Evaluation of the effect of combined intravitreal ranibizumab injection and sub-tenon steroid injection in the treatment of resistant diabetic macular edema

From Monotherapy to Combination Strategies: Redefining Treatment Approaches for Multiple-Cause Macular Edema

Macular edema (ME) is a leading cause of visual impairment in various retinal disorders. Current treatment modalities, including anti-vascular endothelial growth factor (anti-VEGF) agents and corticosteroids, often require repeated applications, increasing both medical and economic burdens. ME is driven by chronic inflammation and VEGF overexpression, causing fluid accumulation in the macula. Recent studies have highlighted the role of various cytokines in ME pathogenesis, necessitating a comprehensive approach to treatment. While monotherapies have shown efficacy, they are associated with limitations such as the need for frequent injections and potential side effects. Combination therapies, including anti-VEGF drugs with macular laser photocoagulation, triamcinolone acetonide, or dexamethasone intravitreal implant (Ozurdex), have emerged as promising strategies. This review analyzes the outcomes of various combination approaches in different types of ME, including diabetic macular edema (DME), retinal vein occlusion-associated ME (RVO-ME), and uveitic macular edema (UME). The potential benefits of combining anti-VEGF and anti-inflammatory treatments are discussed, along with the need for personalized treatment regimens. Future research directions are outlined, emphasizing the importance of large-scale, long-term studies to evaluate the sustained efficacy and safety of combination therapies. The integration of advanced imaging techniques, biomarker analysis, and innovative therapeutic approaches is expected to shape the future landscape of ME management, moving towards more targeted and effective combination therapies.

Anti-Vascular Endothelial Growth Factor Combined with Ocular Steroid Therapy for Persistent Diabetic Macular Edema: A Systematic Review and Meta-Analysis

Purpose: Our purpose was to appraise the efficacy and safety of intravitreous vascular endothelial growth factor inhibitor (anti-VEGF) therapy combined with steroids for persistent diabetic macular edema. Methods: A systematic review was conducted of the research evaluating the combination therapy of anti-VEGF and steroids for persistent diabetic macular edema compared to anti-VEGF alone. A meta-analysis was performed using a protocol registered in PROSPERO (CRD42023476333). Continuous and binary variables were extracted. Results were expressed as the mean difference (MD) and risk ratio (RR). Results: A total of 9 trials with 537 eyes were included. The MDs of improvement in best-corrected visual acuity (BCVA) at 1/2/3/6/9/12 months between the combined and monotherapy groups were 1.33 (95% CI [-1.31,3.96]), 3.03 (95% CI [0.01, 6.06]), -0.37 (95% CI [-4.74, 4.00]), -1.37 (95% CI [-4.65, 1.91]), 1.05 (95% CI [-3.68, 5.77]), and 1.70 (95% CI [-3.52, 6.93]). The MDs concerned with a central retinal thickness (CMT) decline in at 1/2/3/6/9/12 months between the two groups were -47.33, 95% CI [-94.35, -0.32]), -89.19 (95% CI [-114.38, -64.00]), -58.84 (95% CI [-96.93, -20.74]), -57.23 (95% CI [-102.62, -11.84]), -40.59 (95% CI [-80.59, -0.58]), and -38.89 (95% CI [-77.38, -0.40]), respectively. Furthermore, the combined group obtained higher relative risks of experiencing events with high intraocular pressure and progressed cataracts. Conclusions: Anti-VEGF combined with ocular steroids showed a significant advantage in improving the retinal anatomical structure compared to anti-VEGF monotherapy for persistent diabetic macular edema. However, as the treatment period extended, the combination treatment was no more effective than monotherapy after 2 months, with more severe side effects.

Anti-VEGF Monotherapy vs Anti-VEGF and Steroid Combination Therapy for Diabetic Macular Edema: A Meta-analysis

Introduction: To compare the safety and efficacy of antivascular endothelial growth factor (anti-VEGF) monotherapy vs anti-VEGF and steroid combination therapy in treatment-naïve and treatment-resistant patients with diabetic macular edema (DME). Methods: A systematic literature search was conducted from January 2005 to December 2022. Sixteen randomized control trials (RCTs) published in English that reported the efficacy or safety of monotherapy and combination therapy in patients with DME were included. Results: The 16 RCTs included 1166 eyes. Monotherapy was associated with a significantly better best-corrected visual acuity (BCVA) at the final follow-up (weighted mean difference [WMD], -0.04 logMAR; 95% CI, -0.07 to -0.02; P = .002; I 2 = 0%). No significant differences were observed in the change in BCVA between groups at the final observation. Monotherapy was associated with a significantly smaller change in retinal thickness at the final follow-up (WMD, 37.63 μm; 95% CI, 11.67-63.60; P = .005; I 2 = 78%) and with a significantly lower risk for intraocular pressure-related adverse events (AEs) (risk ratio, 0.27; 95% CI, 0.15-0.46; P ≤ .001; I 2 = 0%). The risk for cataract-related AEs was not significantly different between groups (P = .06). The results in treatment-naïve patients were similar. In treatment-resistant patients, the change in retinal thickness at the final follow-up was similar between groups (P = .14) but the risk for cataract-related AEs was significantly lower in the monotherapy group in 2 RCTs (risk ratio, 0.09; 95% CI, 0.01-0.66; P = .02; I 2 = 0%). Conclusions: The changes in BCVA were similar despite combination therapy being associated with greater changes in retinal thickness. However, increased complications were seen with combination therapy. Most results in treatment-naïve patients and treatment-resistant patients were similar.

Anti-VEGF and steroid combination therapy relative to anti-VEGF mono therapy for the treatment of refractory DME: A systematic review of efficacy and meta-analysis of safety

The aim of the study was to determine the efficacy and safety of combined anti-VEGF and steroid therapy in treatment refractory DME patients. We conducted a systematic review and meta-analysis of peer-reviewed articles reporting on visual, anatomical and adverse outcomes to compare the efficacy and safety of combined intravitreal anti-VEGF/steroids versus anti-VEGF monotherapy for refractory DME. Seven studies (4 RCTs and 3 observational studies) reporting on 452 eyes were included. Our systematic review showed that combination therapy is significantly more effective for anatomical outcomes in the treatment of resistant DME compared to anti-VEGF monotherapy in six studies. Two studies found that addition of intravitreal steroids promoted faster visual improvement, but not significantly better final visual outcomes compared to anti-VEGF monotherapy. Combination therapy was associated with a higher incidence of IOP-related adverse events (RR = 0.10, 95% CI = [0.02, 0.42], p = 0.002) and cataract-related adverse events (RR = 0.10, 95% CI = [0.01, 0.71], p = 0.02). Our systematic review and meta-analysis of seven studies and 452 eyes revealed that combination therapy of anti-VEGF and steroid intravitreal drugs in the management of treatment refractory DME resulted in superior anatomical outcomes in all but one study. Combination therapy led to superior short-term visual outcomes in two studies, while others reported no difference between treatment groups. Meta-analysis revealed that combination therapy was associated with more adverse events. Future research should provide guidance on the standard definitions for treatment resistance and therapeutic alternatives for DME patients with sub-optimal response to anti-VEGF treatment.

A combination of suprachoroidal injection of triamcinolone using a custom-made needle and intravitreal Ziv-aflibercept every eight weeks to manage naïve/denovo central DME: a single-center retrospective case series

BACKGROUND

Previous studies have shown promising effects of combining intravitreal bevacizumab and suprachoroidal injection of triamcinolone acetonide in treating DME. However, further research is needed.

OBJECTIVE

To assess the efficacy and safety of combining both intravitreal Ziv-aflibercept and suprachoroidal injection of triamcinolone acetonide using a custom-made needle in naïve and de novo central diabetic macular edema (DME) patients every eight weeks for 24 weeks.

METHODS

Central macular thickness was measured via spectral domain-optical coherence tomography, and best-corrected visual acuity was measured via a Snellen chart at baseline and at 4, 8, 12, 16, and 24 weeks postinjection. Additionally, cataract progression, intraocular pressure (IOP), and ocular safety were analyzed.

RESULTS

A total of 10 eyes of 6 patients were treated with suprachoroidal injections of triamcinolone acteonid combined with an intravitreal injection of Ziv-aflibercept. Vision improved from 0.69 log minimum angle of resolution (MAR) at baseline to 0.39 log MAR after treatment. Central macular thickness significantly decreased from 462.3 ± 166 μm at baseline to 362.7 ± 77.6 μm at 24 weeks postinjection.

CONCLUSION

Suprachoroidal injection of triamcinolone using a custom-made needle with the intravitreal agent Ziv-aflibercept to treat de novo/naïve central DME has favorable outcomes and adequate safety results. Moreover, this study demonstrated the benefit of adapting the previous treatment combination for extending the interval between anti-VEGF treatments from 4 to 8 weeks, which could prevent further expenses, especially in low-income countries.However, large multicenter randomized clinical trials with longer follow-up periods are needed to assess this treatment route, especially in low-income and resourced countries.

Efficacy and Safety of Intravitreal Injection of Triamcinolone Acetonide and Conbercept for Intraocular Lens after Cataract Surgery

Objective

To investigate the effect of intravitreal injection of triamcinolone acetonide and conbercept on the efficacy and safety of diabetic macular edema (DME) after cataract intraocular lens (IOL) surgery.

Methods

A total of 350 patients with cataract complicated with diabetic macular edema in our hospital from January 2017 to July 2021 were randomly divided into conbercept group and triamcinolone acetonide group. Patients in the conbercept group were given intravitreal injection of conbercept during IOL surgery, and patients in the triamcinolone acetonide group were given injection of triamcinolone acetonide during surgery.

Results

Three months after treatment, the best-corrected visual acuity of the two groups was significantly higher than before, the corrected visual acuity of the conbercept group was more significant than the triamcinolone acetonide group, and the intraocular pressure of the triamcinolone acetonide group was higher than the conbercept group. The foveal thickness and macular volume were significantly reduced in both groups, and was reduced more in the conbercept group than in the triamcinolone acetonide group. The contents of VEGF, SDF-1, and IL-6 in both groups were significantly decreased, and the decrease was more significant in the conbercept group than in the triamcinolone acetonide group. The patients with elevated intraocular pressure, headache and vomiting, orbital swelling pain, eye swelling pain, and eye pain in the triamcinolone acetonide group were significantly higher than those in the conbercept group (P < 0.05).

Conclusions

Conbercept and triamcinolone acetonide has a good therapeutic effect on DME in pseudophakic eyes after cataract IOL surgery, which can reduce the degree of macular edema and improve the visual function. However, the therapeutic effect of injection therapy with conbercept is safe, the prognosis is better, and the complication rate is low.

Synergistic Effect of Combined Sub-Tenon Triamcinolone and Intravitreal Anti-VEGF Therapy for Uveitic Macular Edema

Purpose

To investigate effects of intravitreal anti-VEGF in combination therapy with sub-Tenon triamcinolone acetonide (STA) injection for uveitic macular edema (UME).

Design

A single-center, retrospective cohort study.

Methods

The medical records were obtained for 65 eyes of 65 patients with UME. Of which, 32 eyes received combined anti-VEGF with STA injection, and 33 eyes received 40 mg of STA injection alone. The primary outcome was the reduction of central macular thickness (CMT) measured with optical coherence tomography (OCT). Resolution rate of clinical UME and changes of best corrected visual acuity (BCVA) over 24 weeks were secondary outcomes.

Results

There was a significantly greater reduction of CMT with the combination treatment than with STA alone at 1-week (β = −157.9, P < 0.001) and 1-month (β = −53.1, P = 0.019) after injection. The cumulative incidence of macular edema resolution of all eyes was 87.7%, with 90.6% (29/32) in the combined group and 84.8% (28/33) in the STA group, respectively. More incidence of UME resolution was observed in the combined group than the STA group after 1 week (71.9% vs 15.2%, P < 0.001) and 4 weeks (84.4% vs 54.5%, P = 0.009), respectively. BCVA was better for the combination treatment than STA alone at 1-week (β = −0.085, P = 0.070) and 1-month (β = −0.108, P = 0.019) after injection, respectively. Increased intraocular pressure (>25 mmHg) was observed in 4 eyes (12.5%) in the combined group and 5 eyes (15.2%) in the STA group, respectively.

Conclusion

Combined intravitreal anti-VEGF and STA is superior to STA alone for reduction of UME and visual restoration. Addition of anti-VEGF did not increase risk for steroid-induced elevation of intraocular pressure over 6 months.

Intravitreal Ranibizumab Alone or in Combination with Calcium Dobesilate for the Treatment of Diabetic Macular Edema in Nonproliferative Diabetic Retinopathy Patients: 12-Month Outcomes of a Retrospective Study

OBJECTIVE

This study investigates the efficacy of CaD combined with intravitreal ranibizumab for the treatment of diabetic macular edema (DME) in patients with nonproliferative DR.

METHODS

This retrospective, observational, case-control study enrolled consecutive patients newly diagnosed with DME. The patients were treated with 3-monthly loading dose injections of intravitreal ranibizumab (IVR) followed by pro re nata injections (3 + PRN), with or without daily oral CaD. The patients were treated and followed up for 12 months. We reviewed their medical records to determine the optical coherence tomography (OCT) findings, number of injections, best-corrected visual acuity (BCVA), and central macular thickness (CMT) at 3, 6, and 12 months after the first injection.

RESULTS

We reviewed 102 eyes of 102 patients; 54 patients received IVR combined with oral CaD (IVR + CaD group) and 48 received only IVR (IVR group). In both groups, BCVA was higher, and CMT was lower, at 3, 6, and 12 months after the injection compared to those at the baseline (p < 0.05 for all), while there were no significant differences in BCVA improvement or CMT reduction between the two groups (p > 0.05). The mean number of IVR injections was significantly lower in the IVR + CaD group than the IVR group (5.4 ± 1.1 vs. 6.7 ± 1.6 injections, p < 0.05) during 1 year of treatment. No adverse events were noted in either group.

CONCLUSIONS

Compared to IVR alone, the addition of oral CaD to IVR in DME patients was safe and effective for improving visual function and restoring the retinal anatomy and was associated with the need for fewer injections.

Combined intravitreal ranibizumab and posterior subtenon triamcinolone acetonide injections for patients with diabetic macular edema refractory to intravitreal ranibizumab monotherapy

PURPOSE

The purpose of this study is to compare the efficacy of intravitreal ranibizumab (IVR) alone and concurrent IVR with posterior subtenon triamcinolone acetonide (PSTA) injection for patients with diabetic macular edema (DME) refractory to IVR monotherapy.

MATERIALS AND METHODS

We enrolled 43 eyes of 43 patients with DME who received at least three times of IVR, which resulted in poor anatomical responses, with central foveal thickness (CFT) reduction <10% and postinjection CFT >300 μm. All the eyes received initial 3 monthly then pro re nata (PRN) IVR 0.5-mg injections. Twenty eyes continued PRN injections and 23 eyes received combined IVR 0.5 mg and PSTA 40 mg with at least 1-year follow-up. Best-corrected visual acuity (BCVA) and CFT were recorded from 1-month to 1-year follow-up.

RESULTS

Following switch to combined therapy, the mean BCVA significantly improved from 0.61 ± 0.32 logarithm of the minimum angle of resolution (logMAR) to 0.45±0.39 logMAR at 6 month (P = 0.003), 0.43±0.35 logMAR at 9 months (P < 0.001), and 0.48±0.45 logMAR at 1 year (P = 0.03). In eyes with IVR alone, no significant VA improvement was noted throughout the year. Significantly better BCVA was noted in the combined group at 6-month, 9-month, and 1-year follow-up compared to IVR-alone group. The timing of combined therapy showed a significant association with 1-year BCVA (t = 3.25, P = 0.018).

CONCLUSION

Concurrent IVR and PSTA resulted in significantly better visual outcomes in 1-year follow-up for those refractory to preceding ranibizumab monotherapy for DME. Early addition of PSTA predicted a better visual outcome.

Anti-VEGF-Resistant Retinal Diseases: A Review of the Latest Treatment Options

Anti-vascular endothelial growth factor (anti-VEGF) therapy currently plays a central role in the treatment of numerous retinal diseases, most notably exudative age-related macular degeneration (eAMD), diabetic retinopathy and retinal vein occlusions. While offering significant functional and anatomic benefits in most patients, there exists a subset of 15–40% of eyes that fail to respond or only partially respond. For these cases, various treatment options have been explored with a range of outcomes. These options include steroid injections, laser treatment (both thermal therapy for retinal vascular diseases and photodynamic therapy for eAMD), abbreviated anti-VEGF treatment intervals, switching anti-VEGF agents and topical medications. In this article, we review the effectiveness of these treatment options along with a discussion of the current research into future directions for anti-VEGF-resistant eyes.