Combination of Anti-VEGF and Laser Photocoagulation for Diabetic Macular Edema: A Review

Prevalence of Diabetic Retinopathy Among Individuals with Diabetes in Gulf Cooperation Council countries: A Systematic Review and Meta-analysis

Objectives

To determine the proportion of diabetic retinopathy (DR) among individuals with diabetes mellitus in the Gulf Cooperation Council (GCC) countries.

Methods

This study was executed in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. Online databases including Scopus, Web of Sciences, PubMed, Index Medicus for the eastern Mediterranean region, Medline, and ProQuest, were utilized to retrieve studies on the prevalence of DR in GCC countries that were conducted from 2003 to 2019.

Results

Twenty articles were included in the meta-analysis, involving 61 855 patients. The prevalence of DR was 20.5% (95% CI: 20.212-20.850). The highest prevalence rate was observed in Saudi Arabia (69.8%; 95% CI: 64.989-74.216) and the lowest in the UAE (6.0%; 95% CI: 2.780-11.084). There was a significant heterogeneity between the reviewed studies (p < 0.001).

Conclusions

The prevalence of DR was high in the GCC countries. Our findings provide crucial information for the public healthcare systems in these countries to actively educate the public and screen at-risk populations for undiagnosed cases of diabetes, detect early stages of retinopathy, and provide required care to minimize the number of untreated cases.

Diabetic Macular Edema Management: A Review of Anti-Vascular Endothelial Growth Factor (VEGF) Therapies

Diabetic macular edema (DME) is a major cause of vision impairment in diabetic individuals, characterized by fluid accumulation in the macula due to a breakdown of the blood-retinal barrier (BRB). This review article explores the role of anti-vascular endothelial growth factor (anti-VEGF) therapies in the management of DME. Anti-VEGF treatments, including ranibizumab, bevacizumab, and aflibercept, have revolutionized DME management by targeting VEGF, a key mediator in DME pathogenesis. We critically examined the efficacy of these therapies in reducing macular edema and improving visual acuity, assessed their safety and tolerability, and explored the variability in treatment response. The review highlights the latest advancements and future directions in anti-VEGF therapy, including novel drug delivery systems and emerging treatment paradigms. By providing a comprehensive overview of current anti-VEGF therapies, this review seeks to inform clinical practice, guide future research, and contribute to improved patient outcomes in DME management.

Comparison of intravitreal ranibizumab and aflibercept for the treatment of diabetic macular edema: a real-world study

PURPOSE

To compare the visual and anatomic outcomes of intravitreal ranibizumab versus aflibercept in patients with diabetic macular edema (DME) in a real-world study.

METHODS

This is a single-center retrospective comparative study of treatment-naïve patients who received intravitreal ranibizumab or aflibercept administration for DME for at least 12 months on an as needed regimen following three-monthly loading doses. The primary outcomes of the study were the mean change in best-corrected visual acuity (BCVA), central macular thickness (CMT), and central macular volume (CMV). Factors to potentially affect these parameters were also analyzed.

RESULTS

A total of 100 eyes (66 patients) were included in the study. Fifty two eyes received ranibizumab and 48 eyes in aflibercept injections. At the end of follow-up, the improvement in mean BCVA was similar in both groups (p = 0.38). While the decrease in mean CMT at the 4th-month visit was significantly higher in the aflibercept-treated group than in the ranibizumab-treated group (p = 0.02), there was no difference between the two groups at the end of the 1-year follow-up (p = 0.25). There was no significant difference between the two groups in terms of change in mean CMV during the follow-up (p = 0.26, p = 0.27 at 4 and 12 months, respectively). The mean number of injections were also similar between groups (4.5 ± 1 vs. 4.6 ± 1.1 respectively, p = 0.63).

CONCLUSION

In a real-world setting, ranibizumab and aflibercept were both found to be effective in the first-line treatment of DME. Patients with DME who received fewer injections in the real-world could achieve visual and anatomical results comparable to randomized controlled trials participants.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

The role of inflammation in immune system of diabetic retinopathy: Molecular mechanisms, pathogenetic role and therapeutic implications

Diabetic retinopathy is one of the most common complications of diabetes mellitus and the leading cause of low vision and blindness worldwide. Mounting evidence demonstrates that inflammation is a key mechanism driving diabetes-associated retinal disturbance, yet the pathophysiological process and molecular mechanisms of inflammation underlying diabetic retinopathy are not fully understood. Cytokines, chemokines, and adhesion molecules interact with each other to form a complex molecular network that propagates the inflammatory and pathological cascade of diabetic retinopathy. Therefore, it is important to understand and elucidate inflammation-related mechanisms behind diabetic retinopathy progression. Here, we review the current understanding of the pathology and pathogenesis of inflammation in diabetic retinopathy. In addition, we also summarize the relevant clinical trials to further suggest inflammation-targeted therapeutics for prevention and management of diabetic retinopathy.

Identifying best‐practice features of diabetic retinopathy treatment models for Aboriginal and Torres Strait Islander Australians

OBJECTIVE

Indigenous Australians are nearly three times more likely to have diabetes than non-Indigenous Australians. The prevalence of diabetes-related vision impairment for Indigenous Australians is 5.5% compared to 1.5% for non-Indigenous Australians, and treatment rates are lower for Indigenous Australians. Despite this situation, there is limited evidence on effective service delivery models for diabetic retinopathy care and treatment. This study seeks to identify best-practice features of diabetic retinopathy care that could be used to inform current and future service delivery models for Indigenous Australians with diabetic retinopathy.

SETTING

All states, territories and geographic remoteness categories in Australia.

PARTICIPANTS

Eight ophthalmologists engaged in providing eye healthcare to Indigenous Australians.

DESIGN

Semi-structured interviews were conducted. The Framework Approach was used to conduct a thematic analysis of the interviews to facilitate identification of key themes and issues that emerged from these discussions.

RESULTS

Seven best-practice features for service delivery of diabetic retinopathy treatment for Indigenous Australians were identified. These were: cultural safety, affordability and accessibility, partnerships with key stakeholders, timeliness, integration with primary care, clarity of guidelines, and clinician attitude and motivation.

CONCLUSION

The findings from this study identified seven best-practice features for diabetic retinopathy treatment. These have the potential to inform and influence how care is delivered to Indigenous Australians. Although further research is warranted to capture other service provider inputs and Indigenous end-user perspectives, these features in the meantime can begin to inform the decisions of the Indigenous eyecare sector on policy reforms and best-practice diabetic retinopathy treatment approaches.

Diabetic Macular Edema Treatment: Laser Photocoagulation Versus anti-VEGF Drugs

Abstract: Objective: The present study was aimed to compare best-corrected vision and central macular thickness for macular edema in diabetes (DME) after utilizing laser, Avastin, and Lucentis. Methods: A retrospective randomized cross-sectional study was conducted at Alfaisal Eye Center, Khartoum. Best-corrected vision and central macular thickness (CMT) were assessed by Snellen's chart and Heidelberg optical coherence tomography OCT, respectively. Results: In this study, a total of 252 records of DME-treated patients with laser applications, Avastin, and Lucentis were enrolled, their mean age was 57 ± 5.22 yrs. A significant enhancement in best-corrected vision and CMT of studied groups with laser applications, Avastin, and Lucentis was obtained (P= 0.000) with no differences between treated groups (p= 0.445 and 0,479), respectively. Non-significant differences in variable measurements related to gender or age (p = 0.117, 0.781), respectively. CMT of females (260 ± 48 μm) was thinner than males (306 ± 74 μm) after treatment (P = 0.000). Conclusion: laser applications, Avastin, and Lucentis improved best-corrected vision and reduced central macular thickness significantly with no clear differences between studied groups. Age or gender have a non-significant impact on dependent variables. Females gained thinner results compared to males after treatment.  

Current and Novel Therapeutic Approaches for Treatment of Diabetic Macular Edema

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

Therapeutic effect of simultaneous intravitreal dexamethasone and aflibercept on diabetic macular edema

AIMS

To report the effect of simultaneous intravitreal dexamethasone (DEX) and aflibercept for the treatment of diabetic macular edema (DME).

METHODS

This retrospective analysis of an open-label, multicenter, consecutive case series included 102 eyes of 81 patients with DME. Patients were selected into two groups. The control group consisted of 50 eyes treated with aflibercept alone, and the combination group consisted of 52 eyes treated with simultaneous DEX implant and aflibercept injection. The primary endpoints were changes in best-corrected visual acuity (BCVA) and central retinal thickness (CRT) from baseline to month 6. The secondary endpoint was the interval of retreatment.

RESULTS

Baseline BCVA increased and CRT decreased at 6 months in both groups. Pseudophakic eyes in the combination group exhibited significantly greater BCVA improvement compared with phakic eyes (p = 0.031). Fewer intravitreal treatments were required for eyes treated with combination therapy than for those treated with aflibercept alone (1.56 ± 0.54 vs. 4.04 ± 1.26, p < .0001), with a mean retreatment interval of 3.66 ± 0.69 months.

CONCLUSIONS

Simultaneous intravitreal DEX and aflibercept achieved non-inferior improvement of visual and anatomic outcomes compared with aflibercept alone for DME, but exhibited a significantly longer treatment interval and superior visual outcome in pseudophakic eyes. This therapeutic approach is considered a valid strategy for treating DME in the era of COVID-19.

Steroid Treatment in Macular Edema: A Bibliometric Study and Visualization Analysis

The use of steroids to treat macular edema (ME) is a research hotspot in ophthalmology. We utilized CiteSpace and VOSviewer software to evaluate the Web of Science Core Collection publications and to build visualizing maps to describe the research progress in this topic. There were 3,252 publications for three decades during 1988–2021. The number of studies was low during the first 14 years but has risen consistently in the following two decades. The average publications per year were only 4.8 during 1988–2002, which jumped to 113 per year during 2003–2012, and 227 per year during 2013–2021. These publications came from 83 countries/regions, with the United States, Germany, and Italy leading positions. Most studies were published in Investigative Ophthalmology Visual Science, and Ophthalmology was the most cited journal. We found 9,993 authors, with Bandello F having the most publications and Jonas JB being the most frequently co-cited. According to our research, the most popular keyword is triamcinolone acetonide (TA). Macular edema, diabetic macular edema (DME), retinal vein occlusion (RVO), dexamethasone (DEX), fluocinolone acetonide (FA), and some other keywords were commonly studied in this field. In conclusion, the bibliometric analysis provides a comprehensive overview of steroid hotspots and developmental tendencies in the macular edema study. While anti-VEGF therapy is the first-line treatment for DME and RVO-induced macular edema, steroids implant is a valid option for these DME patients not responding to anti-VEGF therapy and non-DME patients with macular edema. Combined therapy with anti-VEGF and steroid agents is vital for future research.

Intraprocedural OCT monitoring of the immediate treatment response during indocyanine green angiography-guided laser therapy of teleangiectatic capillaries in diabetic macular edema

In this retrospective study the morphological response of teleangiectatic capillaries (TCs) to focal laser treatment and the functional and morphological outcome after Indocyanine green angiography (ICGA)-guided laser therapy was evaluated. TCs in eyes with diabetic macular edema (DME) were treated with laser therapy. The immediate and subsequent reaction of the TCs lumina to direct photocoagulation was monitored with customized OCT single scans. Additionally, patients were treated with intravitreal anti-VEGF as needed. 12 eyes of 9 patients with treatment naive (6 eyes) and pretreated (6 eyes) DME were followed-up for a mean of 24 months (± 8.1SD). Best-corrected visual acuity improved from 0.25 logMar (± 0.2SD) to 0.12 (± 0.10SD; p = 0.06) at each patient’s last visit. During laser treatment a darkening of the TCs lumina was achieved in 91.3% of lesions. All these lesions fully resolved, whereas TCs, which showed no darkening of their lumen in OCT persisted and required re-treatment with laser. Additional anti-VEGF injections were indicated in only one eye (8.3%). The darkening of the TCs lumina visible in OCT might provide an image-biomarker that indicates successful coagulation of aneurysmatic lesions. Consequently, a significant functional and morphological improvement with need for anti-VEGF treatment in only one eye, was achieved.

Information concerning the registration of the trial: date of registration: 11th of december, 2019. Trial registration number: 107/2019.

Retinopathy of prematurity shows alterations in Vegfa164 isoform expression

BACKGROUND

Pathologic ocular neovascularization in retinopathy of prematurity (ROP) and other proliferative retinopathies are characterized by dysregulation of vascular endothelial growth factor-A (VEGF-A). A study of Vegfa isoform expression during oxygen-induced ischemic retinopathy (OIR) may enhance our understanding of Vegf dysregulation.

METHODS

Following induction of OIR, immunohistochemistry and polymerase chain reaction (PCR) was performed on room air (RA) and OIR mice.

RESULTS

Total Vegfa messenger RNA (mRNA) expression was stable in RA mice, but increased in OIR mice with a peak at postnatal day 17 (P17), before returning to RA levels. Vegfa_164a expression was similar in both OIR and RA mice at P10 (Phase 1 OIR), but 2.4-fold higher in OIR mice compared to RA mice at P16 (Phase 2 OIR). At P10, Vegfa_164b mRNA was similar in OIR vs RA mice, but was expressed 2.5-fold higher in OIR mice compared to RA mice at P16. At P10 and P16, Vegfr2/Vegfr1 expression was increased in OIR mice compared to RA mice. Increased activation of microglia was seen in OIR mice.

CONCLUSIONS

Vegfa_164a, Vegfa_164b, and Vegfr1 were overexpressed in OIR mice, leading to abnormal signaling and angiogenesis. Further studies of mechanisms of Vegf dysregulation may lead to novel therapies for ROP and other proliferative retinopathies.

IMPACT

Vegfa₁₆₄ has two major isoforms, a proangiogenic, Vegfa_164a, and an antiangiogenic, Vegfa_164b, with opposing receptors, inhibitory Vegfr1, and stimulatory Vegfr2, but their role in OIR is unclear. In Phase 1 OIR, both isoforms and receptors are expressed similarly. In Phase 2 OIR, both isoforms are overexpressed, with an increased ratio of inhibitory Vegfr1. Modulation of angiogenesis by Vegf regulation enables pruning of excess angiogenesis during physiology, but results in ineffective angiogenesis during OIR. Knowledge of VEGF dysregulation may have novel therapeutic implications in the management of ROP and retinal proliferative diseases.

Treatment results of nondamaging retinal laser therapy in diabetic macular edema

BACKGROUND

Subthreshold nondamaging retinal laser therapy (NRT) provides a greater safety profile than conventional laser methods, but more data is needed on the efficacy and safety of subthreshold NRT in diabetic macular edema.

PURPOSE

To evaluate the efficacy and safety of NRT for the treatment of clinically significant macular edema (CSME) that is partially responsive or resistant to intravitreal anti-vascular endothelial growth factor (anti-VEGF) treatment.

METHODS

This was a retrospective case series study. Fifty eyes of 38 diabetic patients with CSME previously treated with at least 6-monthly intravitreal bevacizumab injections with/without intravitreal Ozurdex therapy were evaluated. The patients received 577-nm yellow wavelength laser therapy with PASCAL laser system (Topcon Medical Laser Systems, Santa Clara, CA, USA). Best-corrected visual acuity (BCVA) and central subfield thickness (CST) were evaluated before and 1, 3, 6, 12 and 24 months after laser treatment.

RESULTS

Baseline mean CST was 368.06 ± 86.9 µm. The mean CST values at the 1-, 3-, 6-, 12-, and 24-month visits were 336.93 ± 79.8, 352.40 ± 113.5, 336.36 ± 109.3, 325.10 ± 104 µm, and 310.08 ± 84.7 µm, respectively. The mean CST decreased significantly at the first (p = 0.002) and second year visits (p < 0.001) when compared with pretreatment values. Although visual acuity was improved at the first year compared with baseline, this difference was not statistically significant (p = 0.03). There was no significant difference in visual acuities between pretreatment and posttreatment visits. During 24-month follow-up, while 37 eyes were treated with [mean: 5.7 ± 3.4 (1-14)] intravitreal anti-VEGF injections, 3 eyes were administered single-dose intravitreal steroids. Additional intravitreal injections were not required in 10 (20%) eyes.

CONCLUSION

NRT is effective by itself or in combination with anti-VEGF agents in diabetic macular edema that is partially responsive or resistant to previous intravitreal injections. T role in treating this disorder should be assessed in more detail with prospective controlled studies.

Diabetic maculopathy: multicolour and SD-OCT versus fundus photography

Objective

The English Diabetic Eye Screening (DES) programme recommends patients with M1 diabetic maculopathy to be referred to hospital eye services. DES uses flash fundus photography as the reference standard for maculopathy grading. We compared multicolour versus non-stereoscopic fundus photography at identifying M1 maculopathy, with spectral domain optical coherence tomography (SD-OCT) identifying macular thickening.

Methods and analysis

This cross-sectional study included 345 patients with R1M1 referred from DES and reviewed in secondary care with fundus photographs, multicolour and SD-OCT. Maculopathy was graded based on DES exudate criteria on both multicolour and fundus photography in a blind fashion by two independent graders. Macular thickness was ascertained on SD-OCT.

Results

Intergrader agreement on grading maculopathy using fundus photography (Cohen's κ=0.91) and multicolour (Cohen's κ=0.82) was 'almost perfect'. Agreement between fundus photography and multicolour on grading maculopathy (Cohen's κ=0.76) was 'substantial'. Compared with fundus photography, multicolour had sensitivity of 87% (95% CI 81% to 93%) and specificity of 90% (95% CI 87% to 94%) in detecting M1 maculopathy. SD-OCT identified 84 eyes with macular thickening, 47 of which were graded as M0 by fundus photography. 5 eyes with exudates and severe macular oedema requiring urgent intervention were also missed on fundus photography but not on multicolour. Multicolour, when complemented by SD-OCT, did not miss any clinically significant macular oedema.

Conclusion

Multicolour integrates synergistically in a single platform with SD-OCT providing effective monitoring of M1 diabetic maculopathy. The need for fundus photography is eliminated by multicolour/SD-OCT in dedicated R1M1 virtual clinics not requiring parallel diabetic retinopathy grading.

Visual Outcomes in the Management of Diabetic Maculopathy in Central Australia

PURPOSE

In major urban centres and high-resource settings, treatment of diabetic maculopathy with anti-Vascular Endothelial Growth Factor (VEGF) injections has largely displaced laser treatment. However, intravitreal therapy alone requires frequent follow-up, a barrier to adherence in remote Australia. We report vision outcomes of phased diabetic maculopathy treatment in remote Central Australia for maculopathy using laser and, in a subset, supplementary injection treatment.

METHODS

We audited clinical records of patients undergoing laser treatment for diabetic maculopathy between 2001 and 2013 at an ophthalmology service based at Alice Springs Hospital, a regional hub in remote Australia. All patients receiving macular laser treatment were included, and some required supplementary injection(s). The primary outcome measure was change in best-corrected visual acuity [BCVA] from baseline treatment.

RESULTS

Of 338 maculopathy-treated patients, 88% were indigenous and 39% were male. Of 554 maculopathy laser-treated eyes, 118 (21%) received supplementary injection/s. In the laser treatment phase, median BCVA was 78 letters at baseline (interquartile range 62-80) and decreased by a median of two letters at final visit. In the subset who underwent subsequentinjection treatment, BCVA was 60 letters at first injection, with a median five-letter increase by final visit. Overall outcomes were similar in Indigenous and non-Indigenous Australians. Predictors of reduction in BCVA in the macular laser treatment phase were better baseline BCVA, older age, and PRP treatment (all p < .005).

CONCLUSION

Laser treatment for diabetic maculopathy preserved vision in Central Australia, where barriers to follow-up can preclude regular injections. Supplementary injections stabilized vision in the laser-resistant subset.

Oxidative Stress as the Main Target in Diabetic Retinopathy Pathophysiology

Diabetic retinopathy (DR) is one of the most common complications of diabetes mellitus (DM) causing vision impairment even at young ages. There are numerous mechanisms involved in its development such as inflammation and cellular degeneration leading to endothelial and neural damage. These mechanisms are interlinked thus worsening the diabetic retinopathy outcome. In this review, we propose oxidative stress as the focus point of this complication onset.

3-year-data of combined navigated laser photocoagulation (Navilas) and intravitreal ranibizumab compared to ranibizumab monotherapy in DME patients

PURPOSE

The prospective, comparative evaluation of combined navigated laser photocoagulation and intravitreal ranibizumab in the treatment of diabetic macular edema has shown advantage of a combination therapy compared to ranibizumab monotherapy at year 1 with significantly reduced injections. The purpose of this retrospective study was to determine the long-term visual gains and need of injections in a 3 year-follow-up period.

METHODS

Retrospective analysis of patients of the original study in the long-term follow-up from month 12 to 36. BCVA measurements following the original 1 year study were taken using logMAR charts. Injections were provided with standard of care using PRN, based on change in BCVA and CRT using SD-OCT scans. Main outcome measures were change in BCVA and mean number of injections from 12 to 36 months.

RESULTS

BCVA was stable in both groups from 12 through 36 months, showing a change of 0.16 ± 0.1 log MAR. Following the initial reduction in required injections at month 12, combination therapy patients continued to require 1.3 times fewer injections over the next 24 months (2.91 ± 2.3 vs 3.85±3.7 injections for monotherapy).

CONCLUSIONS

Combination of navigated laser and ranibizumab achieved BCVA gains equivalent to anti-VEGF monotherapy. These results could be maintained through month 36. Required injections were 2.0 injections lower in year 1 and further 1.3 times fewer in year 2 and 3 in the combination group compared to monotherapy. Adding navigated laser photocoagulation to intravitreal anti-VEGF therapy may still represent a superior therapeutic approach to DME patients.

Diabetic Retinopathy: Pathophysiology and Treatments

Diabetic retinopathy (DR) is the most common complication of diabetes mellitus (DM). It has long been recognized as a microvascular disease. The diagnosis of DR relies on the detection of microvascular lesions. The treatment of DR remains challenging. The advent of anti-vascular endothelial growth factor (VEGF) therapy demonstrated remarkable clinical benefits in DR patients; however, the majority of patients failed to achieve clinically-significant visual improvement. Therefore, there is an urgent need for the development of new treatments. Laboratory and clinical evidence showed that in addition to microvascular changes, inflammation and retinal neurodegeneration may contribute to diabetic retinal damage in the early stages of DR. Further investigation of the underlying molecular mechanisms may provide targets for the development of new early interventions. Here, we present a review of the current understanding and new insights into pathophysiology in DR, as well as clinical treatments for DR patients. Recent laboratory findings and related clinical trials are also reviewed.