Evaluation of Intravitreal Ranibizumab on the Surgical Outcome for Diabetic Retinopathy With Tractional Retinal Detachment

Anti-vascular endothelial growth factor for proliferative diabetic retinopathy

BACKGROUND

Proliferative diabetic retinopathy (PDR) is an advanced complication of diabetic retinopathy that can cause blindness. It consists of the presence of new vessels in the retina and vitreous haemorrhage. Although panretinal photocoagulation (PRP) is the treatment of choice for PDR, it has secondary effects that can affect vision. Anti-vascular endothelial growth factor (anti-VEGF), which produces an inhibition of vascular proliferation, could improve the vision of people with PDR.

OBJECTIVES

To assess the effectiveness and safety of anti-VEGFs for PDR and summarise any relevant economic evaluations of their use.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register; 2022, Issue 6); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov, and the WHO ICTRP. We did not use any date or language restrictions. We last searched the electronic databases on 1 June 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing anti-VEGFs to another active treatment, sham treatment, or no treatment for people with PDR. We also included studies that assessed the combination of anti-VEGFs with other treatments. We excluded studies that used anti-VEGFs in people undergoing vitrectomy.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data, and assessed the risk of bias (RoB) for all included trials. We calculated the risk ratio (RR) or the mean difference (MD), and 95% confidence intervals (CI). We used GRADE to assess the certainty of evidence.

MAIN RESULTS

We included 15 new studies in this update, bringing the total to 23 RCTs with 1755 participants (2334 eyes). Forty-five per cent of participants were women and 55% were men, with a mean age of 56 years (range 48 to 77 years). The mean glycosylated haemoglobin (Hb1Ac) was 8.45% for the PRP group and 8.25% for people receiving anti-VEGFs alone or in combination. Twelve studies included people with PDR, and participants in 11 studies had high-risk PDR (HRPDR). Twelve studies were of bevacizumab, seven of ranibizumab, one of conbercept, two of pegaptanib, and one of aflibercept. The mean number of participants per RCT was 76 (ranging from 15 to 305). Most studies had an unclear or high RoB, mainly in the blinding of interventions and outcome assessors. A few studies had selective reporting and attrition bias. No study reported loss or gain of 3 or more lines of visual acuity (VA) at 12 months. Anti-VEGFs ± PRP probably increase VA compared with PRP alone (mean difference (MD) -0.08 logMAR, 95% CI -0.12 to -0.04; I2 = 28%; 10 RCTS, 1172 eyes; moderate-certainty evidence). Anti-VEGFs ± PRP may increase regression of new vessels (MD -4.14 mm2, 95% CI -6.84 to -1.43; I2 = 75%; 4 RCTS, 189 eyes; low-certainty evidence) and probably increase a complete regression of new vessels (RR 1.63, 95% CI 1.19 to 2.24; I2 = 46%; 5 RCTS, 405 eyes; moderate-certainty evidence). Anti-VEGFs ± PRP probably reduce vitreous haemorrhage (RR 0.72, 95% CI 0.57 to 0.90; I2 = 0%; 6 RCTS, 1008 eyes; moderate-certainty evidence). Anti-VEGFs ± PRP may reduce the need for vitrectomy compared with eyes that received PRP alone (RR 0.67, 95% CI 0.49 to 0.93; I2 = 43%; 8 RCTs, 1248 eyes; low-certainty evidence). Anti-VEGFs ± PRP may result in little to no difference in the quality of life compared with PRP alone (MD 0.62, 95% CI -3.99 to 5.23; I2 = 0%; 2 RCTs, 382 participants; low-certainty evidence). We do not know if anti-VEGFs ± PRP compared with PRP alone had an impact on adverse events (very low-certainty evidence). We did not find differences in visual acuity in subgroup analyses comparing the type of anti-VEGFs, the severity of the disease (PDR versus HRPDR), time to follow-up (< 12 months versus 12 or more months), and treatment with anti-VEGFs + PRP versus anti-VEGFs alone. The main reasons for downgrading the certainty of evidence included a high RoB, imprecision, and inconsistency of effect estimates.

AUTHORS' CONCLUSIONS

Anti-VEGFs ± PRP compared with PRP alone probably increase visual acuity, but the degree of improvement is not clinically meaningful. Regarding secondary outcomes, anti-VEGFs ± PRP produce a regression of new vessels, reduce vitreous haemorrhage, and may reduce the need for vitrectomy compared with eyes that received PRP alone. We do not know if anti-VEGFs ± PRP have an impact on the incidence of adverse events and they may have little or no effect on patients' quality of life. Carefully designed and conducted clinical trials are required, assessing the optimal schedule of anti-VEGFs alone compared with PRP, and with a longer follow-up.

Outcomes and Complications of Pars Plana Vitrectomy for Tractional Retinal Detachment in People With Diabetes: A Systematic Review and Meta-analysis

Importance

Tractional retinal detachment (TRD) occurs in approximately 5% of people with proliferative diabetic retinopathy and poses a threat to vision. Pars plana vitrectomy (PPV) is the treatment of choice for TRD.

Objective

To determine anatomic and functional outcomes of PPV for the treatment of TRD in people with diabetes (dTRD).

Data Sources

MEDLINE and Embase were searched systematically from January 1, 2000, to February 20, 2022. In addition, a reference list of eligible studies were screened.

Study Selection

Eligible studies were those published in English, those reporting outcomes of PPV for dTRD, and those that included more than 25 eyes and with a minimum follow-up of 3 months.

Data Extraction and Synthesis

Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for data extraction/synthesis were followed, and the National Institute for Health quality assessment tool was used to assess risk of bias. Study eligibility was determined independently by 2 reviewers; data extraction was conducted by 1 reviewer and entries checked for accuracy by another. Data were pooled using a random-effects model.

Main Outcomes and Measures

Main outcomes included rate of failure of retinal reattachment following 1 surgery and final visual acuity (VA). The association of baseline patient characteristics and surgical maneuvers with postoperative surgical outcomes was investigated.

Results

Of the 406 studies identified, 38 (3839 eyes) were eligible and included for analysis. Patients had a median (IQR) age of 52.2 (49.6-55.7) years. In the studies reporting patient sex (31 of 38 studies), 1441 were female individuals (50.1%). The overall failure rate of retinal reattachment after 1 surgery was 5.9% (95% CI, 1.4%-8.3%), and the mean final VA was 0.94 (95% CI, 0.82-1.05) logMAR (approximate Snellen equivalent, 6/53; 95% CI, 6/39-6/71). People with higher preoperative VA achieved higher postoperative vision (0.66 logMAR worse final vision; 95% CI, 0.39-0.84 per 1.0 logMAR worse at baseline; P <.001). On multivariable analysis, no other patient characteristics or surgical variables had a statistically significant association with outcomes.

Conclusions and Relevance

Results of this systematic review and meta-analysis suggest that PPV was an effective strategy to achieve retinal reattachment in people with dTRD. Given that higher preoperative VA was the only factor associated with higher postoperative vision, early intervention should be considered and discussed in detail with patients. Overall, final postoperative VA remains low, and patients should be counseled on the guarded prognosis of dTRD.

Effect of intravitreal conbercept injection on VEGF-A and -B levels in the aqueous and vitreous humor of patients with proliferative diabetic retinopathy

The present study aimed to investigate the mechanisms of anti-VEGF treatment prior to eye surgery to reduce intraoperative bleeding. A total of 30 patients with proliferative vitreoretinopathy after clinical diagnosis were enrolled in the present study as the surgical group. Furthermore, 30 patients underwent intravitreal injection of the anti-VEGF drug conbercept and were considered the drug pretreatment group. The aqueous and vitreous humors from the eyes of patients in the surgical group were drawn during pars plana vitrectomy surgery. The aqueous humor in the eyes of patients in the drug pretreatment group was drawn prior to conbercept treatment and seven days after conbercept treatment immediately prior to surgery. The vitreous humor in this group was only taken during surgery. Furthermore, ELISA was used to detect the levels of VEGF-A and -B in the aqueous and vitreous humors. Semi-quantitative determination of VEGF-A and VEGF-B levels in fibrovascular proliferative membranes was performed using immunohistochemical staining. The results indicated that in the drug group, the levels of VEGF-A in the aqueous humor of patients prior to and after conbercept injection were 197.66±48.00 and 3.39±2.54 pg/ml, respectively. The levels of VEGF-A in the vitreous humor of patients in the surgical and drug groups were 267.53±179.60 and 21.43±5.81 pg/ml after injection, respectively. The levels of VEGF-B in the aqueous humor of patients prior to and after conbercept injection were 13.66±3.30 (before injection) and 2.17±0.94 pg/ml (after injection), respectively. The levels of VEGF-B in the vitreous humor of patients in the surgical and drug groups were 127.36±16.72 and 18.56±9.82 pg/ml after injection, respectively (P<0.05). Furthermore, in the drug group, the surgery time, bleeding and capillary formation were significantly reduced compared with those in the surgical group. Taken together, these results suggested that the levels of VEGF-A and -B decreased significantly in the aqueous humor of patients with PDR after conbercept injection. Furthermore, the levels of VEGF-A and -B in the vitreous humor of patients dropped significantly in the drug group compared with those in the surgical group. These results provide theoretical clinical support for the preoperative application of conbercept for patients with PDR.

Ranibizumab Pretreatment in Vitrectomy with Internal Limiting Membrane Peeling on Diabetic Macular Edema in Severe Proliferative Diabetic Retinopathy

AIM

To evaluate the efficacy of intravitreal ranibizumab (IVR) pretreatment for pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling in severe proliferative diabetic retinopathy (PDR) combined with macular edema (ME).

METHODS

Sixty-three patients with ME and PDR were divided into IVR and control groups. Three days before PPV stripping, ranibizumab was injected into the patients in the IVR group. The patients were followed for 6 months. The best-corrected visual acuity (BCVA), visual acuity improvement, centre macular thickness (CMT), and intraoperative and postoperative complications were compared between the two groups.

RESULTS

The BCVA of the IVR group was significantly improved at 1, 3 and 6 months compared with the preoperative BCVA (P < 0.01). The BCVA of the control group was significantly improved at 3 and 6 months compared with the preoperative BCVA (P < 0.01), but was not significantly improved at 1 month. At 1 and 3 months, the BCVA of the IVR group was significantly better than that of the control group after surgery, with no difference between the two groups at 6 months. The CMT of the IVR group was thinner than that of the control group at 1 and 3 months (P < 0.01), with no significant difference at 6 months after surgery. The surgical time, the risk of intraoperative bleeding, the incidence of iatrogenic retinal breaks, the frequency of endodiathermy and the rate of silicone oil tamponade were significantly different between the two groups (all P < 0.05). There was no significant difference between the two groups in terms of postoperative complications.

CONCLUSIONS

Ranibizumab pretreatment may improve the outcome of PPV with ILM peeling for severe PDR with ME by decreasing ME and intraoperative complications.

Ghost cell glaucoma after intravitreous injection of ranibizumab in proliferative diabetic retinopathy

Background

The development of ghost cell glaucoma in patients with proliferative diabetic retinopathy (PDR) after intravitreous injection (IV) was rare. Here we reported a series of patients with PDR who received Intravitreous Ranibizumab (IVR) and developed ghost cell glaucoma and analyzed the potential factors that might be related to the development of ghost cell glaucoma.

Methods

Retrospective case series study. The medical records of 71 consecutive eyes of 68 PDR patients who received vitrectomy after IVR from January 2015 to January 2017 were reviewed. The development of ghost cell glaucoma after IVR was recorded. Characteristics of enrolled patients were retrieved from their medical charts. Factors associated with ghost cell glaucoma were compared between eyes with the development of ghost cell glaucoma and eyes without the development of ghost cell glaucoma. Variables were further enrolled in a binary backward stepwise logistic regression model, and the model that had the lowest AIC was chosen.

Results

There were 8 out of 71 eyes of the PDR patients developed ghost cell glaucoma after they received IVR. The interval between detection of elevation of intraocular pressure (IOP) and IV ranged from 0 to 2 days. Among them, after IVR, there were two eyes had IOP greater than 30 mmHg within 30 min, four eyes showed normal IOP at 30 min, and then developed ghost cell glaucoma within 1 day, two eyes developed ghost cell glaucoma between 24 and 48 h. The mean IOP was 46.5 ± 8.0 mmHg. All patients gained normal IOP after vitrectomy without medicine for lowering IOP. The presence of ghost cell glaucoma was associated with tractional retinal detachment (RR = 4.60 [2.02 ~ 8.48], p = 0.004) and fibrovascular membrane involving disk (RR = -3.57 [− 7.59 ~ − 0.92], p = 0.03) (AIC = 39.23, AUC = 0.88) in a logistic regression model.

Conclusion

Attention to postoperative IOP should be paid to patients with PDR undergoing vitrectomy who receive a preoperative IV of anti-VEGF agents. PDR patients with tractional retinal detachment or fibrovasucular membrane involving optic disc are more likely to develop ghost cell glaucoma after IV.

Preoperative Bevacizumab for Tractional Retinal Detachment in Proliferative Diabetic Retinopathy: A Prospective Randomized Clinical Trial

PURPOSE

To assess the effectiveness and safety of an intravitreal injection of 1.25 mg bevacizumab (IVB) as a preoperative adjunct to small-gauge pars plana vitrectomy (PPV) compared with PPV alone in eyes with tractional retinal detachment secondary to proliferative diabetic retinopathy.

METHODS

This prospective, double-masked, randomized, multicenter, active-controlled clinical trial enrolled 224 eyes of 224 patients between November 2013 and July 2015. All eyes underwent a baseline examination including best-corrected visual acuity, color photos, optical coherence tomography, and fluorescein angiography. Data were collected on intraoperative bleeding, total surgical time, early (<1 month) postoperative vitreous hemorrhage, and mean change in best-corrected visual acuity at 12 months. P < .05 was considered statistically significant.

RESULTS

A total of 214 patients (214 eyes) were randomized in a 1:1 ratio to PPV plus IVB ([study group] 102 eyes) or PPV plus sham ([control] 112 eyes). Iatrogenic retinal breaks were noted intraoperatively in 35 eyes (34.3%) in the study group, and 66 eyes (58.9%) in the control group (P = .001). Grade 2 intraoperative bleeding was noted in 32 (31.3%) eyes in the study group and 58 (51.7 %) eyes in the control group (P = .001). Endodiathermy was necessary in 28 (27.4 %) eyes in the study group, compared with 75 (66.9%) eyes in the control group (P = .0001). Mean surgical time was 71.3 ± 32.1 minutes in the study group and 83.6 ± 38.7 minutes in the control group (P = .061).

CONCLUSION

Preoperative IVB seems to reduce intraoperative bleeding, improving surgical field visualization, and reducing intraoperative and postoperative complications. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Surgical management of diabetic tractional retinal detachments

Tractional retinal detachment is an end-stage form of diabetic retinopathy that occurs when contractile forces in the vitreous and neovascular tissue lead to the detachment of the neurosensory retina. We review the literature related to the management of this disease. Preoperative planning includes appropriate patient selection, diagnostic and prognostic imaging, and medical optimization with reduction of systemic risk factors. Use of antivascular endothelial growth factor for preoperative treatment has had significant benefits for tractional retinal detachment repair in improving surgical efficiency and outcomes. Advances in microsurgical instrumentation are discussed, with attention to small-gauge vitrectomy with improved flow dynamics, viewing strategies, and lighting allowing bimanual surgery. Special emphasis is placed on bimanual surgical technique, choice of tamponade, and the avoidance of iatrogenic damage. Complications and special considerations are further explored. Based on our compilation of relevant literature, we propose a surgical algorithm for the management of these complex patients.

Efficacy and Safety of Intravitreal Conbercept, Ranibizumab, and Triamcinolone on 23-Gauge Vitrectomy for Patients with Proliferative Diabetic Retinopathy

Introduction

To compare the effect and safety of intravitreal conbercept (IVC), intravitreal ranibizumab (IVR), or intravitreal triamcinolone acetonide (IVTA) injection on 23-gauge (23-G) pars plana vitrectomy (PPV) for proliferative diabetic retinopathy (PDR).

Methods

Fifty patients (60 eyes) of varying degrees of PDR were randomly grouped into 3 groups (1 : 1 : 1) (n = 20 in each group). The 23-G PPV was performed with intravitreal conbercept or ranibizumab injection 3–7 days before surgery or intravitreal TA injection during surgery. The experiment was randomized controlled, with a noninferiority limit of five letters. Main outcome measures included BCVA, operation time, incidence of iatrogenic retinal breaks, endodiathermy rate, and silicone oil tamponade.

Results

At 6 months after surgery, there were no significant differences of BCVA improvements, operation time, incidence of iatrogenic retinal breaks, endodiathermy rate, silicone oil tamponade, vitreous clear-up time, and the incidence of intraoperative bleeding between the IVC and IVR groups (all P values ≥ 0.05), but they were significantly different from the IVTA group (all P values < 0.05). IOP increases did not show significant differences between the IVC and IVR groups, but both were significantly different with the IVTA group. More patients had higher postoperative IOP in the IVTA group.

Conclusions

The intravitreal injection of conbercept, ranibizumab, or TA for PDR had a significant different effect on outcomes of 23-G PPV surgery. Conbercept and ranibizumab can reduce difficulty of the operation, improve the success rate of PPV surgery, and decrease the incidence of postoperative complications.