Exploring various novel diagnostic and therapeutic approaches in treating diabetic retinopathy

Diabetic retinopathy is regarded as a common manifestation of diabetes mellitus, being a prominent cause of visual impairment and blindness. This microvascular complication is marked by the appearance of microaneurysms, elevated vascular permeability, capillary blockage, and proliferation of neovasculature. The etiology behind retinopathy is ambiguous and the efficacy of current treatment strategies is minimal. Early diagnosis of this complication using a biomarker with high sensitivity and specificity is very essential for providing better therapeutic strategies. The current available therapeutic options are limited with various adverse effects. Laser treatment is not beneficial in all the situations, economic constraints being the major challenge. Surgical interventions are employed when pharmacotherapy and laser treatment fail. New pharmacological treatments are becoming a necessity for treating the condition. This review highlights the use of various diagnostic tools, emerging biomarkers for early detection of diabetic retinopathy, pathological mechanisms associated with the disease, current therapeutic approaches used and future strategies for more enhanced treatment options and more potent pharmacological actions.

Nd:YAG membranotomy for preretinal hemorrhage secondary to valsalva retinopathy

PURPOSE

To report four cases of premacular hemorrhage secondary to valsalva retinopathy treated with Nd:YAG membranotomy and discuss techniques as well as the literature.

DESIGN

Retrospective case series.

METHODS

A retrospective review was conducted for four patients with vision obstructing hemorrhage secondary to valsalva retinopathy. These patients were all treated with Nd:YAG membranotomy.

RESULTS

Four patients with premacular hemorrhage secondary to valsalva retinopathy were treated with Nd:YAG laser creating a membranotomy to drain the hemorrhage. Power settings ranged from 1.7 to 3.8 mJ. Visual acuity at presentation ranged from 20/400 (1 patient) to count fingers (3 patients). Visual acuity improved in three out of four patients after laser treatment. Final visual acuity ranged from 20/20 to 20/30 in these three patients. One patient was lost to follow up after performing laser membranotomy and therefore visual acuity after treatment was not obtained. No complications were noted.

CONCLUSION

Nd:YAG membranotomy is a non-invasive, office-based treatment option that may be successfully used to treat premacular hemorrhage secondary to valsalva retinopathy.

Intravitreal tissue plasminogen activator, perfluoropropane (C3F8), and ranibizumab or photodynamic therapy for submacular hemorrhage secondary to wet age-related macular degeneration

PURPOSE

To report a combined intravitreal treatment for submacular hemorrhage.

METHODS

This retrospective, noncomparative, interventional case series included 7 patients with neovascular age-related macular degeneration and 2 with idiopathic polypoidal choroidal vasculopathy, presenting with fovea-involving submacular hemorrhage ≥ 4 disk areas in size, of <10 days of duration. All patients received a single 0.05-mL intravitreal injection of 50 μg alteplase, 0.3 mL of 100% C3F8, and facedown positioning for 1 week. Patients with newly diagnosed age-related macular degeneration received 3 consecutive monthly intravitreal injections of 0.5 mg ranibizumab, followed by monthly retreatment as needed. Those with idiopathic polypoidal choroidal vasculopathy were treated with photodynamic therapy.

RESULTS

Mean (± SD) logarithm of the minimum angle of resolution visual acuity improved from 0.75 ± 0.35 at presentation to 0.35 ± 0.30 at a mean final follow-up of 15.1 months (P = 0.0078). Median Snellen acuity improved from 20/200 to 20/32. Visual acuity was stable in one case and improved in eight. The average size of submacular hemorrhage was 6.8 disk areas at presentation, reducing to 2.6 within 1 month (P = 0.0039). Subfoveal hemorrhage was displaced in all cases within 9 weeks. The mean pretreatment central retinal thickness of 669 μm reduced to 528 μm (P = 0.0039). One case developed transiently elevated intraocular pressure. Two developed breakthrough vitreous hemorrhage. No adverse events were attributed to tissue plasminogen activator.

CONCLUSION

Tissue plasminogen activator and C3F8, combined with intravitreal ranibizumab or photodynamic therapy, may result in anatomical clearance of submacular hemorrhage and improved visual acuity, in a condition with an otherwise poor visual prognosis.

Diabetic retinopathy - An update

Management of diabetes should involve both systemic and ocular aspects. Control of hyperglycemia, hypertension and dyslipidemia are of major role in the management of diabetic retinopathy. In the ocular part; laser treatment remains the cornerstone of treatment of diabetic macular edema (focal/grid), severe non-proliferative and proliferative diabetic retinopathy (panretinal photocoagulation). There is a strong support to combination therapy. Using one or two intravitreal injections such as anti-VEGF and or steroid to reduce central macular thickness followed by focal or grid laser to give a sustained response may offer an alternative to treatment in diabetic macular edema. Anti-VEGF were found to be effective as an adjunct therapy in proliferative diabetic retinopathy patient who is going to have vitrectomy for vitreous hemorrhage with neovascularization, panretinal photocoagulation, and other ocular surgery such as cases with neovascular glaucoma and cataract with refractory macular edema.