant difference in the RetDQoL score and VFQ-25 score at month 12 compared to those at baseline, whereas the total mean RetTSQ score increased significantly at the exit visit. The two treatment arms did not differ significantly regarding the change in PROMs and health-related QoL questionnaires. Logistic regression analysis showed that visual acuity (VA) of ≥55 letters, central foveal thickness <300 μm and macular volume <9.2 mm3 at the exit visit (month 12) predicted a higher change in RetTSQ. CONCLUSION This study showed that there is a statistically significant improvement in treatment satisfaction, as measured by RetTSQ, in patients with DME treated with dexamethasone intravitreal implant, independent of the dose regimen, namely, fixed or PRN. However, it should be noted that the clinically meaningful change could not be assessed accurately, since no thresholds for clinically meaningful change currently exist for the RetTSQ. On the other hand, there was no significant change in health-related QoL, as measured using VFQ-25 and RetDQoL. Factors affecting the patients' treatment satisfaction were the final VA, the central foveal thickness and the macular volume.
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Affiliation(s)
| | | | - Yit Yang
- The Royal Wolverhampton Hospitals NHS Trust, Wolverhampton
| | | | | | | | - Phil Hykin
- NIHR Moorfields Biomedical Research Centre, London
| | - Sobha Sivaprasad
- NIHR Moorfields Biomedical Research Centre, London
- Correspondence: Sobha Sivaprasad, NIHR Moorfields Biomedical Research Centre, 162 City Road, EC1V 2PD, London, UK, Tel +44 20 7566 2039, Fax +44 20 7566 2472, Email
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Goñi FJ, Stalmans I, Denis P, Nordmann JP, Taylor S, Diestelhorst M, Figueiredo AR, Garway-Heath DF. Elevated Intraocular Pressure After Intravitreal Steroid Injection in Diabetic Macular Edema: Monitoring and Management. Ophthalmol Ther 2016; 5:47-61. [PMID: 27164896 PMCID: PMC4909679 DOI: 10.1007/s40123-016-0052-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION With the increasing use of intravitreal administration of corticosteroids in macular edema, steroid-induced intraocular pressure (IOP) rise is becoming an emergent issue. However, for patients in whom intravitreal steroids are indicated, there are no specific recommendations for IOP monitoring and management after intravitreal administration of corticosteroids. METHOD An expert panel of European ophthalmologists reviewed evidence on corticosteroid-induced IOP elevation. The objective of the panel was to propose an algorithm based on available literature and their own experience for the monitoring and management of corticosteroid-induced IOP elevation, with a focus on diabetic patients. RESULTS Data from trials including diabetic patients with a rise of IOP after intravitreal steroid administration indicate that IOP-lowering medical treatment is sufficient for a large majority of patients; only a small percentage underwent laser trabeculoplasty or filtering filtration surgery. A 2-step algorithm is proposed that is based on the basal value of IOP and evidence for glaucoma. The first step is a risk stratification before treatment. Patients normotensive at baseline (IOP ≤ 21 mmHg), do not require additional baseline diagnostic tests. However, patients with baseline ocular hypertension (OHT) (IOP > 21 mmHg) should undergo baseline imaging and visual field testing. The second step describes monitoring and treatment after steroid administration. During follow-up, patients developing OHT should have baseline and periodical imaging and visual field testing; IOP-lowering treatment is proposed only if IOP is >25 mmHg or if diagnostic tests suggest developing glaucoma. CONCLUSION The management and follow-up of OHT following intravitreal corticosteroid injection is similar to that of primary OHT. If OHT develops, IOP is controlled in a large proportion of patients with standard IOP treatments. The present algorithm was developed to assist ophthalmologists with guiding principles in the management of corticosteroid-induced IOP elevation. FUNDING Alimera Sciences Limited.
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Affiliation(s)
- Francisco J Goñi
- Glaucoma Consultant, CTIG-Hospital Quirón Teknon, Barcelona, Spain.
| | - Ingeborg Stalmans
- Department of Ophthalmology, University Hospitals Leuven, Louvain, Belgium
| | - Philippe Denis
- Department of Ophthalmology, Hôpital de la Croix-Rousse, Lyon, France
| | | | - Simon Taylor
- University of Surrey and Royal Surrey County Hospital, Surrey, UK
| | | | | | - David F Garway-Heath
- NIHR Biomedical Research Centre, Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
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