Neovascular changes after pegaptanib in diabetics

Changing paradigms of anti-VEGF in the Indian scenario

Anti-vascular endothelial growth factors (VEGF) agents have revolutionized the treatment of retinal diseases. Use of anti-VEGF agents in the Indian Scenario present some unique challenges considering the absence of compounding pharmacies, poor penetrance of health insurance and limited affordability of the citizens of a developing economy. To study the changing paradigms of anti-VEGF use in the Indian scenario, all articles published by Indian authors, data from web-based surveys amongst Indian vitreo-retinal specialists were reviewed. In the paucity of compounding pharmacies in India, fractionation and injection techniques differ from those of developed countries. Frequent anti-VEGF monotherapy offers the best anatomical and visual results, but economics of scale do not allow the same in the Indian scenario, resulting in PRN dosing and combination of anti-VEGF with laser photocoagulation, being the commonly employed treatment protocols.

Use of pegaptanib for recurrent and non-clearing vitreous haemorrhage in proliferative diabetic retinopathy

PURPOSE

Diabetes is the leading cause of blindness in the United Kingdom among people of working age. Many with proliferative diabetic retinopathy (PDR) go on to develop vitreous haemorrhage (VH). Those with recurrent or non-clearing VH require vitrectomy to restore vision. Pegaptanib is a vascular endothelial growth factor antagonist that disrupts the proliferative cascade and has been shown to precipitate regression of retinal neovascularisation. We assessed the effect of pre-operative intravitreal (IVT) pegaptanib on the timing, difficulty, and outcome of vitrectomy for recurrent VH in PDR.

METHODS

Fourteen consecutive patients (15 eyes) were given a course of 1-3 IVT pegaptanib injections and vitrectomy was performed when indicated by the recurrence or persistence of VH, or progression of associated tractional retinal detachment (TRD).

RESULTS

The range of patient follow-up was from 6 months to 2 years. All had no further VH for at least 4 weeks after IVT pegaptanib. Five eyes remained free from VH until the end of the study (8-25 months), thus obviating the need for vitrectomy. Two further cases avoided vitrectomy following further IVT pegaptanib. In the majority of patients with VH, IVT pegaptanib created a window for further laser and risk factor optimisation. Surgery was faster and less challenging, compared with conventional vitrectomy for recurrent VH due to PDR.

CONCLUSIONS

IVT pegaptanib can be considered in diabetic patients with VH. Approximately one-third may avoid vitrectomy altogether. There are clear intra-operative advantages of using IVT pegaptanib pre-operatively. However, caution should be exercised where there is pre-existing TRD.