1
|
Cheng Z, Liu X. Comparing the efficacy of glucocorticoids and anti-VEGF in treating diabetic macular edema: systematic review and comprehensive analysis. Front Endocrinol (Lausanne) 2024; 15:1342530. [PMID: 38586457 PMCID: PMC10995385 DOI: 10.3389/fendo.2024.1342530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/07/2024] [Indexed: 04/09/2024] Open
Abstract
Introduction The aim of this study was to better understand the efficacy of various drugs, such as glucocorticoids and anti-vascular endothelial growth factors (VEGF), in the treatment of diabetic macular edema (DME), and to evaluate various clinical treatment regimens consisting of different therapeutic measures. Methods This study included randomized controlled trials up to February 2023 comparing the efficacy of corticosteroid-related therapy and anti-VEGF therapy. PubMed, the Cochrane Library, and Embase were searched, and the quality of the studies was carefully assessed. Finally, 39 studies were included. Results Results at 3-month followup showed that intravitreal injection of bevacizumab (IVB) + triamcinolone acetonide (TA) was the most beneficial in improving best-corrected visual acuity and reducing the thickness of macular edema in the center of the retina in patients with DME. Results at 6-month follow-up showed that intravitreal dexamethasone (DEX) was the most effective in improving patients' bestcorrected visual acuity and reducing the thickness of central macular edema. Discussion Overall, IVB+TA was beneficial in improving best-corrected visual acuity and reducing central macular edema thickness over a 3-month follow-up period, while DEX implants had a better therapeutic effect than anti-VEGF agents at 6 months, especially the patients with severe macular edema and visual acuity impaired. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=397100, identifier CRD42023397100.
Collapse
Affiliation(s)
- Zhi’ang Cheng
- Department of Ophthalmology, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
| | - Xiaoyong Liu
- Department of Ophthalmology, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong, China
- Department of Ophthalmology, The Affiliated Shunde Hospital of Jinan University, Foshan, Guangdong, China
| |
Collapse
|
2
|
Bassi ST, Salim S, Rishi E. Phacoemulsification in patients with diabetic macular edema - A real-world data of 75 eyes. Oman J Ophthalmol 2024; 17:53-58. [PMID: 38524319 PMCID: PMC10957054 DOI: 10.4103/ojo.ojo_75_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/21/2023] [Accepted: 08/25/2023] [Indexed: 03/26/2024] Open
Abstract
PURPOSE The purpose of this study was to evaluate the outcomes of phacoemulsification with intravitreal triamcinolone acetonide (IVTA) injection in patients with cataract and diabetic macular edema (DME) across the grades of diabetic retinopathy (DR). MATERIALS AND METHODS It was a retrospective observational study. The study included 70 patients (75 eyes) with cataract and clinically significant macular edema in diabetics with nonproliferative (61 eyes) or proliferative (14 eyes) DR who underwent phacoemulsification with IVTA. Visual outcome and progression of DME over 3 months were studied in terms of the best-corrected visual acuity (BCVA) and central macular thickness (CMT), respectively. RESULTS The case records of 70 patients (75 eyes) were studied. The mean baseline BCVA (n = 75) in the logMAR scale ± SD was 0.92 ± 0.53. 3 weeks after the surgery, the mean BCVA improved to 0.39 ± 0.26 and the mean CMT (n = 40) was 382.57 ± 192.30 compared with the mean preoperative CMT of 480.57 ± 163.25 in the same set (P = 0.01). The mean CMT decreased at 3 weeks in 22 (55% of the eyes). An improvement of ≥2 lines was seen at 3 weeks in 52 (69.33%) eyes and in 49 (65.33%) eyes at 3 months. The mean CMT at 3 months was 445.51 ± 222.99 (n = 70) compared to the preoperative mean CMT of 470.72 ± 176.15 in the same set (P = 0.29). The mean CMT decreased at 3 months in 34 (48.5%) eyes. CONCLUSIONS Phacoemulsification with IVTA injection improved the mean visual acuity at 3 weeks and 3 months in two-thirds of cases and decreased the mean CMT at 3 weeks in nearly half the numbers.
Collapse
Affiliation(s)
- Shikha Talwar Bassi
- Department of Neuroophthalmology Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Shebin Salim
- Department of Comprehensive Ophthalmology Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Ekta Rishi
- Department of Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
| |
Collapse
|
3
|
Shughoury A, Bhatwadekar A, Jusufbegovic D, Hajrasouliha A, Ciulla TA. The evolving therapeutic landscape of diabetic retinopathy. Expert Opin Biol Ther 2023; 23:969-985. [PMID: 37578843 PMCID: PMC10592121 DOI: 10.1080/14712598.2023.2247987] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 07/30/2023] [Accepted: 08/11/2023] [Indexed: 08/16/2023]
Abstract
INTRODUCTION Diabetic retinopathy (DR) is a leading cause of blindness worldwide. Recent decades have seen rapid progress in the management of diabetic eye disease, evolving from pituitary ablation to photocoagulation and intravitreal pharmacotherapy. The advent of effective intravitreal drugs inhibiting vascular endothelial growth factor (VEGF) marked a new era in DR therapy. Sustained innovation has since produced several promising biologics targeting angiogenesis, inflammation, oxidative stress, and neurodegeneration. AREAS COVERED This review surveys traditional, contemporary, and emerging therapeutics for DR, with an emphasis on anti-VEGF therapies, receptor tyrosine kinase inhibitors, angiopoietin-Tie2 pathway inhibitors, integrin pathway inhibitors, gene therapy 'biofactory' approaches, and novel systemic therapies. Some of these investigational therapies are being delivered intravitreally via sustained release technologies for extended durability. Other investigational agents are being delivered non-invasively via topical and systemic routes. These strategies hold promise for early and long-lasting treatment of DR. EXPERT OPINION The evolving therapeutic landscape of DR is rapidly expanding our toolkit for the effective and durable treatment of blinding eye disease. However, further research is required to validate the efficacy of novel therapeutics and characterize real world outcomes.
Collapse
Affiliation(s)
- Aumer Shughoury
- Department of Ophthalmology, Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, IN, USA 46202
| | - Ashay Bhatwadekar
- Department of Ophthalmology, Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, IN, USA 46202
| | - Denis Jusufbegovic
- Department of Ophthalmology, Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, IN, USA 46202
| | - Amir Hajrasouliha
- Department of Ophthalmology, Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, IN, USA 46202
| | - Thomas A Ciulla
- Department of Ophthalmology, Eugene and Marilyn Glick Eye Institute, Indiana University School of Medicine, Indianapolis, IN, USA 46202
- Midwest Eye Institute, Indianapolis, IN, USA 46290
- Clearside Biomedical, Inc., Alpharetta, GA, USA 30005
| |
Collapse
|
4
|
Chauhan MZ, Rather PA, Samarah SM, Elhusseiny AM, Sallam AB. Current and Novel Therapeutic Approaches for Treatment of Diabetic Macular Edema. Cells 2022; 11:cells11121950. [PMID: 35741079 PMCID: PMC9221813 DOI: 10.3390/cells11121950] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 12/13/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Muhammad Z. Chauhan
- Department of Ophthalmology, Harvey and Bernice Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.Z.C.); (P.A.R.); (S.M.S.); (A.M.E.)
- Miami Integrative Metabolomics Research Center, Bascom Palmer Eye Institute, University of Miami, Miami, FL 33136, USA
| | - Peyton A. Rather
- Department of Ophthalmology, Harvey and Bernice Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.Z.C.); (P.A.R.); (S.M.S.); (A.M.E.)
| | - Sajida M. Samarah
- Department of Ophthalmology, Harvey and Bernice Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.Z.C.); (P.A.R.); (S.M.S.); (A.M.E.)
| | - Abdelrahman M. Elhusseiny
- Department of Ophthalmology, Harvey and Bernice Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.Z.C.); (P.A.R.); (S.M.S.); (A.M.E.)
| | - Ahmed B. Sallam
- Department of Ophthalmology, Harvey and Bernice Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA; (M.Z.C.); (P.A.R.); (S.M.S.); (A.M.E.)
- Correspondence: ; Tel.: +501-686-5822; Fax: +501-686-7037
| |
Collapse
|
5
|
Rush RB, Rush SW. Pars Plana Vitrectomy with Internal Limiting Membrane Peeling for Treatment-Naïve Diabetic Macular Edema: A Prospective, Uncontrolled Pilot Study. Clin Ophthalmol 2021; 15:2619-2624. [PMID: 34188440 PMCID: PMC8232852 DOI: 10.2147/opth.s320214] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 06/11/2021] [Indexed: 12/04/2022] Open
Abstract
Purpose To report the outcomes in subjects undergoing pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling for the management of treatment-naïve diabetic macular edema (DME). Methods Ten treatment-naïve subjects with non-proliferative diabetic retinopathy prospectively underwent PPV with ILM peeling for the treatment of DME at a single university-affiliated institution. The preoperative features, intraoperative details and postoperative outcomes were collected and analyzed. Results All 10 subjects underwent PPV with ILM peeling without significant intraoperative or postoperative complications at 6 months follow-up. Visual acuity improved from a baseline of 0.74 (95% CI: 0.48–1.0) logMAR (Snellen 20/110) to 0.46 (95% CI: 0.3–0.62) logMAR (Snellen 20/58) at 6 months follow-up (p=0.045). Optical coherence tomography central macular thickness reduced from a baseline of 456 (95% CI: 394.7–516.4) microns to 316.8 (95% CI: 275.9–357.7) microns at 6 months follow-up (p < 0.001). Conclusion This pilot study suggests that PPV with ILM peeling may be a viable treatment option for the management of treatment naïve DME in subjects with non-proliferative diabetic retinopathy. Development of a randomized controlled trial may be justified to validate the results of this study. Clinicaltrials.gov Identifier # NCT03660345.
Collapse
Affiliation(s)
- Ryan B Rush
- Instituto de la Visión- Hospital La Carlota, Montemorelos, Nuevo León, 67530, México.,Panhandle Eye Group, Amarillo, TX, 79106, USA.,Department of Surgery, Texas Tech University Health Science Center, Amarillo, TX, 79106, USA.,Southwest Retina Specialists, Amarillo, TX, 79106, USA
| | - Sloan W Rush
- Panhandle Eye Group, Amarillo, TX, 79106, USA.,Department of Surgery, Texas Tech University Health Science Center, Amarillo, TX, 79106, USA
| |
Collapse
|
6
|
Bong A, Doughty MJ, Button NF, Mansfield DC. On the relationship between visual acuity and central retinal (macular) thickness after interventions for macular oedema in diabetics: a review. Clin Exp Optom 2021; 99:491-497. [DOI: 10.1111/cxo.12393] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 11/24/2015] [Accepted: 01/07/2016] [Indexed: 12/28/2022] Open
Affiliation(s)
- Anna Bong
- Department of Vision Sciences, Glasgow‐Caledonian University, Glasgow, UK,
| | - Michael J Doughty
- Department of Vision Sciences, Glasgow‐Caledonian University, Glasgow, UK,
| | - Norman F Button
- Department of Vision Sciences, Glasgow‐Caledonian University, Glasgow, UK,
| | | |
Collapse
|
7
|
|
8
|
Abdel-Maboud M, Menshawy E, Bahbah EI, Outani O, Menshawy A. Intravitreal bevacizumab versus intravitreal triamcinolone for diabetic macular edema-Systematic review, meta-analysis and meta-regression. PLoS One 2021; 16:e0245010. [PMID: 33434220 PMCID: PMC7802957 DOI: 10.1371/journal.pone.0245010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 12/19/2020] [Indexed: 01/02/2023] Open
Abstract
Background The most frequent cause of vision loss from diabetic retinopathy is diabetic macular edema (DME). Earlier clinical trials tried to examine the role of intravitreal triamcinolone (IVT) and intravitreal bevacizumab (IVB) in DME; they either qualified IVT over IVB or IVB over IVT or did not exhibit a significant difference. Objective This paper aims to compare the efficacy and safety of IVB versus IVT alone or combined IVB+IVT in the treatment of DME. Methods We systematically searched PubMed, CENTRAL, Scopus, Embase, Science Direct, OVID, and Web of Science for randomized controlled trials of IVB versus IVT alone or combined IVB+IVT and IVT versus the combined IVB+IVT in DME patients. Results A total of 1243 eyes of 17 trials were included in our meta-analysis and regression. Repeated injections of IVB were superior at improving VA comparing with those of IVT at 12, 24, 48-weeks, and IVB+IVT at 12, 24, 48-weeks. Single injections were comparable across the three arms regarding BCVA improvement. CMT reductions were also comparable across the three arms. Meanwhile, the overall safety regarding intraocular pressure and intraocular hypertension significantly favored the IVB group. Improvement in VA was best modified with CMT reduction from 480 um to 320um. This association was significant at 12-weeks in the three arms and persisted till 24-weeks and 48-weeks exclusively in the IVB group. Conclusions and relevance Our analysis reveals that repeated successive injections associate with better BCVA compared to single injection. Current evidence affirms that IVB is superior to IVT and IVB+IVT at improving BCVA, comparable at reducing CMT, and presents a better safety profile in the treatment of DME.
Collapse
Affiliation(s)
| | | | - Eshak I. Bahbah
- Faculty of Medicine, Al-Azhar University, New Damietta, Egypt
| | - Oumaima Outani
- Faculty of Medicine and Pharmacy of Rabat, Mohammed 5 University, Rabat, Morocco
| | - Amr Menshawy
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| |
Collapse
|
9
|
Abstract
BACKGROUND Diabetic macular edema (DME) is secondary to leakage from diseased retinal capillaries with thickening of central retina, and is an important cause of poor central visual acuity in people with diabetic retinopathy. Intravitreal steroids have been used to reduce retinal thickness and improve vision in people with DME. OBJECTIVES To assess the effectiveness and safety of intravitreal steroid therapy compared with other treatments for DME. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase on 15 May, 2019. We also searched reference lists, Science Citation Index, conference proceedings, and relevant trial registers. We conducted a top up search on 21 October, 2020. SELECTION CRITERIA We included randomized controlled trials that evaluated any type of intravitreal steroids as monotherapy against any other intervention (e.g. observation, laser photocoagulation, anti-vascular endothelial growth factor (antiVEGF) for DME. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study eligibility and risk of bias and extracted data. Where appropriate, we performed meta-analyses. MAIN RESULTS We included 10 trials (4348 participants, 4505 eyes). These trials compared intravitreal steroid therapies versus other treatments, including intravitreal antiVEGF therapy, laser photocoagulation, and sham injection. Most trials had an overall unclear or high risk of bias. One trial (701 eyes ) compared intravitreal dexamethasone implant 0.7mg with sham. We found moderate-certainty evidence that dexamethasone leads to slightly more improvement of visual acuity than sham at 12 months (mean difference [MD] -0.08 logMAR, 95% confidence interval [CI] -0.12 to -0.05 logMAR). Regarding improvement of three or more lines of visual acuity, there was moderate-certainty evidence in favor of dexamethasone at 12 months, but the CI covered the null value (risk ratio (RR) 1.39, 95% CI 0.91 to 2.12). Regarding adverse events, dexamethasone increased by about four times the risk of cataract progression and the risk of using intraocular pressure (IOP)-lowering medications compared to sham (RR 3.89, 95% CI 2.75 to 5.50 and RR 4.54, 95% CI 3.19 to 6.46, respectively; moderate-certainty evidence); about 4 in 10 participants treated with dexamethasone needed IOP-lowering medications. Two trials (451 eyes) compared intravitreal dexamethasone implant 0.7mg with intravitreal antiVEGF (bevacizumab and ranibizumab). There was moderate-certainty evidence that visual acuity improved slightly less with dexamethasone compared with antiVEGF at 12 months (MD 0.07 logMAR, 95% CI 0.04 to 0.09 logMAR; 2 trials; 451 participants/eyes; I2 = 0%). The RR of gain of three or more lines of visual acuity was inconsistent between trials, with one trial finding no evidence of a difference between dexamethasone and bevacizumab at 12 months (RR 0.99, 95% CI 0.70 to 1.40; 1 trial; 88 eyes), and the other, larger trial finding the chances of vision gain were half with dexamethasone compared with ranibizumab (RR 0.50, 95% CI 0.32 to 0.79; 1 trial; 432 participants). The certainty of evidence was low. Cataract progression and the need for IOP-lowering medications increased more than 4 times with dexamethasone implant compared to antiVEGF (moderate-certainty evidence). One trial (560 eyes) compared intravitreal fluocinolone implant 0.19mg with sham. There was moderate-certainty evidence that visual acuity improved slightly more with fluocinolone at 12 months (MD -0.04 logMAR, 95% CI -0.06 to -0.01 logMAR). There was moderate-certainty evidence that an improvement in visual acuity of three or more lines was more common with fluocinolone than with sham at 12 months (RR 1.79, 95% CI 1.16 to 2.78). Fluocinolone also increased the risk of cataract progression (RR 1.63, 95% CI 1.35 to 1.97; participants = 335; moderate-certainty evidence), which occurred in about 8 in 10 participants, and the use of IOP-lowering medications (RR 2.72, 95% CI 1.87 to 3.98; participants = 558; moderate-certainty evidence), which were needed in 2 to 3 out of 10 participants. One small trial with 43 participants (69 eyes) compared intravitreal triamcinolone acetonide injection 4 mg with sham. There may be a benefit in visual acuity at 24 months (MD -0.11 logMAR, 95% CI -0.20 to -0.03 logMAR), but the certainty of evidence is low. Differences in adverse effects were poorly reported in this trial. Two trials (615 eyes) compared intravitreal triamcinolone acetonide injection 4mg with laser photocoagulation and reached discordant results. The smaller trial (31 eyes followed up to 9 months) found more visual acuity improvement with triamcinolone (MD -0.18 logMAR, 95% CI -0.29 to -0.07 logMAR), but a larger, multicenter trial (584 eyes, 12-month follow-up) found no evidence of a difference regarding change in visual acuity (MD 0.02 logMAR, 95% CI -0.03 to 0.07 logMAR) or gain of three or more lines of visual acuity (RR 0.85, 95% CI 0.55 to 1.30) (overall low-certainty evidence). Cataract progression was about three times more likely (RR 2.68, 95% CI 2.21 to 3.24; moderate-certainty evidence) and the use of IOP-lowering medications was about four times more likely (RR 3.92, 95% CI 2.59 to 5.96; participants = 627; studies = 2; I2 = 0%; moderate-certainty evidence) with triamcinolone. About 1 in 3 participants needed IOP-lowering medication. One small trial (30 eyes) compared intravitreal triamcinolone acetonide injection 4mg with intravitreal antiVEGF (bevacizumab or ranibizumab). Visual acuity may be worse with triamcinolone at 12 months (MD 0.18 logMAR, 95% CI 0.10 to 0.26 logMAR); the certainty of evidence is low. Adverse effects were poorly reported in this trial. Four trials reported data on pseudophakic participants, for whom cataract is not a concern. These trials found no decrease in visual acuity in the second treatment year due to cataract progression. AUTHORS' CONCLUSIONS Intravitreal steroids may improve vision in people with DME compared to sham or control. Effects were small, about one line of vision or less in most comparisons. More evidence is available for dexamethasone or fluocinolone implants when compared to sham, and the evidence is limited and inconsistent for the comparison of dexamethasone with antiVEGF treatment. Any benefits should be weighed against IOP elevation, the use of IOP-lowering medication and, in phakic patients, the progression of cataract. The need for glaucoma surgery is also increased, but remains rare.
Collapse
Affiliation(s)
- Thanitsara Rittiphairoj
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Tahreem A Mir
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tianjing Li
- Department of Ophthalmology, University of Colorado Denver Anschutz Medical Campus, Aurora, CO, USA
| | - Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| |
Collapse
|
10
|
Nithianandan H, Kuriyan AE, Venincasa MJ, Sridhar J. <p>Analysis of Funding Source and Spin in the Reporting of Studies of Intravitreal Corticosteroid Therapy for Diabetic Macular Edema: A Systematic Review</p>. Clin Ophthalmol 2020; 14:2383-2395. [PMID: 32903959 PMCID: PMC7445525 DOI: 10.2147/opth.s262085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 07/28/2020] [Indexed: 01/05/2023] Open
Affiliation(s)
- Harrish Nithianandan
- Department of Ophthalmology & Visual Sciences, McGill University, Montreal, Quebec, Canada
| | - Ajay E Kuriyan
- Retina Service, Wills Eye Hospital, Philadelphia, PA, USA
| | - Michael J Venincasa
- Department of Ophthalmology, Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Jayanth Sridhar
- Department of Ophthalmology, Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
- Correspondence: Jayanth Sridhar Email
| |
Collapse
|
11
|
Mansour SE, Browning DJ, Wong K, Flynn HW, Bhavsar AR. The Evolving Treatment of Diabetic Retinopathy. Clin Ophthalmol 2020; 14:653-678. [PMID: 32184554 PMCID: PMC7061411 DOI: 10.2147/opth.s236637] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 02/18/2020] [Indexed: 12/13/2022] Open
Abstract
Purpose To review the current therapeutic options for the management of diabetic retinopathy (DR) and diabetic macular edema (DME) and examine the evidence for integration of laser and pharmacotherapy. Methods A review of the PubMed database was performed using the search terms diabetic retinopathy, diabetic macular edema, neovascularization, laser photocoagulation, intravitreal injection, vascular endothelial growth factor (VEGF), vitrectomy, pars plana vitreous surgery, antiangiogenic therapy. With additional cross-referencing, this yielded 835 publications of which 301 were selected based on content and relevance. Results Many recent studies have evaluated the pharmacological, laser and surgical therapeutic strategies for the treatment and prevention of DR and DME. Several newer diagnostic systems such as optical coherence tomography (OCT), microperimetry, and multifocal electroretinography (mfERG) are also assisting in further refinements in the staging and classification of DR and DME. Pharmacological therapies for both DR and DME include both systemic and ocular agents. Systemic agents that promote intensive glycemic control, control of dyslipidemia and antagonists of the renin-angiotensin system demonstrate beneficial effects for both DR and DME. Ocular therapies include anti-VEGF agents, corticosteroids and nonsteroidal anti-inflammatory drugs. Laser therapy, both as panretinal and focal or grid applications continue to be employed in management of DR and DME. Refinements in laser devices have yielded more tissue-sparing (subthreshold) modes in which many of the benefits of conventional continuous wave (CW) lasers can be obtained without the adverse side effects. Recent attempts to lessen the burden of anti-VEGF injections by integrating laser therapy have met with mixed results. Increasingly, vitreoretinal surgical techniques are employed for less advanced stages of DR and DME. The development and use of smaller gauge instrumentation and advanced anesthesia agents have been associated with a trend toward earlier surgical intervention for diabetic retinopathy. Several novel drug delivery strategies are currently being examined with the goal of decreasing the therapeutic burden of monthly intravitreal injections. These fall into one of the five categories: non-biodegradable polymeric drug delivery systems, biodegradable polymeric drug delivery systems, nanoparticle-based drug delivery systems, ocular injection devices and with sustained release refillable devices. At present, there remains no one single strategy for the management of the particular stages of DR and DME as there are many options that have not been rigorously tested through large, randomized, controlled clinical trials. Conclusion Pharmacotherapy, both ocular and systemic, will be the primary mode of intervention in the management of DR and DME in many cases when cost and treatment burden are less constrained. Conventional laser therapy has become a secondary intervention in these instances, but remains a first-line option when cost and treatment burden are more constrained. Results with subthreshold laser appear promising but will require more rigorous study to establish its role as adjunctive therapy. Evidence to support an optimal integration of the various treatment options is lacking. Central to the widespread adoption of any therapeutic regimen for DR and DME is substantiation of safety, efficacy, and cost-effectiveness by a body of sound clinical trials.
Collapse
Affiliation(s)
- Sam E Mansour
- George Washington University, Washington, DC, USA.,Virginia Retina Center, Warrenton, VA, 20186, USA
| | - David J Browning
- Charlotte Eye Ear Nose & Throat Associates, Charlotte, NC 28210, USA
| | - Keye Wong
- Retina Associates of Sarasota, Sarasota, FL 34233, USA
| | - Harry W Flynn
- Bascom Palmer Eye Institute, University of Miami Health System, Miami, FL, USA
| | | |
Collapse
|
12
|
Abstract
Background:
Currently, diabetic retinopathy is the leading cause of permanent visual loss in workingage
adults in industrialized nations. The chronic microangiopathic changes associated with diabetic retinopathy
lead to the most common causes of severe permanent visual loss: diabetic macular edema (DME) and proliferative
diabetic retinopathy (PDR). Multiple studies have evaluated different pharmacotherapies for different levels
of retinopathy.
Methods:
A review of the pathophysiology of diabetic retinopathy and current and emerging pharmacotherapies
for diabetic retinopathy.
Results:
Historically, DME has been the primary focus of treatment in patients with nonproliferative diabetic
retinopathy (NPDR). Due to the rapidly increasing number of agents and treatment options, management algorithms
for DME have become increasingly complex. Furthermore, spectral domain optical coherence tomography
(OCT) has allowed unparalleled sensitivity and specificity for detecting macular edema. All available intravitreal
vascular endothelial growth factor (VEGF) inhibitors have demonstrated efficacy in the treatment of patients with
DME and PDR. Intravitreal triamcinolone acetonide has also proven beneficial in diabetic retinopathy. Most
recently, various corticosteroids have been designed as sustained-release intraocular implants in order to reduce
the burden and risks associated with retreatment. Current research is focused on providing new agents that target
alternate pathways and signaling molecules to provide patients with additional therapeutic tools, especially in
patients who have an incomplete response to the current medications.
Conclusion:
Anti-VEGF therapy has revolutionized the medical management of diabetic retinopathy. The most
important existing challenges in the treatment of diabetic retinopathy are improving visual outcomes and decreasing
the treatment burden associated with repeated intravitreal injections. Combination therapy with anti-VEGF
and corticosteroids with other previously available treatments, such as panretinal photocoagulation, may be a
reasonable clinical strategy to reduce the intravitreal injections burden. Many exciting novel drugs that target
newly discovered pathways hold clinical promise. The results of ongoing randomized clinical trials will answer
the important concerns surrounding new drugs and delivery devices: safety and visual outcomes.
Collapse
Affiliation(s)
- Victor M. Villegas
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Stephen G. Schwartz
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| |
Collapse
|
13
|
Elmasry K, Ibrahim AS, Abdulmoneim S, Al-Shabrawey M. Bioactive lipids and pathological retinal angiogenesis. Br J Pharmacol 2019; 176:93-109. [PMID: 30276789 PMCID: PMC6284336 DOI: 10.1111/bph.14507] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/14/2018] [Accepted: 08/22/2018] [Indexed: 12/22/2022] Open
Abstract
Angiogenesis, disruption of the retinal barrier, leukocyte-adhesion and oedema are cardinal signs of proliferative retinopathies that are associated with vision loss. Therefore, identifying factors that regulate these vascular dysfunctions is critical to target pathological angiogenesis. Given the conflicting role of bioactive lipids reported in the current literature, the goal of this review is to provide the reader a clear road map of what has been accomplished so far in the field with specific focus on the role of polyunsaturated fatty acids (PUFAs)-derived metabolites in proliferative retinopathies. This necessarily entails a description of the different retina cells, blood retina barriers and the role of (PUFAs)-derived metabolites in diabetic retinopathy, retinopathy of prematurity and age-related macular degeneration as the most common types of proliferative retinopathies.
Collapse
Affiliation(s)
- Khaled Elmasry
- Department of Oral Biology and Diagnostic Sciences, Dental College of Georgia, Augusta University, Augusta, GA, USA
- Cellular Biology and Anatomy, MCG, Augusta University, Augusta, GA, USA
- Department of Anatomy, Faculty of Medicine, Mansoura University, Mansoura, Egypt
- Schepens Eye Research Institute/Massachusetts Eye and Ear & Department of ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Ahmed S Ibrahim
- Department of Oral Biology and Diagnostic Sciences, Dental College of Georgia, Augusta University, Augusta, GA, USA
- Department of Biochemistry, Faculty of Pharmacy, Mansoura University, Mansoura, Egypt
- Department of Ophthalmology and Culver Vision Discovery Institute, Medical College of Georgia (MCG), Augusta University, Augusta, GA, USA
| | - Samer Abdulmoneim
- Department of Oral Biology and Diagnostic Sciences, Dental College of Georgia, Augusta University, Augusta, GA, USA
- Cellular Biology and Anatomy, MCG, Augusta University, Augusta, GA, USA
| | - Mohamed Al-Shabrawey
- Department of Oral Biology and Diagnostic Sciences, Dental College of Georgia, Augusta University, Augusta, GA, USA
- Cellular Biology and Anatomy, MCG, Augusta University, Augusta, GA, USA
- Department of Anatomy, Faculty of Medicine, Mansoura University, Mansoura, Egypt
- Department of Ophthalmology and Culver Vision Discovery Institute, Medical College of Georgia (MCG), Augusta University, Augusta, GA, USA
| |
Collapse
|
14
|
Abstract
Background: The reliability of an instrument is dependent on its accuracy and repeatability. The iVue-100 optical coherence tomographer (OCT) is a spectral domain device that has the advantage of being able to measure both the anterior and posterior segments of the eye. But its repeatability for macular thickness measurements has not been assessed and this was the primary purpose of this study.Aim: To determine the repeatability of the iVue-100 OCT for macular thickness measurements.Settings: This study was conducted at the University of KwaZulu-Natal.Methods: Repeatability (intra-observer, inter-observer and inter-session) of the iVue-100 OCT was assessed on 50 participants selected using convenience sampling. Data were statistically analysed using Bland–Altman analysis, the intra-class correlation coefficient (ICC), coefficient of variation and the paired t-test.Results: The mean age and standard deviation for the 50 participants were 23.88 ± 6.93 years (range 18–51 years). The ICCs for intra-observer repeatability ranged between 0.940 and 0.989, whereas the coefficients of variation ranged between 0.040 and 0.084. For both inter-observer and inter-session repeatability, the t-test showed no statistically significant differences (p > 0.05), and Bland–Altman analysis found the majority of the measurements to be within the 95% limits of agreement.Conclusion: Irrespective of whether repeated measurements are being taken consecutively by the same examiner, by a different observer or at a different time, the iVue-100 OCT is highly reliable in terms of repeatability which is of paramount importance in any clinical or research setting.
Collapse
|
15
|
Lu L, Jiang Y, Jaganathan R, Hao Y. Current Advances in Pharmacotherapy and Technology for Diabetic Retinopathy: A Systematic Review. J Ophthalmol 2018; 2018:1694187. [PMID: 29576875 DOI: 10.1155/2018/1694187] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 10/12/2017] [Accepted: 11/07/2017] [Indexed: 01/01/2023] Open
Abstract
Diabetic retinopathy (DR) is classically defined by its vascular lesions and damage in the neurons of the retina. The cellular and clinical elements of DR have many features of chronic inflammation. Understanding the individual cell-specific inflammatory changes in the retina may lead to novel therapeutic approaches to prevent vision loss. The systematic use of available pharmacotherapy has been reported as a useful adjunct tool to laser photocoagulation, a gold standard therapy for DR. Direct injections or intravitreal anti-inflammatory and antiangiogenesis agents are widely used pharmacotherapy to effectively treat DR and diabetic macular edema (DME). However, their effectiveness is short term, and the delivery system is often associated with adverse effects, such as cataract and increased intraocular pressure. Further, systemic agents (particularly hypoglycemic, hypolipidemic, and antihypertensive agents) and plants-based drugs have also provided promising treatment in the progression of DR. Recently, advancements in pluripotent stem cells technology enable restoration of retinal functionalities after transplantation of these cells into animals with retinal degeneration. This review paper summarizes the developments in the current and potential pharmacotherapy and therapeutic technology of DR. Literature search was done on online databases, PubMed, Google Scholar, clinitrials.gov, and browsing through individual ophthalmology journals and leading pharmaceutical company websites.
Collapse
|
16
|
Al Hinai A, Wali UK, Rasool TA, Rizvi SG. Experience of intravitreal triamcinolone acetonide for treatment of diabetic macular edema among Omani population. Oman J Ophthalmol 2017; 10:177-183. [PMID: 29118493 PMCID: PMC5657160 DOI: 10.4103/ojo.ojo_173_2016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE: The purpose of this study was to evaluate the outcome of intravitreal (IVT) triamcinolone in diabetic macular edema (DME). MATERIALS AND METHODS: A retrospective study of 42 eyes diagnosed clinically and supported with optical coherence tomography (OCT), with DME of more than 300 μm in thickness. All eyes were injected with a single IVT injection of preservative free triamcinolone acetonide (TA) with dose of 4 mg. Patients were subjected to visual acuity (VA) and OCT on each follow-up visit which was continued for 6 months. The total number of IVT injections given was 48. Six eyes had a repeat injection. None of the eyes had any other IVT injection within 6 weeks of TA. Twenty-one eyes were pseudophakic. RESULTS: Mean age of the patients was 58.8 years. The mean central subfield thickness (CST) at baseline was 504.6 μm. At 6 weeks, the mean CST dropped by 183.6 μm (P < 0.00001). At 6-month follow-up, the mean CST had increased by 74.6 μm from 6 weeks level; however, the 6-month mean CST was 109 μ less than mean baseline thickness (P < 0.0005). The mean baseline VA was 0.80 LogMAR units. At 6 weeks, the mean VA dropped by 0.01 LogMAR. At 6 months, VA improved by 0.02 LogMAR units from baseline. Overall, VA improved in 47% eyes, dropped from baseline in 35% eyes, and remained unchanged in 18% eyes. CONCLUSION: Triamcinolone acetonide is a safe, effective, and promising therapy in DME.
Collapse
Affiliation(s)
- Ahmed Al Hinai
- Department of Ophthalmology, College of Medicine and Health Sciences, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Upender Krishen Wali
- Department of Ophthalmology, College of Medicine and Health Sciences, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Tayseer Abdul Rasool
- Department of Ophthalmology, College of Medicine and Health Sciences, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| | - Syed G Rizvi
- Department of Family Medicine and Public Health, Sultan Qaboos University Hospital, Muscat, Sultanate of Oman
| |
Collapse
|
17
|
Zhang L, Wang W, Gao Y, Lan J, Xie L. The Efficacy and Safety of Current Treatments in Diabetic Macular Edema: A Systematic Review and Network Meta-Analysis. PLoS One 2016; 11:e0159553. [PMID: 27434498 PMCID: PMC4951132 DOI: 10.1371/journal.pone.0159553] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 07/04/2016] [Indexed: 12/20/2022] Open
Abstract
Purpose To compare the efficacy and safety of current treatments in diabetic macular edema (DME). Methods PubMed, Embase and CENTRAL were systematically reviewed for randomized controlled trials of current treatments in DME through August 2015. Data on the mean change of best-corrected visual acuity (BCVA) and central macular thickness (CMT) were extracted, and adverse events (AEs) were collected. Results A total of 21 trials were included in our network meta-analysis. Intravitreal ranibizumab improved BCVA most significantly (OR: +7.01 95%CI (2.56 to 11.39)) in 6 months and intravitreal aflibercept (+8.19 (5.07 to 11.96)) in 12 months. Intravitreal triamcinolone combined with LASER decreased CMT most significantly (-111.34 (-254.61 to 37.93)) in 6 months and intravitreal aflibercept (-110.83 (-190.25 to -35.27)) in 12 months. Compared with the relatively high rate of ocular AEs in the groups with administration of steroids, systematic AEs occurred more frequently in the groups with vascular endothelial growth factor inhibitors involved. Conclusions Our analysis confirms that intravitreal aflibercept is most favorable with both BCVA improvement and CMT decrease than other current therapies in the management of DME within 12 months. Vascular endothelial growth factor inhibitors for DME should be used with caution due to systematic AEs. Combined intravitreal triamcinolone with LASER has a stronger efficacy in decreasing CMT than the other interventions in the early stage after injection. More high-quality randomized controlled trials will be necessary.
Collapse
Affiliation(s)
- Lu Zhang
- Department of Ophthalmology, School of Medicine, Shandong University, Jinan, China
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao, China
| | - Wen Wang
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Yan Gao
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao, China
| | - Jie Lan
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao, China
| | - Lixin Xie
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong Academy of Medical Sciences, Qingdao, China
- * E-mail:
| |
Collapse
|
18
|
Liu XD, Zhou XD, Wang Z, Shen YM. Macular laser photocoagulation with or without intravitreal triamcinolone pretreatment for diabetic macular edema: a result from five randomized controlled trials. Int J Ophthalmol 2016; 9:132-8. [PMID: 26949623 DOI: 10.18240/ijo.2016.01.22] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 05/29/2015] [Indexed: 11/23/2022] Open
Abstract
AIM To assess possible benefits of intravitreal triamcinolone acetonide (IVTA) injection as pretreatment for macular laser photocoagulation (MLP) in patients with diabetic macular edema (DME). METHODS Published randomized controlled trials (RCTs) concerning MLP with or without IVTA pretreatment for DME were retrieved from databases CNKI, Medline, EMbase, Web of Science, and the Cochrane Library. A Meta-analysis on eligible studies was conducted using RevMan 5.0 software. Two investigators independently assessed the quality of the trials and extracted data. Main outcome measures included the change in best corrected visual acuity (BCVA), difference in central macular thickness (CMT) and adverse events reporting in particular elevated intraocular pressure within the follow-up period. The results were pooled using weight mean difference (WMD) or odds risk (OR) with their corresponding 95% confidence intervals (CI). A fixed- or random-effect model was employed depending on the heterogeneity of the inclusion trials. RESULTS Finally, five independent RCTs were identified and used for comparing MLP with IVTA pretreatment (131 eyes) with MLP alone (133 eyes, control group). The overall study quality was relatively higher according to the modified Jadad scale. The Meta-analysis showed that MLP with IVTA pretreatment significantly reduced CMT at one, three and six months (P=0.002, 0.0003 and 0.04, respectively), compared with MLP alone. The IVTA pretreatment group showed statistically significant improvements in BCVA at the one-month follow up as compared with the control group (P=0.03). At three- and six-month follow up, there was a beneficial trend towards improving visual acuity in the IVTA pretreatment group without statistical significance between groups (P=0.06 and 0.20, respectively). The incidence of elevation of intraocular pressure was significantly higher in the IVTA pretreatment group than in the control group (P<0.0001). No evidence of publication bias was present according to Begg's test and Egger's test. There was a low level of heterogeneity in the included studies. CONCLUSION This Meta-analysis indicates that MLP with IVTA pretreatment has a better therapeutic effect in terms of CMT reduction and earlier (1mo) visual improvement for patients with DME as compared with MLP alone. Further confirmation with rigorously well-designed multi-center trials is needed.
Collapse
Affiliation(s)
- Xiang-Dong Liu
- Department of Ophthalmology, Affiliated Jinshan Hospital, Fudan University, Shanghai 201508, China
| | - Xiao-Dong Zhou
- Department of Ophthalmology, Affiliated Jinshan Hospital, Fudan University, Shanghai 201508, China
| | - Zhi Wang
- Department of Ophthalmology, Affiliated Jinshan Hospital, Fudan University, Shanghai 201508, China
| | - Yong-Ming Shen
- Department of Ophthalmology, Affiliated Jinshan Hospital, Fudan University, Shanghai 201508, China
| |
Collapse
|
19
|
Lee DH, Kim YJ, Yoon YH. Minimally Invasive Microincision Vitrectomy Surgery with an Intraoperative Dexamethasone Implant for Refractory Diabetic Macular Edema. Ophthalmologica 2016; 235:150-6. [PMID: 26908130 DOI: 10.1159/000443751] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 12/21/2015] [Indexed: 11/19/2022]
Abstract
PURPOSE To evaluate the 1-year results of 25-gauge microincision vitrectomy surgery (MIVS25) combined with intraoperative dexamethasone (DEX) implant for persistent diabetic macular edema (DME). METHODS This study enrolled patients who had a history of DME for ≥12 months and underwent MIVS25 and DEX implant injection. Best corrected visual acuity (BCVA) and central retinal thickness (CRT) were assessed postoperatively. RESULTS Eighteen eyes were included in the analysis. Preoperatively, logMAR BCVA was 0.90 and CRT was 594 µm on average. CRT decreased until the 3-month follow-up visit and tended to increase at 6 months, but stabilized at 12 months with additional treatments in five eyes at 5 months postoperatively. Statistically significant improvement in BCVA was noted 1 month after treatment and at each subsequent follow-up visit (p < 0.001). CONCLUSION MIVS25 combined with DEX implant injection might be utilized as an effective and safe alternative treatment for intractable DME.
Collapse
Affiliation(s)
- Dong Hoon Lee
- Department of Ophthalmology, The Eagle Eye Clinic, Seongnam, South Korea
| | | | | |
Collapse
|
20
|
Rajavi Z, Safi S, Javadi MA, Azarmina M, Moradian S, Entezari M, Nourinia R, Ahmadieh H, Shirvani A, Shahraz S, Ramezani A, Dehghan MH, Shahsavari M, Soheilian M, Nikkhah H, Ziaei H, Behboudi H, Farrahi F, Falavarjani KG, Parvaresh MM, Fesharaki H, Abrishami M, Shoeibi N, Rahimi M, Javadzadeh A, Karkhaneh R, Riazi-Esfahani M, Manaviat MR, Maleki A, Kheiri B, Golbafian F. Diabetic Retinopathy Clinical Practice Guidelines: Customized for Iranian Population. J Ophthalmic Vis Res 2016; 11:394-414. [PMID: 27994809 PMCID: PMC5139552 DOI: 10.4103/2008-322x.194131] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Purpose: To customize clinical practice guidelines (CPGs) for management of diabetic retinopathy (DR) in the Iranian population. Methods: Three DR CPGs (The Royal College of Ophthalmologists 2013, American Academy of Ophthalmology [Preferred Practice Pattern 2012], and Australian Diabetes Society 2008) were selected from the literature using the AGREE tool. Clinical questions were designed and summarized into four tables by the customization team. The components of the clinical questions along with pertinent recommendations extracted from the above-mentioned CPGs; details of the supporting articles and their levels of evidence; clinical recommendations considering clinical benefits, cost and side effects; and revised recommendations based on customization capability (applicability, acceptability, external validity) were recorded in 4 tables, respectively. Customized recommendations were sent to the faculty members of all universities across the country to score the recommendations from 1 to 9. Results: Agreed recommendations were accepted as the final recommendations while the non-agreed ones were approved after revision. Eventually, 29 customized recommendations under three major categories consisting of screening, diagnosis and treatment of DR were developed along with their sources and levels of evidence. Conclusion: This customized CPGs for management of DR can be used to standardize the referral pathway, diagnosis and treatment of patients with diabetic retinopathy.
Collapse
Affiliation(s)
- Zhale Rajavi
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sare Safi
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Javadi
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Azarmina
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Siamak Moradian
- Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Morteza Entezari
- Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ramin Nourinia
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Ahmadieh
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Armin Shirvani
- Standardization and CPG Development Office, Deputy of Curative Affairs, Ministry of Health and Medical Education, Tehran, Iran
| | | | - Alireza Ramezani
- Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Ophthalmology, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Hossein Dehghan
- Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Shahsavari
- Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoud Soheilian
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Homayoun Nikkhah
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Ophthalmology, Torfeh Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hossein Ziaei
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hasan Behboudi
- Department of Ophthalmology, Gilan University of Medical Sciences, Rasht, Iran
| | - Fereydoun Farrahi
- Department of Ophthalmology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | | | - Mohammad Mehdi Parvaresh
- Department of Ophthalmology, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid Fesharaki
- Department of Ophthalmology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Majid Abrishami
- Department of Ophthalmology, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Nasser Shoeibi
- Department of Ophthalmology, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mansour Rahimi
- Department of Ophthalmology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Javadzadeh
- Department of Ophthalmology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reza Karkhaneh
- Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Riazi-Esfahani
- Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Alireza Maleki
- Department of Ophthalmology, Al Zahra Eye Center, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Bahareh Kheiri
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | |
Collapse
|
21
|
|
22
|
Bucolo C, Grosso G, Drago V, Gagliano C. Intravitreal triamcinolone acetonide in the treatment of ophthalmic inflammatory diseases with macular edema: a meta-analysis study. J Ocul Pharmacol Ther 2015; 31:228-40. [PMID: 25825799 DOI: 10.1089/jop.2014.0094] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE To perform a meta-analysis of randomized controlled trials (RCTs) that compared the effects of treatment with intravitreal injections of triamcinolone acetonide (TA) with the standard of care for ocular inflammatory diseases. METHODS Medline database was searched for causes of macular edema terms in association with intravitreal triamcinolone. The primary outcome of interest included changes in best corrected visual acuity (BCVA) and central macular thickness (CMT). Pooled summary estimates for primary outcomes were calculated as weighted mean differences (WMD) either on a fixed- or random-effect model. RESULTS A total of 8 studies were included for quantitative analysis. Treatment with intravitreal TA showed improvement in BCVA compared with standard of care at 1 month (WMD, -0.09; 95% confidence interval [CI], -0.17 to -0.02), at 4 months (WMD, -0.09; 95% CI, -0.15 to -0.03), at 6 months (WMD, -0.13; 95% CI, -0.21 to -0.05), and in CMT at 1 month (WMD, -88.14; 95% CI, -105.86 to -70.43). Increased intraocular pressure (IOP) among patients treated with intravitreal TA was found at 4 months (WMD, 2.83; 95% CI, 1.96 to 3.70), persisting also at 12 months (WMD, 3.78; 95% CI, 2.97 to 4.59), compared with those receiving the standard of care. All outcomes are mostly equivalent at further follow-up times. CONCLUSIONS Intravitreal injections of TA may offer certain advantages over the standard of care for ocular inflammatory diseases, especially in the early stage of follow-up. However, it is necessary to take into account risks and benefits of TA treatment for ocular inflammatory diseases due to possible ocular hypertension elicited, in general, by intravitreal injection of corticosteroids.
Collapse
Affiliation(s)
- Claudio Bucolo
- 1 Section of Pharmacology and Biochemistry, Department of Biomedical and Biotechnological Sciences, University of Catania , Catania, Italy
| | | | | | | |
Collapse
|
23
|
Murugan C, Golodza BZ, Pillay K, Mthembu BN, Singh P, Maseko SK, Rampersad N, Jhetam S. Retinal thickness in black and Indian myopic students at the University of KwaZulu-Natal. African Vision and Eye Health 2015. [DOI: 10.4102/aveh.v74i1.300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background: It has been suggested that retinal thickness varies with demographic variables. Understanding the influence of demographic variables on retinal thickness could improve our knowledge of risk factors for retinal pathologies. Previous studies have focused exclusively on white and African-American populations, with limited attention to black and Indian populations.Aim: To compare retinal thickness in black and Indian myopic students at the University of KwaZulu-Natal (UKZN).Methods: A cross-sectional comparative research design was used. The study was conducted at UKZN, Westville campus. Retinal thickness was measured in 80 healthy myopic students using the Fourier/spectral domain iVue 100 optical coherence tomographer. Retinal thickness measurements of the right and left eyes showed significant correlations, therefore data from only the right eyes were analysed. Racial and gender variations in retinal thickness of the nine Early Treatment Diabetic Retinopathy Study (ETDRS) segments were assessed.Results: The mean central foveal thickness in black participants was 238 μm compared with 243 μm in Indian participants (p = 0.06). Indian participants had thicker parafoveal thickness measurements whilst black participants had thicker perifoveal thickness measurements. Male participants had thicker retinal thickness measurements in all nine ETDRS segments than female participants. Central foveal thickness showed no significant correlation with spherical equivalent (r = -0.14, p > 0.05) or axial length (r = 0.09, p > 0.05).Conclusion: The average central foveal thickness was slightly thinner in black and female participants than in Indian and male participants. Optometrists and ophthalmologists should consider these differences when evaluating black and Indian individuals with foveal retinal diseases.
Collapse
|
24
|
Simunovic MP, Hunyor AP, Ho I. Vitrectomy for diabetic macular edema: a systematic review and meta-analysis. Can J Ophthalmol 2014; 49:188-95. [DOI: 10.1016/j.jcjo.2013.11.012] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 10/06/2013] [Accepted: 11/14/2013] [Indexed: 02/07/2023]
|
25
|
Abstract
Diabetic retinopathy (DR), the most common long-term complication of diabetes mellitus, remains one of the leading causes of blindness worldwide. Tight glycemic and blood pressure control has been shown to significantly decrease the risk of development as well as the progression of retinopathy and represents the cornerstone of medical management of DR. The two most threatening complications of DR are diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR). Focal/grid photocoagulation and panretinal photocoagulation are standard treatments for both DME and PDR, respectively. Focal/grid photocoagulation is a better treatment than intravitreal triamcinolone acetonide in eyes with DME. Currently, most experts consider combination focal/grid laser therapy and pharmacotherapy with intravitreal antivascular endothelial growth factor agents in patients with center-involving DME. Combination therapy reduces the frequency of injections needed to control edema. Vitrectomy with removal of the posterior hyaloid seems to be effective in eyes with persistent diffuse DME, particularly in eyes with associated vitreomacular traction. Emerging therapies include fenofibrate, ruboxistaurin, renin-angiotensin system blockers, peroxisome proliferator-activated receptor gamma agonists, pharmacologic vitreolysis, and islet cell transplantation.
Collapse
Affiliation(s)
- Ahmed M Abu El-Asrar
- Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| |
Collapse
|
26
|
Abstract
Diabetic macular edema (DME) is the main cause of visual impairment in diabetic patients. Macular edema within 1 disk diameter of the fovea is present in 9% of the diabetic population. The management of DME is complex and often multiple treatment approaches are needed. This review demonstrates the benefits of intravitreal triamcinolone, bevacizumab and ranibizumab as adjunctive therapy to macular laser treatment in DME. The published results indicate that intravitreal injections of these agents may have a beneficial effect on macular thickness and visual acuity, independent of the type of macular edema that is present. Therefore, pharmacotherapy could complement focal/grid laser photocoagulation in the management of DME. For this review, we performed a literature search and summarized recent findings regarding combined therapy for DME.
Collapse
Affiliation(s)
- Saba Al Rashaed
- Vitreoretinal Division, King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia
| | | |
Collapse
|
27
|
|
28
|
|
29
|
Toyoda F, Tanaka Y, Ota A, Shimmura M, Kinoshita N, Takano H, Matsumoto T, Tsuji J, Kakehashi A. Effect of ranirestat, a new aldose reductase inhibitor, on diabetic retinopathy in SDT rats. J Diabetes Res 2014; 2014:672590. [PMID: 25215304 PMCID: PMC4158328 DOI: 10.1155/2014/672590] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 08/01/2014] [Accepted: 08/04/2014] [Indexed: 12/01/2022] Open
Abstract
PURPOSE To evaluate the effect of ranirestat, a new aldose reductase inhibitor (ARI), on diabetic retinopathy (DR) in Spontaneously Diabetic Torii (SDT) rats. METHODS The animals were divided into six groups, normal Sprague-Dawley rats (n = 8), untreated SDT rats (n = 9), ranirestat-treated SDT rats (0.1, 1.0, and 10 mg/kg/day, n = 7, 8, and 6, resp.), and epalrestat-treated SDT rats (100 mg/kg/day, n = 7). Treated rats received oral ranirestat or epalrestat once daily for 40 weeks after the onset of diabetes. After the eyes were enucleated, the retinal thickness and the area of stained glial fibrillary acidic protein (GFAP) were measured. RESULTS The retinas in the untreated group were significantly thicker than those in the normal and ranirestat-treated (0.1, 1.0, and 10 mg/kg/day) groups. The immunostained area of GFAP in the untreated group was significantly larger than that in the normal and ranirestat-treated (1.0 and 10 mg/kg/day) groups. There were no significant differences between the untreated group and epalrestat-treated group in the retinal thickness and the area of stained GFAP. CONCLUSION Ranirestat reduced the retinal thickness and the area of stained GFAP in SDT rats and might suppress DR and have a neuroprotective effect on diabetic retinas.
Collapse
Affiliation(s)
- Fumihiko Toyoda
- Department of Ophthalmology, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama 330-8503, Japan
| | - Yoshiaki Tanaka
- Department of Ophthalmology, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama 330-8503, Japan
| | - Ayumi Ota
- Department of Ophthalmology, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama 330-8503, Japan
| | - Machiko Shimmura
- Department of Ophthalmology, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama 330-8503, Japan
| | - Nozomi Kinoshita
- Department of Ophthalmology, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama 330-8503, Japan
| | - Hiroko Takano
- Department of Ophthalmology, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama 330-8503, Japan
| | - Takafumi Matsumoto
- Drug Development Research Laboratories, Sumitomo Dainippon Pharma Co., Ltd., 6-8-2 Doshomachi, Chuo-ku, Osaka 541-0045, Japan
| | - Junichi Tsuji
- Drug Development Research Laboratories, Sumitomo Dainippon Pharma Co., Ltd., 6-8-2 Doshomachi, Chuo-ku, Osaka 541-0045, Japan
| | - Akihiro Kakehashi
- Department of Ophthalmology, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Omiya-ku, Saitama 330-8503, Japan
- *Akihiro Kakehashi:
| |
Collapse
|
30
|
Abstract
Diabetic macular edema (DME) is a significant cause of vision loss and represents an important clinical and public health problem. It is characterized by breakdown of the blood retinal barrier with fluid accumulation in the sub-retinal and intra-retinal spaces. Although several hypotheses exist for the causes of diabetic macular edema, specific molecular mechanisms remain unclear. Current thinking includes the role of vascular endothelial growth factor (VEGF) and inflammatory cytokines in vascular permeability. We review studies showing a relationship between elevated aqueous VEGF, monocyte chemoattractant protein -1, interleukin 6, or interleukin 8 in association with DME and as predictors of DME. The presence of mediators in both the angiogenesis and inflammatory pathways data suggest a multifactorial model for the development of DME. Further studies targeting individual cytokine activity will be important to our understanding of the pathogenesis and treatment.
Collapse
Affiliation(s)
- Leah A Owen
- Department Of Ophthalmology, Moran Eye Center, University of Utah, Salt Lake City, UT 84132, USA.
| | | |
Collapse
|
31
|
Kim JH, Kang SW, Ha HS, Kim JR. Vitrectomy combined with intravitreal triamcinolone acetonide injection and macular laser photocoagulation for nontractional diabetic macular edema. Korean J Ophthalmol 2013; 27:186-93. [PMID: 23730111 PMCID: PMC3663061 DOI: 10.3341/kjo.2013.27.3.186] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 06/27/2012] [Indexed: 12/20/2022] Open
Abstract
Purpose To evaluate the efficacy of vitrectomy combined with intravitreal injection of triamcinolone acetonide (IVTA) and macular laser photocoagulation for the treatment of nontractional diabetic macular edema (DME) refractory to anti-vascular endothelial growth factor (VEGF) therapy. Methods Twenty-eight eyes from 28 subjects who were diagnosed with nontractional DME refractory to three or more sequential anti-VEGF injections underwent sequential vitrectomy, IVTA, and macular laser photocoagulation. Changes in best-corrected visual acuity (BCVA) and central subfield thickness (CST) during the six months following vitrectomy were evaluated. Additionally, the CST and BCVA outcomes were compared with those of 26 eyes treated with the same triple therapy for nontractional DME refractory to conventional treatment, such as IVTA or macular laser photocoagulation, or both. Results The mean logarithm of the minimum angle of resolution BCVAs before and one, three, and six months after vitrectomy were 0.44 ± 0.15, 0.36 ± 0.18, 0.31 ± 0.14, and 0.34 ± 0.22, respectively. The mean CSTs were 433.3 ± 77.9, 329.9 ± 59.4, 307.2 ± 60.2, and 310.1 ± 80.1 microns, respectively. The values of both BCVA and CST at one, three, and six months were significantly improved from baseline (p < 0.05). The extent of CST reduction during the first month after triple therapy was greater in eyes refractory to conventional treatment than in eyes refractory to anti-VEGF (p = 0.012). Conclusions Vitrectomy combined with IVTA and macular laser photocoagulation had a beneficial effect on both anatomical and functional outcomes in eyes with nontractional DME refractory to anti-VEGF therapy.
Collapse
Affiliation(s)
- Jae Hui Kim
- Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | | | | | | |
Collapse
|
32
|
Ford JA, Lois N, Royle P, Clar C, Shyangdan D, Waugh N. Current treatments in diabetic macular oedema: systematic review and meta-analysis. BMJ Open 2013; 3:e002269. [PMID: 23457327 PMCID: PMC3612765 DOI: 10.1136/bmjopen-2012-002269] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 02/01/2013] [Accepted: 02/01/2013] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES The aim of this systematic review is to appraise the evidence for the use of anti-VEGF drugs and steroids in diabetic macular oedema (DMO) as assessed by change in best corrected visual acuity (BCVA), central macular thickness and adverse events DATA SOURCE MEDLINE, EMBASE, Web of Science with Conference Proceedings and the Cochrane Library (inception to July 2012). Certain conference abstracts and drug regulatory web sites were also searched. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS Randomised controlled trials were used to assess clinical effectiveness and observational trials were used for safety. Trials which assessed triamcinolone, dexamethasone, fluocinolone, bevacizumab, ranibizumab, pegaptanib or aflibercept in patients with DMO were included. STUDY APPRAISAL AND SYNTHESIS METHODS Risk of bias was assessed using the Cochrane risk of bias tool. Study results are narratively described and, where appropriate, data were pooled using random effects meta-analysis. RESULTS Anti-VEGF drugs are effective compared to both laser and placebo and seem to be more effective than steroids in improving BCVA. They have been shown to be safe in the short term but require frequent injections. Studies assessing steroids (triamcinolone, dexamethasone and fluocinolone) have reported mixed results when compared with laser or placebo. Steroids have been associated with increased incidence of cataracts and intraocular pressure rise but require fewer injections, especially when steroid implants are used. LIMITATIONS The quality of included studies varied considerably. Five of 14 meta-analyses had moderate or high statistical heterogeneity. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS The anti-VEGFs ranibizumab and bevacizumab have consistently shown good clinical effectiveness without major unwanted side effects. Steroid results have been mixed and are usually associated with cataract formation and intraocular pressure increase. Despite the current wider spectrum of treatments for DMO, only a small proportion of patients recover good vision (≥20/40), and thus the search for new therapies needs to continue.
Collapse
Affiliation(s)
- John Alexander Ford
- Department of Population Health and Primary Care, Faculty of Medicine and Health Sciences,Norwich Medical School, University of East Anglia, Norwich,UK
| | - Noemi Lois
- Centre for Vascular and Visual Sciences, Queens University, Belfast, UK
| | - Pamela Royle
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, Coventry, UK
| | | | - Deepson Shyangdan
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, Coventry, UK
| | - Norman Waugh
- Warwick Evidence, Division of Health Sciences, Warwick Medical School, Coventry, UK
| |
Collapse
|
33
|
Abstract
Retinal vein occlusions (RVOs) are second to diabetic retinopathy in the prevalence as retinal vascular disorder and are characterized by dilatation of the retinal veins with retinal and subretinal hemorrhages, macular edema, hard retinal exudates, retinal ischemia, and consequent atrophy of the retina and optic nerve. They are differentiated into central RVOs and branch RVOs (BRVO), into ischemic versus nonischemic RVOs, and in the case of BRVOs, into intrapapillary BRVOs and extrapapillary BRVOs. Diagnosis is based on ophthalmoscopy, fluorescein angiography, and spectral-domain optical coherence tomography. The latter can display the presence and integrity of the retinal outer limiting membrane and of the inner and outer segments of the photoreceptors as useful information for prognosis and a guide for treatment. Risk factors for RVOs are glaucoma and arterial hypertension. Ischemic RVOs can develop iris neovascularization and secondary angle-closure glaucoma. Formerly, therapy consisted of laser photocoagulation in a "grid" pattern over the leaking area, leading to a reduction of macular edema and, as adverse effect, to focal retinal destruction. Intravitreal medical therapy including steroids and vascular endothelial growth factor inhibitors shows a marked antiedematous effect leading to an at least temporary reduction in foveal edema and correspondingly improves visual function. Intravitreal medical therapy is associated with the disadvantage of a limited duration of its effect and the advantage of not damaging the retina. A preventive therapy to avoid a recurrence of RVO or the development of an RVO in the contralateral eye has not been proven yet.
Collapse
Affiliation(s)
- Jost B Jonas
- From the *Department of Ophthalmology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; and †State Key Laboratory (Ophthalmology) and Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | | |
Collapse
|
34
|
Abstract
Treatment for diabetic macular edema (DME) is continuously evolving with the advent of pharmacologic therapies. Focal laser photocoagulation remains the historical standard of care; however, a new wave of studies is rapidly emerging that shows the benefit of intravitreal antivascular endothelial growth factor medications and corticosteroids. The goal of this review is to compare the various treatment options for DME, and include data from the most recent clinical trials of therapies for this complex condition.
Collapse
Affiliation(s)
- Amol D. Kulkarni
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI USA
| | - Michael S. Ip
- University of Wisconsin Fundus Photograph Reading Center, 8010 Excelsior Drive, Suite 100, Madison, WI 53717 USA
| |
Collapse
|
35
|
Cho HY, Kang SW, Kim YT, Chung SE, Lee SW. A three-year follow-up of intravitreal triamcinolone acetonide injection and macular laser photocoagulation for diffuse diabetic macular edema. Korean J Ophthalmol 2012; 26:362-8. [PMID: 23060723 PMCID: PMC3464320 DOI: 10.3341/kjo.2012.26.5.362] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 11/11/2011] [Indexed: 11/23/2022] Open
Abstract
Purpose To report the three-year outcomes of macular laser photocoagulation following intravitreal injection of triamcinolone acetonide (IVTA) for diffuse diabetic macular edema (DME). Methods A prospective, randomized controlled study was completed. Eighty-six eyes of 74 patients with diffuse DME were randomized into two groups. Eyes assigned to the combination group (n = 48) were subjected to macular laser photocoagulation three weeks after IVTA. Eyes in the IVTA group (n = 38) underwent IVTA alone. Central macular thickness was measured by optical coherence tomography, and the number of additional treatments and mean time to recurrence were assessed. Results Thirty-seven eyes in the combination group and 26 eyes in the IVTA group completed the three-year follow-up. Recurrence of DME after initial treatment was not observed for nine of the 37 (24.3%) eyes in the combination group or for one of the 26 (3.9$) eyes in the IVTA group (p = 0.028). DME was absent for 19.9 months after treatment in the combination group compared to 10.3 months in the IVTA group (p = 0.027). The mean number of additional treatments was 0.92 in the combination group and 1.88 in the IVTA group (p = 0.001). Conclusions Results in the subset of subjects who completed the three-year follow-up demonstrated that laser photocoagulation following IVTA is more effective than IVTA monotherapy for diffuse DME. Combination therapy required fewer additional treatments and resulted in a lower recurrence rate than IVTA monotherapy.
Collapse
Affiliation(s)
- Hee Yoon Cho
- Department of Ophthalmology, Hanyang University School of Medicine, Seoul, Korea
| | | | | | | | | |
Collapse
|
36
|
Abstract
Diabetic retinopathy is the leading cause of blindness in working age individuals in developed countries. Most cases of diabetes related vision loss result from breakdown of the blood-retinal barrier with resultant diabetic macular edema (DME). For over 30 years, laser photocoagulation has been the standard therapy for DME, but most eyes do not experience significant improvements in visual acuity. Intravitreal injections of drugs that inhibit the action of vascular endothelial growth factor (VEGF) lead to gains in vision, but can be expensive and need to be repeated frequently. In addition to VEGF-mediated breakdown of the blood-retinal barrier, recent evidence suggests that inflammation plays an important role in the development of DME. Recognizing this, physicians have injected steroids into the vitreous and developers have created sustained release implants. Intravitreal injections of triamcinolone acetonide lead to rapid resolution of macular edema and significant short-term improvements in visual acuity, but unfortunately, visual acuities diminish when treatment is continued through 2 years. However, intravitreal triamcinolone remains an attractive treatment option for eyes that are pseudophakic, scheduled to undergo cataract surgery, resistant to laser photocoagulation, or require urgent panretinal photocoagulation for proliferative retinopathy. In controlled trials, intraocular implants that slowly release dexamethasone and fluocinolone show promise in reducing macular edema and improving visual acuity. The high incidences of drug related cataracts and glaucoma, however, require that corticosteroids be used cautiously and that patients be selected carefully. The increasing number of patients with DME, the burgeoning cost of medical care and the continuing development of intravitreal steroids suggest that the use of these agents will likely increase in coming years.
Collapse
|
37
|
Chan CKM, Lai TYY, Mohamed S, Lee VYW, Liu DTL, Li C, Lam DSC. COMBINED HIGH-DOSE SUB-TENON TRIAMCINOLONE, INTRAVITREAL BEVACIZUMAB, AND LASER PHOTOCOAGULATION FOR REFRACTORY DIABETIC MACULAR EDEMA: A Pilot Study. Retina 2012; 32:672-8. [DOI: 10.1097/iae.0b013e31823043c6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
38
|
Casson RJ, Raymond G, Newland HS, Gilhotra JS, Gray TL. Pilot randomized trial of a nanopulse retinal laser versus conventional photocoagulation for the treatment of diabetic macular oedema. Clin Exp Ophthalmol 2012; 40:604-10. [DOI: 10.1111/j.1442-9071.2012.02756.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
39
|
Abstract
The benchmark treatment for diabetic macular oedema, the major cause of visual impairment in patients with diabetes mellitus, has traditionally been laser photocoagulation; however, as laser treatment does not always improve vision or even prevent further loss in many cases, several new pharmacotherapies that are injected into the vitreous for diabetic macular oedema have been successfully trialled over the past decade. Others are currently being evaluated. The two major classes of these drugs are steroids and vascular endothelial growth factor antagonists. In this article we briefly review the major clinical studies recently conducted in this field.
Collapse
Affiliation(s)
- Wedad Salem
- Save Sight Institute, University of Sydney, Sydney, New South Wales, Australia.
| | | | | |
Collapse
|
40
|
Elbendary AM, Shahin MM. Intravitreal diclofenac versus intravitreal triamcinolone acetonide in the treatment of diabetic macular edema. Retina 2011; 31:2058-64. [PMID: 21765371 DOI: 10.1097/IAE.0b013e31822a042a] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To compare the efficacy and safety of intravitreal diclofenac versus intravitreal triamcinolone acetonide in the treatment of diabetic macular edema. METHODS Thirty-two eyes with diffuse diabetic macular edema were randomly allocated to intravitreal injection of 4 mg/0.1 mL of triamcinolone (Group 1: N = 16) or 500 μg/0.1 mL of diclofenac (Group 2: N = 16). Preoperative and postoperative visual acuity, intraocular pressure, and central macular thickness were recorded and compared between the 2 groups up to 12 weeks. RESULTS Both groups showed statistically significant reduction in central macular thickness (triamcinolone: P = 0.02 and diclofenac: P = 0.01), without statistically significant difference between the 2 groups. Visual improvement was significant only in triamcinolone group (P = 0.05). However, the 2 groups showed no statistically significant difference in mean visual acuity or mean line improvement. Transient elevation of intraocular pressure occurred in 12.5% of the triamcinolone group. Diclofenac group showed statistically significant reduced intraocular pressure (P = 0.02). CONCLUSION Intravitreal diclofenac is effective in the treatment of diffuse diabetic macular edema up to 12 weeks. Intravitreal triamcinolone and diclofenac appear to have comparable therapeutic effects on retinal thickness. The degree of visual improvement is higher with triamcinolone.
Collapse
|
41
|
Chin EK, Sedeek RW, Li Y, Beckett L, Redenbo E, Chandra K, Park SS. Reproducibility of macular thickness measurement among five OCT instruments: effects of image resolution, image registration, and eye tracking. Ophthalmic Surg Lasers Imaging Retina 2012; 43:97-108. [PMID: 22201525 DOI: 10.3928/15428877-20111222-02] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Accepted: 11/07/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVE To study the effect of image resolution, eye tracking, and image registration on central macular thickness reproducibility (rCMT) among spectral-domain and time-domain optical coherence tomography (SD-OCT and TD-OCT) instruments. PATIENTS AND METHODS Seventy-six eyes were imaged (44 normal, 32 maculopathy) either twice using four SD-OCT and one TD-OCT devices or three times using Spectralis SD-OCT (with and without eye tracking) (Heidelberg Engineering, Inc., Heidelberg, Germany). Cirrus images (Carl Zeiss Meditec, Dublin, CA) were further analyzed with three-point image registration. RESULTS All instruments had superior rCMT in normal versus pathologic eyes (P < .001). No difference in rCMT was noted among instruments in normal eyes (P = .92), but TD-OCT was superior to SD-OCT (P = .017) in pathologic eyes. Cirrus image registration improved rCMT for normal eyes (P = .04), with borderline improvement in pathologic eyes (P = .06). Spectralis eye tracking improved rCMT in normal (P = .01) and pathologic (P = .004) eyes. CONCLUSION Higher image resolution with SD-OCT may not improve rCMT, but image registration and eye tracking options may improve rCMT.
Collapse
Affiliation(s)
- Eric K Chin
- Department of Ophthalmology & Vision Science, University of California Davis Eye Center, Sacramento, California 95817, USA
| | | | | | | | | | | | | |
Collapse
|
42
|
|
43
|
Norlaili M, Bakiah S, Zunaina E. Intravitreal triamcinolone versus laser photocoagulation as a primary treatment for diabetic macular oedema--a comparative pilot study. BMC Ophthalmol 2011; 11:36. [PMID: 22111945 PMCID: PMC3231950 DOI: 10.1186/1471-2415-11-36] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2010] [Accepted: 11/23/2011] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Diabetic macular oedema is the leading causes of blindness. Laser photocoagulation reduces the risk of visual loss. However recurrences are common and despite laser treatment, patients with diabetic macular oedema experienced progressive loss of vision. Stabilization of the blood retinal barrier introduces a rationale for intravitreal triamcinolone treatment in diabetic macular oedema. This study is intended to compare the best corrected visual acuity (BCVA) and the macular oedema index (MEI) at 3 month of primary treatment for diabetic macular oedema between intravitreal triamcinolone acetonide (IVTA) and laser photocoagulation. METHODS This comparative pilot study consists of 40 diabetic patients with diabetic macular oedema. The patients were randomized into two groups using envelope technique sampling procedure. Treatment for diabetic macular oedema was based on the printed envelope technique selected for every patient. Twenty patients were assigned for IVTA group (one injection of IVTA) and another 20 patients for LASER group (one laser session). Main outcome measures were mean BCVA and mean MEI at three months post treatment. The MEI was quantified using Heidelberg Retinal Tomography II. RESULTS The mean difference for BCVA at baseline [IVTA: 0.935 (0.223), LASER: 0.795 (0.315)] and at three months post treatment [IVTA: 0.405 (0.224), LASER: 0.525 (0.289)] between IVTA and LASER group was not statistically significant (p = 0.113 and p = 0.151 respectively). The mean difference for MEI at baseline [IVTA: 2.539 (0.914), LASER: 2.139 (0.577)] and at three months post treatment [IVTA: 1.753 (0.614), LASER: 1.711 (0.472)] between IVTA and LASER group was also not statistically significant (p = 0.106 and p = 0.811 respectively). CONCLUSIONS IVTA demonstrates good outcome comparable to laser photocoagulation as a primary treatment for diabetic macular oedema at three months post treatment. TRIAL REGISTRATION ISRCTN05040192 (http://www.controlled-trial.com).
Collapse
Affiliation(s)
- Mustapha Norlaili
- Department of Ophthalmology, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Shaharuddin Bakiah
- Advanced Medical and Dental Institute, Universiti Sains Malaysia, 13200 Kepala Batas, Pulau Pinang, Malaysia
| | - Embong Zunaina
- Department of Ophthalmology, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| |
Collapse
|
44
|
Liu T, Hu AY, Kaines A, Yu F, Schwartz SD, Hubschman J. A PILOT STUDY OF NORMATIVE DATA FOR MACULAR THICKNESS AND VOLUME MEASUREMENTS USING CIRRUS HIGH-DEFINITION OPTICAL COHERENCE TOMOGRAPHY: . Retina 2011; 31:1944-50. [DOI: 10.1097/iae.0b013e31820d3f13] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
45
|
Lee SJ, Kim ET, Moon YS. Intravitreal bevacizumab alone versus combined with macular photocoagulation in diabetic macular edema. Korean J Ophthalmol 2011; 25:299-304. [PMID: 21976935 PMCID: PMC3178762 DOI: 10.3341/kjo.2011.25.5.299] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Accepted: 10/13/2010] [Indexed: 11/23/2022] Open
Abstract
Purpose To compare the efficacy between intravitreal bevacizumab and combination treatment (bevacizumab and macular photocoagulation) for the treatment of diabetic macular edema (DME). In addtion, changes of DME type were researched using optical coherence tomography. Methods The present study included 90 eyes with bevacizumab injection and 38 eyes with combination treatment. Using chart records, patients were reviewed until 6 months after treatment. The present study compared changes of visual acuity (VA) and macular thickness at each follow up. DME was classified into 4 types and the morphologic pattern was compared. Results In patients with the bevacizumab injection only, VA improved from 0.29 ± 0.18 to 0.48 ± 0.26 at 1 month and returned to 0.32 ± 0.20 at 6 months after treatment. In the combination treatment, VA improved from 0.32 ± 0.22 to 0.52 ± 0.26 at 1 month and returned to 0.36 ± 0.18 at 6 months after treatment. There was no significant improvement of VA at the final follow-up with either treatment. There was significant decrease of macular thickness except in the mixed DME type. Conclusions The combination treatment did not yield better VA or macular thickness reduction at 6 months than bevacizumab injection alone. By classifying and observing the change of DME type, determining the treatment objectively and predicting the effectiveness of treatment can be helpful.
Collapse
Affiliation(s)
- Soo Jeong Lee
- Department of Ophthalmology, Inha University School of Medicine, Incheon, Korea
| | | | | |
Collapse
|
46
|
Abstract
Diabetic retinopathy (DR) is a major cause of blindness worldwide and is the number one cause of blindness in working-age individuals in developed countries. We review the current literature and discuss the pathogenesis, modifying risk factors, genetics, and treatment of DR. Special focus is placed on the rationale and effectiveness of therapeutic modalities, both current and future.
Collapse
Affiliation(s)
- Louis K Chang
- Jules Stein Eye Institute, Department of Ophthalmology, University of California, Los Angeles, Los Angeles, CA, USA
| | | |
Collapse
|
47
|
|
48
|
Abstract
Diabetic macular oedema (DMO) is a significant cause of visual loss in the working population. Focal/grid photocoagulation remains an effective treatment for DMO and the benchmark to which clinicians compare other newer treatment modalities. There are, however, patients who do not respond adequately or who are refractory to laser photocoagulation. This has led to the development of newer treatments such as the intravitreal injection of vascular endothelial growth factor (VEGF) inhibitors as well as intravitreal corticosteroid releasing delivery systems. Cataract formation and raised intraocular pressure remain the major disadvantages of corticosteroid use. There is mounting evidence that intravitreal VEGF inhibitors with or without combined laser photocoagulation will become the gold standard treatment for DMO.
Collapse
Affiliation(s)
- Adam H Ross
- Department of Ophthalmology, Bristol Eye Hospital, Bristol, United Kingdom
| | | |
Collapse
|
49
|
Abstract
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.
Collapse
|
50
|
Abstract
Diabetic retinopathy, the most common long-term complication of diabetes mellitus, remains one of the leading causes of blindness worldwide. Strict metabolic control, tight blood pressure control, laser photocoagulation, and vitrectomy remain the standard care for diabetic retinopathy. Focal/grid photocoagulation is a better treatment than intravitreal triamcinolone acetonide in eyes with diabetic macular edema and should be considered as the first-line therapeutic option. The current evidence suggests that intravitreal triamcinolone acetonide or anti-vascular endothelial growth factor agents result in a temporary improvement of visual acuity and a short-term reduction in central macular thickness in patients with refractory diabetic macular edema and are an effective adjunctive treatments to laser photocoagulation or vitrectomy. However, triamcinolone is associated with risks of elevated intraocular pressure and cataract. Vitrectomy with the removal of the posterior hyaloid without internal limiting membrane peeling seems to be effective in eyes with persistent diffuse diabetic macular edema, particularly in eyes with associated vitreomacular traction. Emerging therapies include islet cell transplantation, fenofibrate, ruboxistaurin, pharmacologic vitreolysis, rennin-angiotensin system blockers, and peroxisome proliferator-activated receptor gamma agonists.
Collapse
Affiliation(s)
- Ahmed M. Abu El-Asrar
- Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | |
Collapse
|