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Virgili G, Curran K, Lucenteforte E, Peto T, Parravano M. Anti-vascular endothelial growth factor for diabetic macular oedema: a network meta-analysis. Cochrane Database Syst Rev 2023; 2023:CD007419. [PMID: 38275741 PMCID: PMC10294542 DOI: 10.1002/14651858.cd007419.pub7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Background Diabetic macular oedema (DMO) is a common complication of diabetic retinopathy. Antiangiogenic therapy with anti-vascular endothelial growth factor (anti-VEGF) can reduce oedema, improve vision, and prevent further visual loss. These drugs have replaced laser photocoagulation as the standard of care for people with DMO. In the previous update of this review, we found moderate-quality evidence that, at 12 months, aflibercept was slightly more effective than ranibizumab and bevacizumab for improving vision in people with DMO, although the difference may have been clinically insignificant (less than 0.1 logarithm of the minimum angle of resolution (logMAR), or five Early Treatment Diabetic Retinopathy Study (ETDRS) letters, or one ETDRS line). Objectives The objective of this updated review was to compare the effectiveness and safety of the different anti-VEGF drugs in RCTs at longer followup (24 months). Search methods We searched various electronic databases on 8 July 2022. Selection criteria We included randomised controlled trials (RCTs) that compared any anti-angiogenic drug with an anti-VEGF mechanism of action versus another anti-VEGF drug, another treatment, sham, or no treatment in people with DMO. Data collection and analysis We used standard Cochrane methods for pairwise meta-analysis and we augmented this evidence using network meta-analysis (NMA) methods. We used the Stata 'network' meta-analysis package for all analyses. We used the CINeMA (Confidence in Network Meta-Analysis) web application to grade the certainty of the evidence. Main results We included 23 studies (13 with industry funding) that enrolled 3513 people with DMO (median central retinal thickness (CRT) 460 microns, interquartile range (IQR) 424 to 482) and moderate vision loss (median best-corrected visual acuity (BCVA) 0.48 logMAR, IQR 0.42 to 0.55. One study that investigated ranibizumab versus sham and one study that mainly enrolled people with subclinical DMO and normal BCVA were not suitable for inclusion in the efficacy NMA. Consistent with the previous update of this review, we used ranibizumab as the reference drug for efficacy, and control (including laser, observation, and sham) as the reference for systemic safety. Eight trials provided data on the primary outcome (change in BCVA at 24 months, in logMAR: lower is better). We found no evidence of a difference between the following interventions and ranibizumab alone: aflibercept (mean difference (MD) -0.05 logMAR, 95% confidence interval (CI) -0.12 to 0.02; moderate certainty); bevacizumab (MD -0.01 logMAR, 95% CI -0.13 to 0.10; low certainty), brolucizumab (MD 0.00 logMAR, 95% CI -0.08 to 0.07; low certainty), ranibizumab plus deferred laser (MD 0.00 logMAR, 95% CI -0.11 to 0.10; low certainty), and ranibizumab plus prompt laser (MD 0.03 logMAR, 95% CI -0.04 to 0.09; very low certainty). We also analysed BCVA change at 12 months, finding moderate-certainty evidence of increased efficacy with brolucizumab (MD -0.07 logMAR, 95%CI -0.10 to -0.03 logMAR), faricimab (MD -0.08 logMAR, 95% CI -0.12 to -0.05), and aflibercept (MD -0.07 logMAR, 95 % CI -0.10 to -0.04) compared to ranibizumab alone, but the difference could be clinically insignificant. Compared to ranibizumab alone, NMA of six trials showed no evidence of a difference with aflibercept (moderate certainty), bevacizumab (low certainty), or ranibizumab with prompt (very low certainty) or deferred laser (low certainty) regarding improvement by three or more ETDRS lines at 24 months. There was moderate-certainty evidence of greater CRT reduction at 24 months with brolucizumab (MD -23 microns, 95% CI -65 to -1 9) and aflibercept (MD -26 microns, 95% CI -53 to 0.9) compared to ranibizumab. There was moderate-certainty evidence of lesser CRT reduction with bevacizumab (MD 28 microns, 95% CI 0 to 56), ranibizumab plus deferred laser (MD 63 microns, 95% CI 18 to 109), and ranibizumab plus prompt laser (MD 72 microns, 95% CI 25 to 119) compared with ranibizumab alone. Regarding all-cause mortality at the longest available follow-up (20 trials), we found no evidence of increased risk of death for any drug compared to control, although effects were in the direction of an increase, and clinically relevant increases could not be ruled out. The certainty of this evidence was low for bevacizumab (risk ratio (RR) 2.10, 95% CI 0.75 to 5.88), brolucizumab (RR 2.92, 95% CI 0.68 to 12.58), faricimab (RR 1.91, 95% CI 0.45 to 8.00), ranibizumab (RR 1.26, 95% CI 0.68 to 2.34), and very low for conbercept (RR 0.33, 95% CI 0.01 to 8.81) and aflibercept (RR 1.48, 95% CI 0.79 to 2.77). Estimates for Antiplatelet Trialists Collaboration arterial thromboembolic events at 24 months did not suggest an increase with any drug compared to control, but the NMA was overall incoherent and the evidence was of low or very low certainty. Ocular adverse events were rare and poorly reported and could not be assessed in NMAs. Authors' conclusions There is limited evidence of the comparative efficacy and safety of anti-VEGF drugs beyond one year of follow-up. We found no clinically important differences in visual outcomes at 24 months in people with DMO, although there were differences in CRT change. We found no evidence that any drug increases all-cause mortality compared to control, but estimates were very imprecise. Evidence from RCTs may not apply to real-world practice, where people in need of antiangiogenic treatment are often under-treated, and the individuals exposed to these drugs may be less healthy than trial participants.
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Key Words
- Angiogenesis Inhibitors [adverse effects, *therapeutic use]
- Aptamers, Nucleotide [adverse effects, therapeutic use]
- Bevacizumab [adverse effects, therapeutic use]
- Diabetic Retinopathy [*complications]
- Laser Coagulation [methods]
- Macular Edema [*drug therapy, etiology, surgery]
- Network Meta-Analysis
- Quality of Life
- Randomized Controlled Trials as Topic
- Ranibizumab [adverse effects, therapeutic use]
- Receptors, Vascular Endothelial Growth Factor [therapeutic use]
- Recombinant Fusion Proteins [adverse effects, therapeutic use]
- Triamcinolone [adverse effects, therapeutic use]
- Vascular Endothelial Growth Factor A [*antagonists & inhibitors]
- Visual Acuity [*drug effects, physiology]
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Affiliation(s)
- Gianni Virgili
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | | | - Ersilia Lucenteforte
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Tunde Peto
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Mariacristina Parravano
- Ophthalmology, Fondazione G.B. Bietti per lo studio e la ricerca in Oftalmolologia-IRCCS, Rome, Italy
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Patil NS, Mihalache A, Hatamnejad A, Popovic MM, Kertes PJ, Muni RH. Intravitreal steroids compared to anti-vascular endothelial growth factor treatment for diabetic macular edema: a meta-analysis. Ophthalmol Retina 2022; 7:289-299. [PMID: 36272716 DOI: 10.1016/j.oret.2022.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 10/10/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022]
Abstract
TOPIC Diabetic macular edema (DME) can be treated with either intravitreal anti-VEGF injections or intravitreal corticosteroid injections. CLINICAL RELEVANCE We provide an updated meta-analysis of the comparative efficacy and safety of intravitreal steroids and anti-VEGF agents for DME. METHODS A systematic search was performed on Ovid MEDLINE, Embase, and Cochrane Controlled Register of Trials from January 2005 to November 2021. Inclusion criteria included published randomized clinical trial data comparing the efficacy and safety of intravitreal steroids versus anti-VEGF agents for DME. Nonrandomized, noncomparative, and non-English studies were excluded. RESULTS Fourteen randomized clinical trials reporting on 827 eyes were included. Between these 2 treatments, our analysis revealed no significant difference in best-corrected visual acuity (BCVA) outcomes at 3 months (P = 0.11), 6 months (P = 0.21), 12 months (P = 0.24), and final follow-up (P = 0.91). Retinal thickness was significantly lower with steroid treatment at 3 months (P = 0.04), 6 months (P < 0.00001), and final follow-up (weighted mean difference = 39.99 μm; 95% confidence interval [CI] = 14.58,65.41; P = 0.002); however, there was no significant difference at 12 months (P = 0.18). Intravitreal anti-VEGF agents were associated with a lower incidence of intraocular pressure-related adverse events (risk ratio = 0.13; 95% CI = 0.05, 0.34; P < 0.00001). There was no significant difference between comparators for other adverse events, including cataract-related adverse events (P = 0.22). CONCLUSIONS Overall, intravitreal steroid treatment for DME was associated with no significant differences in BCVA, a significantly lower retinal thickness, and a higher risk of intraocular pressure-related events. The certainty of evidence ranged from low to moderate and the analysis was limited by heterogeneity. Our results reinforce the importance of a continual reevaluation of the role of intravitreal steroids in DME management. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.
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Affiliation(s)
- Nikhil S Patil
- Michael DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Andrew Mihalache
- Schulich School of Medicine and Dentristry, University of Western Ontario, London, Ontario, Canada
| | - Amin Hatamnejad
- Michael DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Marko M Popovic
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Peter J Kertes
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada; John and Liz Tory Eye Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Rajeev H Muni
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada; Department of Ophthalmology, St. Michael's Hospital/Unity Health Toronto, Toronto, Ontario, Canada.
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Zhang X, Liu Y, Wang M, Li Q, Zhang W, Zhang R, Wu Y. Efficacy of Antiangiogenic Drugs in the Treatment of Diabetic Macular Edema: A Bayesian Network Analysis. Front Pharmacol 2021; 12:637667. [PMID: 33935727 PMCID: PMC8082725 DOI: 10.3389/fphar.2021.637667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 03/11/2021] [Indexed: 11/22/2022] Open
Abstract
Aims: To compare the efficacy of five kinds of antiangiogenic drugs in the treatment of diabetic macular edema Methods: A comprehensive search of seven databases without language restrictions includes PubMed, EMBASE, Web of Science, CBM, the Cochrane Library, CNKI, and WanFang date. All literature used was published before October 2020. Eligible randomized trials were screened for inclusion in this study, and Bayesian framework was used to perform a network meta-analysis (NMA). Data on the mean change of best-corrected visual acuity (BCVA), central macular thickness (CMT) and intraocular pressure (IOP) at 6 months were extracted. Results: 25 randomized controlled trials (RCTs) that covered 2214 eyes, which received treatment of more than 3 months durations were included. In the pooled pair-wise meta-analysis, there was no statistically significant difference between all treatments. The same result was observed in the network meta-analysis with 0-37.82% Global I-squared. For BCVA at 6 months, conbercept and ranibizumab may be favorable than bevacizumab, aflibercept, triamcinolone acetonide and sham injections according to the ranking probabilities. As for CMT at 6 months, ranibizumab may be the most effective compared to bevacizumab, aflibercept and triamcinolone acetonide. In terms of IOP at 6 months, ranibizumab have better effect than bevacizumab, triamcinolone acetonide and sham injections. The results of sensitivity analysis also confirm it. Conclusion: The analysis confirms that ranibizumab may be the most favorable for BCVA improvement and have a stronger efficacy in decreasing CMT and IOP than other drugs when taking all the indicators into consideration. This conclusion may provide clinical evidence to guide treatment decisions. However, more high-quality randomized controlled trials will be necessary to further confirm this.
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Affiliation(s)
- Xuexue Zhang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- China Academy of Chinese Medical Sciences, Beijing, China
| | - Yi Liu
- Chongqing Medical University, Chongqing, China
| | - Miaoran Wang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
- China Academy of Chinese Medical Sciences, Beijing, China
| | - Qiuyan Li
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Wantong Zhang
- Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Rui Zhang
- Beijing University of Chinese Medicine, Beijing, China
| | - Yufei Wu
- Beijing University of Chinese Medicine, Beijing, China
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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] [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,
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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] [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.
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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
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Sharma DS, Singh SK, Thakur D, K.R A, Khursheed R, Wadhwa S. Current Strategies and Future Perspective for the Effective Treatment of Diabetic Retinopathy. CURRENT DRUG THERAPY 2020. [DOI: 10.2174/1574885514666191007101007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Diabetes Retinopathy (DR) is one of the main complications due to diabetes. DR will
damage the retinal capillaries and block them, which causes the loss of vision. Different drugs and
therapies are used for the treatment and prevention of the DR. The most commonly used treatment
is laser technology and combination therapy, along with some drugs. But these drugs possess side
effects in the form of cataract, glaucoma, and complete blindness of the eye. The main strategy to
overcome In DR, medicines with minimum side effects or maximum therapeutic effects are used.
This article emphasizes the current strategy used for the treatment of DR with allopathic as well as
herbal drugs.
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Affiliation(s)
- Deep Shikha Sharma
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab, India
| | - Sachin Kumar Singh
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab, India
| | - Divya Thakur
- Department of Pharmaceutical Sciences and Drug Research, Punjabi University, Patiala, Punjab, India
| | - Arya K.R
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab, India
| | - Rubiya Khursheed
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab, India
| | - Sheetu Wadhwa
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab, India
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7
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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.
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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
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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] [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
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Rodrigues MW, Cardillo JA, Messias A, Siqueira RC, Scott IU, Jorge R. Bevacizumab versus triamcinolone for persistent diabetic macular edema: a randomized clinical trial. Graefes Arch Clin Exp Ophthalmol 2019; 258:479-490. [PMID: 31873786 DOI: 10.1007/s00417-019-04564-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/25/2019] [Accepted: 12/10/2019] [Indexed: 10/25/2022] Open
Abstract
PURPOSE To evaluate 24-week visual acuity and anatomic outcomes of two "pro re nata" (prn) treatment strategies (intravitreal bevacizumab [IVB] prn versus intravitreal triamcinolone acetonide [IVT] prn) in patients with persistent diabetic macular edema (pDME) after 24 weeks of prn-IVB. METHODS One hundred eyes with center-involving DME were enrolled and treated with prn-IVB for 24 weeks; at week 24, eyes with pDME (central subfield thickness [CST] on spectral domain optical coherence tomography > 300 μm) were randomized to IVB monthly prn (group I; prn-IVB) or IVT every 3 months prn (group II; prn-IVT) and eyes in which the CST was ≤ 300 μm were assigned to continue prn-IVB (group III). RESULTS Seventy-four eyes completed a 48-week study period. At week 24, 65 (79.3%) eyes still had DME with CST > 300 μm and, therefore, were randomized to prn-IVB (group I, n = 33) or prn-IVT (group II, n = 32); the remaining 17 (20.7%) eyes had CST ≤ 300 μm and were assigned to continued treatment with prn-IVB (group III). At baseline, mean CST (μm) ± standard error of the mean (SEM) was 447.2 ± 24.4, 478.0 ± 19.7, and 386.0 ± 21.0 in groups I, II, and III, respectively (p > 0.05). At week 48, there was no significant difference in mean CST between groups I and II (369.9 ± 23.3 and 426.0 ± 26.1, respectively; p = 0.9995). A significant reduction in mean CST, compared with baseline, was noted at weeks 28 (p = 0.0002) and 44 (p = 0.0002) in group II. Group I did not show a significant reduction in mean CST compared with baseline at any study visit. There were no significant differences in mean CST between groups I and II at any study visit. At baseline, mean ± SEM best-corrected visual acuity (BCVA) (logMAR) was 0.50 ± 0.00, 0.60 ± 0.10, and 0.50 ± 0.10 in groups I, II, and III, respectively (p > 0.05). At week 48, there was no statistically significant difference in mean BCVA between groups I and II (0.50 ± 0.10 and 0.80 ± 0.10, respectively; p = 0.4473). There was no significant improvement in mean BCVA, as compared with baseline, at any study follow-up visit in any of the groups. Group II demonstrated significantly lower BCVA after 24 weeks of IVT (at week 48) compared with baseline (p = 0.0435). There was no significant difference in mean BCVA between groups I and II at any time-point. CONCLUSION In eyes with pDME after 24 weeks of treatment with prn-IVB, there was no difference between continued treatment with prn-IVB versus a treatment switch to prn-IVT with respect to mean BCVA or mean CST at week 48. However, BCVA was stable in the prn-IVB group, while prn-IVT was associated with BCVA reduction from baseline and a higher risk of IOP elevation.
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Affiliation(s)
- Murilo W Rodrigues
- Department of Ophthalmology, Ribeirão Preto Medical School, University of São Paulo, Brazil, 3900, Bandeirantes av., Campus, 12fl., Ribeirão Preto, São Paulo, 14048-900, Brazil.
| | - José A Cardillo
- Department of Ophthalmology, Ribeirão Preto Medical School, University of São Paulo, Brazil, 3900, Bandeirantes av., Campus, 12fl., Ribeirão Preto, São Paulo, 14048-900, Brazil
| | - André Messias
- Department of Ophthalmology, Ribeirão Preto Medical School, University of São Paulo, Brazil, 3900, Bandeirantes av., Campus, 12fl., Ribeirão Preto, São Paulo, 14048-900, Brazil
| | - Rubens C Siqueira
- Department of Ophthalmology, Ribeirão Preto Medical School, University of São Paulo, Brazil, 3900, Bandeirantes av., Campus, 12fl., Ribeirão Preto, São Paulo, 14048-900, Brazil
| | - Ingrid U Scott
- Departments of Ophthalmology and Public Health Sciences, Penn State College of Medicine, 700 HMC Crescent Road, Hershey, PA, 17033, USA
| | - Rodrigo Jorge
- Department of Ophthalmology, Ribeirão Preto Medical School, University of São Paulo, Brazil, 3900, Bandeirantes av., Campus, 12fl., Ribeirão Preto, São Paulo, 14048-900, Brazil
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10
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Mello Filho P, Andrade G, Maia A, Maia M, Biccas Neto L, Muralha Neto A, Moura Brasil O, Minelli E, Dalloul C, Iglicki M. Effectiveness and Safety of Intravitreal Dexamethasone Implant (Ozurdex) in Patients with Diabetic Macular Edema: A Real-World Experience. Ophthalmologica 2018; 241:9-16. [PMID: 30408801 DOI: 10.1159/000492132] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 07/13/2018] [Indexed: 12/18/2022]
Abstract
INTRODUCTION There are few real-life studies on the intravitreal 0.7-mg dexamethasone implant for the treatment of diabetic macular edema (DME) conducted in Latin America. We aimed to assess the effectiveness and safety of this implant in clinical practice. METHODS Twenty-seven centers from Brazil and one from Argentina provided information on patients with DME treated with Ozurdex. The efficacy outcome variables were best-corrected visual acuity (BCVA) in Snellen and central retinal thickness (CRT). Safety was assessed by the elevation in intraocular pressure (IOP), occurrence of cataracts, and adverse events. RESULTS A total of 329 eyes (both treated cases and naïve eyes) from 282 patients underwent treatment. The time since diagnosis of DME ranged from 1 to 156 months. The median BCVA was 0.7 logMAR/50 letters at baseline and 0.3 logMAR/70 letters after treatment (both p < 0.001). Median CRT values decreased from 425 µm at baseline to 270 µm after treatment (p < 0.001). Increases in IOP of at least 10 mm Hg were observed in 7.4% of eyes, and 4% of eyes had cataract evolution. No cases of endophthalmitis were reported. CONCLUSION These real-life results suggest that the intravitreal dexamethasone implant is effective and safe for eyes with DME.
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Affiliation(s)
- Paulo Mello Filho
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil
| | - Gabriel Andrade
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil,
| | - Andre Maia
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil
| | - Mauricio Maia
- Department of Ophthalmology, Federal University of São Paulo, São Paulo, Brazil
| | | | - Acacio Muralha Neto
- Department of Ophthalmology, Rio de Janeiro State University, Rio de Janeiro, Brazil
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Virgili G, Parravano M, Evans JR, Gordon I, Lucenteforte E. Anti-vascular endothelial growth factor for diabetic macular oedema: a network meta-analysis. Cochrane Database Syst Rev 2018; 10:CD007419. [PMID: 30325017 PMCID: PMC6517135 DOI: 10.1002/14651858.cd007419.pub6] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Diabetic macular oedema (DMO) is a common complication of diabetic retinopathy. Antiangiogenic therapy with anti-vascular endothelial growth factor (anti-VEGF) can reduce oedema, improve vision and prevent further visual loss. These drugs have replaced laser photocoagulation as the standard of care for people with DMO. OBJECTIVES The 2014 update of this review found high-quality evidence of benefit with anti-VEGF modalities, compared to laser photocoagulation, for the treatment of DMO. The objective of this updated review is to compare the effectiveness and safety of the different anti-VEGF drugs using network meta-analysis methods. SEARCH METHODS We searched various electronic databases on 26 April 2017. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared any anti-angiogenic drug with an anti-VEGF mechanism of action versus another anti-VEGF drug, another treatment, sham or no treatment in people with DMO. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods for pair-wise meta-analysis and we augmented this evidence using network meta-analysis methods. We focused on the relative efficacy and safety of the three most commonly used drugs as interventions of direct interest for practice: aflibercept and ranibizumab, used on-label; and off-label bevacizumab.We collected data on three efficacy outcomes (gain of 15 or more Early Treatment Diabetic Retinopathy Study (ETDRS) letters; mean change in best-corrected visual acuity (BCVA); mean change in central retinal thickness (CRT)), three safety outcomes (all severe systemic adverse events (SSAEs); all-cause death; arterial thromboembolic events) and quality of life.We used Stata 'network' meta-analysis package for all analyses. We investigated the risk of bias of mixed comparisons based on the variance contribution of each study, having assigned an overall risk of bias to each study. MAIN RESULTS Twenty-four studies included 6007 participants with DMO and moderate vision loss, of which two studies randomised 265 eyes of 230 participants and one was a cross-over study on 56 participants (62 eyes) that was treated as a parallel-arm trial. Data were collected on drugs of direct interest from three studies on aflibercept (975 eyes), eight studies on bevacizumab (515 eyes), and 14 studies on ranibizumab (1518 eyes). As treatments of indirect interest or legacy treatment we included three studies on pegaptanib (541 eyes), five studies on ranibizumab plus prompt laser (557 eyes), one study on ranibizumab plus deferred laser (188 eyes), 13 studies on laser photocoagulation (936 eyes) and six studies on sham treatment (793 eyes).Aflibercept, bevacizumab and ranibizumab were all more effective than laser for improving vision by 3 or more lines after one year (high-certainty evidence). Approximately one in 10 people improve vision with laser, and about three in 10 people improve with anti-VEGF treatment: risk ratio (RR) versus laser 3.66 (95% confidence interval (CI) 2.79 to 4.79) for aflibercept; RR 2.47 (95% CI 1.81 to 3.37) for bevacizumab; RR 2.76 (95% CI 2.12 to 3.59) for ranibizumab. On average there was no change in visual acuity (VA) with laser after one year, compared with a gain of 1 or 2 lines with anti-VEGF treatment: laser versus aflibercept mean difference (MD) -0.20 (95% CI -0.22 to -0.17) logMAR; versus bevacizumab MD -0.12 (95% CI -0.15 to -0.09) logMAR; versus ranibizumab MD -0.12 (95% CI -0.14 to -0.10) logMAR. The certainty of the evidence was high for the comparison of aflibercept and ranibizumab with laser and moderate for bevacizumab comparison with laser due to inconsistency between the indirect and direct evidence.People receiving ranibizumab were less likely to gain 3 or more lines of VA at one year compared with aflibercept: RR 0.75 (95% CI 0.60 to 0.94), moderate-certainty evidence. For every 1000 people treated with aflibercept, 92 fewer would gain 3 or more lines of VA at one year if treated with ranibizumab (22 to 148 fewer). On average people receiving ranibizumab had worse VA at one year (MD 0.08 logMAR units, 95% CI 0.05 to 0.11), moderate-certainty evidence; and higher CRT (MD 39 µm, 95% CI 2 µm to 76 µm; low-certainty evidence). Ranibizumab and bevacizumab were comparable with respect to aflibercept and did not differ in terms of VA: RR of gain of 3 or more lines of VA at one year 1.11 (95% CI 0.87 to 1.43), moderate-certainty evidence, and difference in change in VA was 0.00 (95% CI -0.02 to 0.03) logMAR, moderate-certainty evidence. CRT reduction favoured ranibizumab by -29 µm (95% CI -58 µm to -1 µm, low-certainty evidence). There was no evidence of overall statistical inconsistency in our analyses.The previous version of this review found moderate-certainty evidence of good safety of antiangiogenic drugs versus control. This update used data at the longest available follow-up (one or two years) and found that aflibercept, ranibizumab and bevacizumab do not differ regarding systemic serious adverse events (SSAEs) (moderate- or high-certainty evidence). However, risk of bias was variable, loop inconsistency could be found and estimates were not precise enough on relative safety regarding less frequent events such as arterial thromboembolic events or death (low- or very low-certainty evidence).Two-year data were available and reported in only four RCTs in this review. Most industry-sponsored studies were open-label after one year. One large publicly-funded study compared the three drugs at two years and found no difference. AUTHORS' CONCLUSIONS Anti-VEGF drugs are effective at improving vision in people with DMO with three to four in every 10 people likely to experience an improvement of 3 or more lines VA at one year. Aflibercept may confer some advantage over ranibizumab and bevacizumab in people with DMO at one year in visual and anatomic terms but it is unclear whether this applies to the long-term. There is a need for more evidence on the long-term (greater than two years) comparative effects of these anti-VEGF agents. Evidence from RCTs may not apply to real-world practice, where people in need of antiangiogenic treatment are often under-treated and under-monitored.We found no signals of differences in overall safety between the three antiangiogenic drugs that are currently available to treat DMO, but our estimates are imprecise for cardiovascular events and death.
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Affiliation(s)
- Gianni Virgili
- University of FlorenceDepartment of Translational Surgery and Medicine, Eye ClinicLargo Brambilla, 3FlorenceItaly50134
| | - Mariacristina Parravano
- Fondazione G.B. Bietti per lo studio e la ricerca in Oftalmolologia‐IRCCSOphthalmologyVia Livenza n 3RomeItaly00198
| | - Jennifer R Evans
- London School of Hygiene & Tropical MedicineCochrane Eyes and Vision, ICEHKeppel StreetLondonUKWC1E 7HT
| | - Iris Gordon
- London School of Hygiene & Tropical MedicineCochrane Eyes and Vision, ICEHKeppel StreetLondonUKWC1E 7HT
| | - Ersilia Lucenteforte
- University of FlorenceDepartment of Neurosciences, Psychology, Drug Research and Children’s Healthviale Gaetano Pieraccini, 6FlorenceItaly50139
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12
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Cho YJ, Lee DH, Kim M. Optical coherence tomography findings predictive of response to treatment in diabetic macular edema. J Int Med Res 2018; 46:4455-4464. [PMID: 30259774 PMCID: PMC6259392 DOI: 10.1177/0300060518798503] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Objective To evaluate the short-term efficacy of intravitreal bevacizumab (IVB) and posterior sub-tenon triamcinolone injections (PSTI) on the basis of spectral-domain optical coherence tomography (SD-OCT) patterns in diabetic macular edema (DME). Methods We retrospectively reviewed 73 eyes of 73 patients with DME. Based on the presence of serous retinal detachment (SRD), eyes were categorized into two groups, and either IVB or PSTI treatment was performed. Central macular thickness (CMT) and the degree of SRD were assessed preoperatively and 1 month postoperatively. The severity of intraretinal edema was approximated based on the distance from the external limiting membrane to the internal limiting membrane. Results In eyes with SRD, reduction of SRD was greater with IVB than with PSTI. Moreover, reduction of intraretinal edema was greater with PSTI than with IVB. In eyes without SRD, PSTI achieved greater CMT reduction, compared with IVB. Conclusions In DME patients with SRD, IVB achieved greater reduction of SRD, compared with PSTI; however, intraretinal edema responded more favorably to PSTI, regardless of the presence of SRD. Our results suggest that the classification of DME based on OCT findings may be useful to predict responses to IVB or PSTI treatments.
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Affiliation(s)
- Young Joo Cho
- 1 Department of Ophthalmology, HanGil Eye Hospital, Incheon, Korea
| | - Dong Hyun Lee
- 2 Institute of Vision Research, Department of Ophthalmology, Severance Eye and ENT Hospital, Yonsei, University College of Medicine, Seoul, Republic of Korea
| | - Min Kim
- 3 Department of Ophthalmology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Potential Interplay between Hyperosmolarity and Inflammation on Retinal Pigmented Epithelium in Pathogenesis of Diabetic Retinopathy. Int J Mol Sci 2018; 19:ijms19041056. [PMID: 29614818 PMCID: PMC5979527 DOI: 10.3390/ijms19041056] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 03/21/2018] [Accepted: 03/30/2018] [Indexed: 12/15/2022] Open
Abstract
Diabetic retinopathy is a frequent eyesight threatening complication of type 1 and type 2 diabetes. Under physiological conditions, the inner and the outer blood-retinal barriers protect the retina by regulating ion, protein, and water flux into and out of the retina. During diabetic retinopathy, many factors, including inflammation, contribute to the rupture of the inner and/or the outer blood-retinal barrier. This rupture leads the development of macular edema, a foremost cause of sight loss among diabetic patients. Under these conditions, it has been speculated that retinal pigmented epithelial cells, that constitute the outer blood-retinal barrier, may be subjected to hyperosmolar stress resulting from different mechanisms. Herein, we review the possible origins and consequences of hyperosmolar stress on retinal pigmented epithelial cells during diabetic retinopathy, with a special focus on the intimate interplay between inflammation and hyperosmolar stress, as well as the current and forthcoming new pharmacotherapies for the treatment of such condition.
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14
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Das GK, Sahu PK, Biakthangi LVL, Jain D. Evaluation of intravitreal bevacizumab as monotherapy and in combination with macular grid laser photocoagulation in diffuse diabetic macular edema. Oman J Ophthalmol 2018; 11:248-253. [PMID: 30505116 PMCID: PMC6219322 DOI: 10.4103/ojo.ojo_196_2016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND OBJECTIVE The objective of the study was to compare the efficacy of intravitreal bevacizumab (IVB) as monotherapy versus combination with modified macular grid (MMG) laser photocoagulation in the primary treatment of diffuse diabetic macular edema (DDME). MATERIALS AND METHODS A prospective randomized trial was carried out in sixty eyes with DDME after Institutional Ethical clearance. Group A received three doses of IVB at a 1-month interval. Group B received MMG in addition to IVB. Complete examination including best-corrected visual acuity (BCVA) (Snellen's), central macular thickness (CMT) using spectral domain-optical coherence tomography was carried out at 0, 1, 4, 8, 12, and 24 weeks. RESULTS mean CMT at baseline, 12 and 24 weeks in Group A was 401 (±76), 280 (±49), and 307 (±46) and in Group B, 405 (±73), 237 (±33), and 242 (±45), respectively. Group B had significantly greater reductions (P < 0.001) from 12 weeks onward. BCVA and contrast sensitivity showed improvements with no significant difference. CONCLUSION Combined therapy has more advantage in primary DDME by reducing CMT on longer follow-up.
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Affiliation(s)
- Gopal K Das
- Department of Ophthalmology, University College of Medical Sciences and GTB Hospital, Delhi University, New Delhi, India
| | - Pramod K Sahu
- Department of Ophthalmology, University College of Medical Sciences and GTB Hospital, Delhi University, New Delhi, India
| | - Laura V L Biakthangi
- Department of Ophthalmology, University College of Medical Sciences and GTB Hospital, Delhi University, New Delhi, India
| | - Divya Jain
- Department of Ophthalmology, University College of Medical Sciences and GTB Hospital, Delhi University, New Delhi, India
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15
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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] [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.
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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
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16
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Virgili G, Parravano M, Evans JR, Gordon I, Lucenteforte E. Anti-vascular endothelial growth factor for diabetic macular oedema: a network meta-analysis. Cochrane Database Syst Rev 2017; 6:CD007419. [PMID: 28639415 PMCID: PMC6481463 DOI: 10.1002/14651858.cd007419.pub5] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Diabetic macular oedema (DMO) is a common complication of diabetic retinopathy. Antiangiogenic therapy with anti-vascular endothelial growth factor (anti-VEGF) modalities can reduce oedema and thereby improve vision and prevent further visual loss. These drugs have replaced laser photocoagulation as the standard of care for people with DMO. OBJECTIVES The 2014 update of this review found high-quality evidence of benefit with antiangiogenic therapy with anti-VEGF modalities, compared to laser photocoagulation, for the treatment of DMO.The objective of this updated review is to compare the effectiveness and safety of the different anti-VEGF drugs in preserving and improving vision and quality of life using network meta-analysis methods. SEARCH METHODS We searched various electronic databases on 26 April 2017. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared any anti-angiogenic drug with an anti-VEGF mechanism of action versus another anti-VEGF drug, another treatment, sham or no treatment in people with DMO. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods for pair-wise meta-analysis and we augmented this evidence using network meta-analysis methods. We focused on the relative efficacy and safety of the three most commonly used drugs as interventions of direct interest for practice: aflibercept and ranibizumab, used on-label; and off-label bevacizumab.We collected data on three efficacy outcomes (gain of 15 or more Early Treatment Diabetic Retinopathy Study (ETDRS) letters; mean change in best-corrected visual acuity (BCVA); mean change in central retinal thickness (CRT)), three safety outcomes (all severe systemic adverse events (SSAEs); all-cause death; arterial thromboembolic events) and quality of life.We used Stata 'network' meta-analysis package for all analyses. We investigated the risk of bias of mixed comparisons based on the variance contribution of each study, having assigned an overall risk of bias to each study. MAIN RESULTS Twenty-four studies included 6007 participants with DMO and moderate vision loss, of which two studies randomised 265 eyes of 230 participants and one was a cross-over study on 56 participants (62 eyes) that was treated as a parallel-arm trial. Data were collected on drugs of direct interest from three studies on aflibercept (975 eyes), eight studies on bevacizumab (515 eyes), and 14 studies on ranibizumab (1518 eyes). As treatments of indirect interest or legacy treatment we included three studies on pegaptanib (541 eyes), five studies on ranibizumab plus prompt laser (557 eyes), one study on ranibizumab plus deferred laser (188 eyes), 13 studies on laser photocoagulation (936 eyes) and six studies on sham treatment (793 eyes).Aflibercept, bevacizumab and ranibizumab were all more effective than laser for improving vision by 3 or more lines after one year (high-certainty evidence). Approximately one in 10 people improve vision with laser, and about three in 10 people improve with anti-VEGF treatment: risk ratio (RR) versus laser 3.66 (95% confidence interval (CI) 2.79 to 4.79) for aflibercept; RR 2.47 (95% CI 1.81 to 3.37) for bevacizumab; RR 2.76 (95% CI 2.12 to 3.59) for ranibizumab. On average there was no change in visual acuity (VA) with laser after one year, compared with a gain of 1 or 2 lines with anti-VEGF treatment: laser versus aflibercept mean difference (MD) -0.20 (95% CI -0.22 to -0.17) logMAR; versus bevacizumab MD -0.12 (95% CI -0.15 to -0.09) logMAR; versus ranibizumab MD -0.12 (95% CI -0.14 to -0.10) logMAR. The certainty of the evidence was high for the comparison of aflibercept and ranibizumab with laser and moderate for bevacizumab comparison with laser due to inconsistency between the indirect and direct evidence.People receiving ranibizumab were less likely to gain 3 or more lines of VA at one year compared with aflibercept: RR 0.75 (95% CI 0.60 to 0.94), moderate-certainty evidence. For every 1000 people treated with aflibercept, 92 fewer would gain 3 or more lines of VA at one year if treated with ranibizumab (22 to 148 fewer). On average people receiving ranibizumab had worse VA at one year (MD 0.08 logMAR units, 95% CI 0.05 to 0.11), moderate-certainty evidence; and higher CRT (MD 39 µm, 95% CI 2 µm to 76 µm; low-certainty evidence). Ranibizumab and bevacizumab were comparable with respect to aflibercept and did not differ in terms of VA: RR of gain of 3 or more lines of VA at one year 1.11 (95% CI 0.87 to 1.43), moderate-certainty evidence, and difference in change in VA was 0.00 (95% CI -0.02 to 0.03) logMAR, moderate-certainty evidence. CRT reduction favoured ranibizumab by -29 µm (95% CI -58 µm to -1 µm, low-certainty evidence). There was no evidence of overall statistical inconsistency in our analyses.The previous version of this review found moderate-certainty evidence of good safety of antiangiogenic drugs versus control. This update used data at the longest available follow-up (one or two years) and found that aflibercept, ranibizumab and bevacizumab do not differ regarding systemic serious adverse events (SSAEs) (moderate- or high-certainty evidence). However, risk of bias was variable, loop inconsistency could be found and estimates were not precise enough on relative safety regarding less frequent events such as arterial thromboembolic events or death (low- or very low-certainty evidence).Two-year data were available and reported in only four RCTs in this review. Most industry-sponsored studies were open-label after one year. One large publicly-funded study compared the three drugs at two years and found no difference. AUTHORS' CONCLUSIONS Anti-VEGF drugs are effective at improving vision in people with DMO with three to four in every 10 people likely to experience an improvement of 3 or more lines VA at one year. There is moderate-certainty evidence that aflibercept confers some advantage over ranibizumab and bevacizumab in people with DMO at one year in visual and anatomic terms. Relative effects among anti-VEGF drugs at two years are less well known, since most studies were short term. Evidence from RCTs may not apply to real-world practice, where people in need of antiangiogenic treatment are often under-treated and under-monitored.We found no signals of differences in overall safety between the three antiangiogenic drugs that are currently available to treat DMO, but our estimates are imprecise for cardiovascular events and death.
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Key Words
- humans
- angiogenesis inhibitors
- angiogenesis inhibitors/therapeutic use
- antibodies, monoclonal
- antibodies, monoclonal/therapeutic use
- antibodies, monoclonal, humanized
- antibodies, monoclonal, humanized/therapeutic use
- aptamers, nucleotide
- aptamers, nucleotide/therapeutic use
- bevacizumab
- diabetic retinopathy
- diabetic retinopathy/complications
- laser coagulation
- laser coagulation/methods
- macular edema
- macular edema/drug therapy
- macular edema/surgery
- randomized controlled trials as topic
- ranibizumab
- receptors, vascular endothelial growth factor
- receptors, vascular endothelial growth factor/therapeutic use
- recombinant fusion proteins
- recombinant fusion proteins/therapeutic use
- triamcinolone
- triamcinolone/therapeutic use
- vascular endothelial growth factor a
- vascular endothelial growth factor a/antagonists & inhibitors
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Affiliation(s)
- Gianni Virgili
- University of FlorenceDepartment of Translational Surgery and Medicine, Eye ClinicLargo Brambilla, 3FlorenceItaly50134
| | - Mariacristina Parravano
- Fondazione G.B. Bietti per lo studio e la ricerca in Oftalmolologia‐IRCCSOphthalmologyVia Livenza n 3RomeItaly00198
| | - Jennifer R Evans
- London School of Hygiene & Tropical MedicineCochrane Eyes and Vision, ICEHKeppel StreetLondonUKWC1E 7HT
| | - Iris Gordon
- London School of Hygiene & Tropical MedicineCochrane Eyes and Vision, ICEHKeppel StreetLondonUKWC1E 7HT
| | - Ersilia Lucenteforte
- University of FlorenceDepartment of Neurosciences, Psychology, Drug Research and Children’s Healthviale Gaetano Pieraccini, 6FlorenceItaly50139
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Intravitreal bevacizumab alone or combined with 1 mg triamcinolone in diabetic macular edema: a randomized clinical trial. Int Ophthalmol 2017; 38:585-598. [PMID: 28349504 DOI: 10.1007/s10792-017-0496-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 03/08/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE To compare the results of intravitreal bevacizumab (IVB) injection alone or in combination with intravitreal 1 mg triamcinolone acetonide (IVT) in center-involved diabetic macular edema. METHODS In this randomized clinical trial study, ninety-two eyes of 46 patients with bilateral center-involved diabetic macular edema and no previous treatment were included in the study. One eye of each patient was randomly assigned to 1.25 mg of IVB injection or combination of 1.25 IVB and 1 mg IVT. Evaluation of best-corrected visual acuity (BCVA), central macular thickness (CMT), intraocular pressure (IOP) and grading of lens opacity was conducted at baseline, and weeks 2, 4, 6, 8, 12 and 24 after treatment. Retreatment was performed at a 6-week interval whenever indicated based on CMT. RESULTS Between the groups, BCVA changes were not statistically different until 24-week follow-up (P > 0.05), but at 24 weeks after treatment, BCVA improvement was significantly better in IVB group (P = 0.049). Significant CMT reduction was observed in each group along the follow-up period (P = 0.001). The mean CMT reduction was more significant in combination (IVB + IVT) group at 2 weeks of follow-up (P < 0.001), but CMT changes were not significant between the groups at weeks 12th and 24th after injection. Overall, retreatment was applied for 59 eyes up to 24 weeks (33 in the IVB group, 26 in the IVB + IVT group). Among patients with 2 or more injections, number of injections was significantly lower in IVB + IVT group (P = 0.043). Three eyes within IVB + IVT group developed IOP rise beyond 21 mmHg, which were controlled with topical anti-glaucoma medications within 1 week. Changes in lens opacity were not significant between two groups. CONCLUSION Eyes treated with IVB plus 1 mg IVT injections had more significant reduction in CMT in early post-injection, but this effect was transient. Although after 24 weeks visual acuity improvement was better in IVB group, combination therapy may decrease the number of injections. Combining 1 mg of intravitreal triamcinolone with bevacizumab was not accompanied with significant side effects.
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Corticosteroidi per via Intravitreale per il Trattamento Dell'edema Maculare: Revisione e Valutazione Della Qualità Dell'evidenza. GLOBAL & REGIONAL HEALTH TECHNOLOGY ASSESSMENT 2017. [DOI: 10.5301/grhta.5000251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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19
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Ocular neovascular-related diseases: immunological mechanisms of development and the potential of anti-angiogenic therapy. OPHTHALMOLOGY JOURNAL 2016. [DOI: 10.17816/ov9458-67] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
The paper adresses three ocular diseases - “wet” type of age-related macular degeneration, diabetic macular edema and neovascular glaucoma, which have similar neovascular changes and immunological disorders. The key moment of neovascularization development is an imbalance between pro- and anti-angiogenic factors. Particular attention is paid to vascular endothelial growth factor (VEGF-A), pigment epithelial derived factor (PEDF), transforming growth factor-beta (ТGF-β). The paper discusses the “immune privilege” of the eye, ACAID phenomenon, aspects of choroidal neovascularization pathogenesis, inflammation as an important part of neovascularization and the protective response to endogenous and exogenous damage, as well as complement system’s disorders, cytokine status impairment and autoimmune mechanisms. Laser treatment is widely used for treatment of neovascular diseases, but pharmacotherapy is very important too. Anti-angiogenic therapy is extremely promising and is held to provide regression of the newly-formed vasculature and/or normalization of newly formed blood vessels structure and suppress the functional activity of a key proangiogenic factor VEGF-A. Pegaptanib, ranibizumab and bevacizumab are discussed, and results of international clinical trials MARINA, ANCHOR, FOCUS, PrONTO, IVAN, CATT, RESTORE are provided.
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Lim LL, Morrison JL, Constantinou M, Rogers S, Sandhu SS, Wickremasinghe SS, Kawasaki R, Al-Qureshi S. Diabetic Macular Edema at the time of Cataract Surgery trial: a prospective, randomized clinical trial of intravitreous bevacizumab versus triamcinolone in patients with diabetic macular oedema at the time of cataract surgery - preliminary 6 month results. Clin Exp Ophthalmol 2016; 44:233-42. [DOI: 10.1111/ceo.12720] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 01/11/2016] [Accepted: 01/16/2016] [Indexed: 01/28/2023]
Affiliation(s)
- Lyndell L Lim
- Centre for Eye Research Australia; Royal Victorian Eye and Ear Hospital; Ophthalmology, University of Melbourne, Department of Surgery; Melbourne Victoria Australia
- Medical Retina Clinic; Royal Victorian Eye and Ear Hospital; Melbourne Victoria Australia
| | - Julie L Morrison
- Centre for Eye Research Australia; Royal Victorian Eye and Ear Hospital; Ophthalmology, University of Melbourne, Department of Surgery; Melbourne Victoria Australia
| | - Marios Constantinou
- Centre for Eye Research Australia; Royal Victorian Eye and Ear Hospital; Ophthalmology, University of Melbourne, Department of Surgery; Melbourne Victoria Australia
| | - Sophie Rogers
- Centre for Eye Research Australia; Royal Victorian Eye and Ear Hospital; Ophthalmology, University of Melbourne, Department of Surgery; Melbourne Victoria Australia
| | - Sukhpal S Sandhu
- Centre for Eye Research Australia; Royal Victorian Eye and Ear Hospital; Ophthalmology, University of Melbourne, Department of Surgery; Melbourne Victoria Australia
- Medical Retina Clinic; Royal Victorian Eye and Ear Hospital; Melbourne Victoria Australia
| | - Sanjeewa S Wickremasinghe
- Centre for Eye Research Australia; Royal Victorian Eye and Ear Hospital; Ophthalmology, University of Melbourne, Department of Surgery; Melbourne Victoria Australia
- Medical Retina Clinic; Royal Victorian Eye and Ear Hospital; Melbourne Victoria Australia
| | - Ryo Kawasaki
- Yamagata University Faculty of Medicine; Yamagata Japan
| | - Salmaan Al-Qureshi
- Centre for Eye Research Australia; Royal Victorian Eye and Ear Hospital; Ophthalmology, University of Melbourne, Department of Surgery; Melbourne Victoria Australia
- Medical Retina Clinic; Royal Victorian Eye and Ear Hospital; Melbourne Victoria Australia
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Kim K, Kim ES, Kwak HW, Yu SY. Long-term Outcomes of Diabetic Macular Edema Following Initial Intravitreal Ranibizumab Injection Based on Morphologic Pattern. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2016. [DOI: 10.3341/jkos.2016.57.10.1604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Kiyoung Kim
- Division of Ophthalmology, Department of Medicine, Kyung Hee University Graduate School, Seoul, Korea
| | - Eung Suk Kim
- Department of Ophthalmology, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Korea
| | - Hyung Woo Kwak
- Department of Ophthalmology, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Korea
| | - Seung-Young Yu
- Department of Ophthalmology, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Korea
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Lee JH, Chung HY, Lee KM, Park YS, Sohn JH, Hwang DJ. Intravitreal Bevacizumab versus Intravitreal Bevacizumab Combined with Posterior Subtenon Triamcinolone Acetonide for Diabetic Macular Edema. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2016. [DOI: 10.3341/jkos.2016.57.12.1903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Yang Y, Bailey C, Loewenstein A, Massin P. INTRAVITREAL CORTICOSTEROIDS IN DIABETIC MACULAR EDEMA: PHARMACOKINETIC CONSIDERATIONS. Retina 2015; 35:2440-9. [PMID: 26352555 PMCID: PMC4697357 DOI: 10.1097/iae.0000000000000726] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSE To review the relationship between kinetics, efficacy, and safety of several corticosteroid formulations for the treatment of diabetic macular edema. METHODS Reports of corticosteroid use for the treatment of diabetic macular edema were identified by a literature search, which focused on the pharmacokinetics, efficacy, and safety of these agents in preclinical animal models and clinical trials. RESULTS Available corticosteroids for diabetic macular edema treatment include intravitreal triamcinolone acetonide, dexamethasone, and fluocinolone acetonide. Because of differences in solubility and bioavailability, various delivery mechanisms are used. Bioerodible delivery systems achieve higher maximum concentrations than nonbioerodible formulations. There is a relationship between visual gains and drug persistence in the intravitreal compartment. Safety effects were more complex; level of intravitreal triamcinolone acetonide exposure is related to development of elevated intraocular pressure and cataract; this does not seem to be the case for dexamethasone, where two different doses showed similar mean intraocular pressure and incidence of cataract surgery. With fluocinolone acetonide, rates of intraocular pressure elevations requiring surgery seem to be dose related; rates of cataract extraction were similar regardless of dose. CONCLUSION Available corticosteroids for diabetic macular edema exhibit different pharmacokinetic profiles that impact efficacy and adverse events and should be taken into account when developing individualized treatment plans.
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Affiliation(s)
- Yit Yang
- Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, United Kingdom
| | - Clare Bailey
- University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Anat Loewenstein
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; and
| | - Pascale Massin
- Department of Ophthalmology, Lariboisière Hospital, Paris, France
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Comparison of intravitreal triamcinolone acetonide versus intravitreal bevacizumab as the primary treatment of clinically significant macular edema. Retina 2015; 35:272-9. [PMID: 25105313 DOI: 10.1097/iae.0000000000000300] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To evaluate the short-term efficacy of triamcinolone acetonide versus bevacizumab for the treatment of diabetic, clinically significant, macular edema with different optical coherence tomography findings. METHODS Fifty eyes of 45 consecutive patients with diabetic, clinically significant, macular edema were incorporated in this prospective interventional case series. Patients were divided into 3 groups according to findings on optical coherence tomography: 1) macular edema combined with serous retinal detachment (Group 1), 2) diffused macular thickening (Group 2), and 3) cystoid macular edema (Group 3). Patients from each group were treated with a single intravitreal injection of triamcinolone (IVTA) or 2 intravitreal injections of bevacizumab (IVB) with an interval of 6 weeks. Patients were observed at 6, 12, and 24 weeks after IVTA or the first IVB injection. Best-corrected visual acuity (BCVA) and central retinal thickness (CRT) were examined at each visit. Repeated-measures analysis of variance was used to compare the efficacy of the treatment groups. RESULTS In Group 1, IVTA showed more favorable effects on CRT reduction and BCVA improvement compared with IVB at 6, 12, and 24 weeks (P = 0.002, 0.001, 0.027 and P = 0.036, 0.001, 0.027), respectively. In Group 2, IVB had more CRT reduction than IVTA at 6 and 12 weeks (P = 0.013 and 0.036), although there was no significant difference in BCVA improvement between the 2 groups (P > 0.05). In Group 3, IVTA and IVB did not have significant effects on CRT reduction and BCVA improvement (P > 0.05). CONCLUSION The short-term efficacy of IVTA and IVB on treating clinically significant macular edema varied with different optical coherence tomography findings. In clinically significant macular edema combined with serous retinal detachment, IVTA may be more favorable than IVB in CRT reduction and BCVA improvement. In patients with diffused macular thickening, IVB may be better than IVTA in macular thickness reduction, although this does not translate to a significant improvement in BCVA.
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Aksoy S, Yilmaz G, Akkoyun I, Yazici AC. Comparison of intravitreal bevacizumab and triamcinolone acetonide theraphies for diffuse diabetic macular edema. Int J Ophthalmol 2015; 8:550-5. [PMID: 26086006 DOI: 10.3980/j.issn.2222-3959.2015.03.20] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 07/21/2014] [Indexed: 01/07/2023] Open
Abstract
AIM To compare therapeutic effects of intravitreal triamcinolone acetonide (IVTA) versus intravitreal bevacizumab (IVB) injections for bilateral diffuse diabetic macular edema (DDME). METHODS Forty eyes of 20 patients with bilateral DDME participated in this study. For each patient, 4 mg/0.1 mL IVTA was injected to one eye and 2.5 mg/0.1 mL IVB was injected to the other eye. The effects of injection for diabetic macular edema (DME) were evaluated using best-corrected visual acuity (BCVA), central macular thickness (CMT) by optical coherence tomography (OCT) and intraocular pressure (IOP) by applanation tonometer. Patients underwent eye examinations, including BCVA, CMT, and IOP at pre-injection, 1, 4, 8, 12 and 24wk after injection. During the follow-up, second injections were performed to eyes which have CMT greater than 400 µm at 12wk for salvage therapy. RESULTS BCVA (logarithm of the minimum angle of resolution) at pre-injection, 1, 4, 8, 12 and 24wk after injection was 0.71±0.19, 0.62±0.23, 0.63±0.12, 0.63±0.13, 0.63±0.14 and 0.61±0.24 in the IVTA group and 0.68±0.25, 0.61±0.22, 0.60±0.24, 0.62±0.25, 0.65±0.26 and 0.59±0.25 in the IVB group, respectively. CMT (µm) at pre-injection, 1, 4, 8, 12 and 24wk after injection was 544±125, 383±96, 335±87, 323±87, 333±92, 335±61 in the IVTA group and 514±100, 431±86, 428±107, 442±106, 478±112, 430±88 in the IVB group respectively. Reduction ratios of mean CMT were 29% at 1wk, 38% at 4wk, 40% at 8wk, 38% at 12wk, and 38% at 24wk in the IVTA group. Second IVTA injections were performed to the 6 eyes (30%) at 12wk. Reduction ratios of mean CMT were 16% at 1wk, 17% at 4wk, 14% at 8wk, 7% at 12wk, and 16% at 24wk in the IVB group. Second IVB injections were performed to the 15 eyes (75%) at 12wk. CONCLUSION This study showed earlier and more frequent macular edema recurrences in the eyes treated with bevacizumab compared with the ones treated with triamcinolone acetonide. Triamcinolone acetonide was found to provide more efficient and long-standing effect in terms of reducing CMT compared with the bevacizumab.
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Affiliation(s)
- Sibel Aksoy
- Department of Ophthalmology, Fatih Sultan Mehmet Training and Research Hospital, Istanbul 34452, Turkey
| | - Gursel Yilmaz
- Department of Ophthalmology, Faculty of Medicine, Baskent University, Ankara 06490, Turkey
| | - Imren Akkoyun
- Department of Ophthalmology, Faculty of Medicine, Baskent University, Ankara 06490, Turkey
| | - Ayse Canan Yazici
- Department of Biostatistics, Faculty of Medicine, Baskent University, Ankara 06490, Turkey
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Micro-implant d’acétonide de fluocinolone (ILUVIEN®) pour l’œdème maculaire diabétique chronique. J Fr Ophtalmol 2015; 38:159-67. [DOI: 10.1016/j.jfo.2014.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 08/08/2014] [Accepted: 09/11/2014] [Indexed: 11/19/2022]
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Strategy for the management of diabetic macular edema: the European vitreo-retinal society macular edema study. BIOMED RESEARCH INTERNATIONAL 2015; 2015:352487. [PMID: 25695062 PMCID: PMC4324105 DOI: 10.1155/2015/352487] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 06/30/2014] [Indexed: 02/05/2023]
Abstract
Objective. To compare the efficacy of different therapies in the treatment of diabetic macular edema (DME). Design. Nonrandomized, multicenter clinical study. Participants. 86 retina specialists from 29 countries provided clinical information on 2,603 patients with macular edema including 870 patients with DME. Methods. Reported data included the type and number of treatment(s) performed, the pre- and posttreatment visual acuities, and other clinical findings. The results were analyzed by the French INSEE (National Institute of Statistics and Economic Studies). Main Outcome Measures. Mean change of visual acuity and mean number of treatments performed. Results. The change in visual acuity over time in response to each treatment was plotted in second order polynomial regression trend lines. Intravitreal triamcinolone monotherapy resulted in some improvement in vision. Treatment with threshold or subthreshold grid laser also resulted in minimal vision gain. Anti-VEGF therapy resulted in more significant visual improvement. Treatment with pars plana vitrectomy and internal limiting membrane (ILM) peeling alone resulted in an improvement in vision greater than that observed with anti-VEGF injection alone. In our DME study, treatment with vitrectomy and ILM peeling alone resulted in the better visual improvement compared to other therapies.
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Lee SH, Kim SY, Park HS. Short-Term Results of Dexamethasone Intravitreal Implant in Patients with Refractory Diabetic Macular Edema. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2015. [DOI: 10.3341/jkos.2015.56.8.1201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Johnson D, Jagan L, Kurji A, Jumaa K, Sharma S. Emergency department visits after intravitreal bevacizumab and ranibizumab injections in diabetic patients. Can J Ophthalmol 2014; 49:e146-8. [PMID: 25433751 DOI: 10.1016/j.jcjo.2014.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 08/22/2014] [Accepted: 08/31/2014] [Indexed: 10/24/2022]
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Virgili G, Parravano M, Menchini F, Evans JR. Anti-vascular endothelial growth factor for diabetic macular oedema. Cochrane Database Syst Rev 2014:CD007419. [PMID: 25342124 DOI: 10.1002/14651858.cd007419.pub4] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Diabetic macular oedema (DMO) is a common complication of diabetic retinopathy. Although grid or focal laser photocoagulation has been shown to reduce the risk of visual loss in DMO, or clinically significant macular oedema (CSMO), vision is rarely improved. Antiangiogenic therapy with anti-vascular endothelial growth factor (anti-VEGF) modalities is used to try to improve vision in people with DMO. OBJECTIVES To investigate the effects in preserving and improving vision and acceptability, including the safety, compliance with therapy and quality of life, of antiangiogenic therapy with anti-VEGF modalities for the treatment of DMO. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2014, Issue 3), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to April 2014), EMBASE (January 1980 to April 2014), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to April 2014), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 28 April 2014. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing any antiangiogenic drugs with an anti-VEGF mechanism of action versus another treatment, sham treatment or no treatment in people with DMO. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. The risk ratios (RR) for visual loss and visual gain of three or more lines of logMAR visual acuity were estimated at one year of follow-up (plus or minus six months) after treatment initiation. MAIN RESULTS Eighteen studies provided data on four comparisons of interest in this review. Participants in the trials had central DMO and moderate vision loss.Compared with grid laser photocoagulation, people treated with antiangiogenic therapy were more likely to gain 3 or more lines of vision at one year (RR 3.6, 95% confidence interval (CI) 2.7 to 4.8, 10 studies, 1333 cases, high quality evidence) and less likely to lose 3 or more lines of vision (RR 0.11, 95% CI 0.05 to 0.24, 7 studies, 1086 cases, high quality evidence). In meta-analyses, no significant subgroup difference was demonstrated between bevacizumab, ranibizumab and aflibercept for the two primary outcomes, but there was little power to detect a difference. The quality of the evidence was judged to be high, because the effect was large, precisely measured and did not vary across studies, although some studies were at high or unclear risk of bias for one or more domains. Regarding absolute benefit, we estimated that 8 out of 100 participants with DMO may gain 3 or more lines of visual acuity using photocoagulation whereas 28 would do so with antiangiogenic therapy, meaning that 100 participants need to be treated with antiangiogenic therapy to allow 20 more people (95% CI 13 to 29) to markedly improve their vision after one year. People treated with anti-VEGF on average had 1.6 lines better vision (95% CI 1.4 to 1.8) after one year compared to laser photocoagulation (9 studies, 1292 cases, high quality evidence). To achieve this result, seven to nine injections were delivered in the first year and three or four in the second, in larger studies adopting either as needed regimens with monthly monitoring or fixed regimens.In other analyses antiangiogenic therapy was more effective than sham (3 studies on 497 analysed participants, high quality evidence) and ranibizumab associated with laser was more effective than laser alone (4 studies on 919 participants, high quality evidence).Ocular severe adverse events, such as endophthalmitis, were rare in the included studies. Meta-analyses conducted for all antiangiogenic drugs compared with either sham or photocoagulation did not show a significant difference regarding serious systemic adverse events (15 studies, 441 events in 2985 participants, RR 0.98, 95% CI 0.83 to 1.17), arterial thromboembolic events (14 studies, 129 events in 3034 participants, RR 0.89, 95% CI 0.63 to 1.25) and overall mortality (63 events in 3562 participants, RR 0.88, 95% CI 0.52 to 1.47). We judged the quality of the evidence on adverse effects as moderate due to partial reporting of safety data and the exclusion of participants with previous cardiovascular events in some studies. AUTHORS' CONCLUSIONS There is high quality evidence that antiangiogenic drugs provide a benefit compared to current therapeutic options for DMO, that is grid laser photocoagulation, in clinical trial populations at one or two years. Future research should investigate differences between drugs, effectiveness under real-world monitoring and treatment conditions, and safety in high-risk populations, particularly regarding cardiovascular risk.
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Affiliation(s)
- Gianni Virgili
- Department of Translational Surgery and Medicine, Eye Clinic, University of Florence, Largo Brambilla, 3, Florence, Italy, 50134
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Noma H, Mimura T, Yasuda K, Shimura M. Role of inflammation in diabetic macular edema. Ophthalmologica 2014; 232:127-35. [PMID: 25342084 DOI: 10.1159/000364955] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 05/29/2014] [Indexed: 11/19/2022]
Abstract
Vitreous fluid levels of vascular endothelial growth factor (VEGF), soluble VEGF receptor (sVEGFR)-2, soluble intercellular adhesion molecule (sICAM)-1, monocyte chemotactic protein (MCP)-1 and pentraxin 3 (PTX3) were measured by enzyme-linked immunosorbent assay in 36 patients with diabetic macular edema (DME) and 15 patients with macular hole (MH). Aqueous flare values were measured with a laser flare meter, and macular edema was examined by optical coherence tomography. Vitreous fluid levels of VEGF, sVEGFR-2, sICAM-1, MCP-1 and PTX3 were significantly higher in the patients with DME than in those with MH. There was a significant correlation between the vitreous fluid level of sVEGFR-2 and the levels of sICAM-1, MCP-1 and PTX3. The aqueous flare value was significantly correlated with the vitreous fluid levels of sVEGFR-2, sICAM-1, MCP-1 and PTX3. These findings suggest that inflammatory factors may induce an increase in vascular permeability and disrupt the blood-aqueous barrier in DME patients.
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Affiliation(s)
- Hidetaka Noma
- Department of Ophthalmology, Hachioji Medical Center, Tokyo Medical University, Hachioji, Tokyo, Japan
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López-Gálvez MI, García-Campos JM. [From scientific evidence to clinical practice: treatment protocols for diabetic macular edema]. ACTA ACUST UNITED AC 2014; 87 Suppl 1:38-45. [PMID: 24278988 DOI: 10.1016/s0365-6691(12)70050-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Diabetic macular edema (DME) is now considered the leading cause of moderate vision loss in type 2 diabetic patients and has a high socioeconomic burden. In recent years, the therapeutic approach to this entity has changed. The role of laser treatment, considered the gold standard in clinical practice worldwide for more than 25 years, has been redefined. To understand current treatment algorithms, the pathophysiology of diabetic macular edema and the role played by vascular endothelial growth factor must be elucidated. Many clinical trials have emerged showing that intravitreal ranibizumab provides effective therapy with an acceptable safety profile. Based in these data, the European Medicines Agency has approved ranibizumab for the treatment of diabetic macular edema. This article aims to discuss new treatment options and the recently developed evidence-based algorithms.
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Lee K, Chung H, Park Y, Sohn J. Efficacy of intravitreal anti-vascular endothelial growth factor or steroid injection in diabetic macular edema according to fluid turbidity in optical coherence tomography. KOREAN JOURNAL OF OPHTHALMOLOGY 2014; 28:298-305. [PMID: 25120338 PMCID: PMC4120350 DOI: 10.3341/kjo.2014.28.4.298] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 02/06/2014] [Indexed: 12/01/2022] Open
Abstract
Purpose To determine if short term effects of intravitreal anti-vascular endothelial growth factor or steroid injection are correlated with fluid turbidity, as detected by spectral domain optical coherence tomography (SD-OCT) in diabetic macular edema (DME) patients. Methods A total of 583 medical records were reviewed and 104 cases were enrolled. Sixty eyes received a single intravitreal bevacizumab injection (IVB) on the first attack of DME and 44 eyes received triamcinolone acetonide treatment (IVTA). Intraretinal fluid turbidity in DME patients was estimated with initialintravitreal SD-OCT and analyzed with color histograms from a Photoshop program. Central macular thickness and visual acuity using a logarithm from the minimum angle of resolution chart, were assessed at the initial period and 2 months after injections. Results Visual acuity and central macular thickness improved after injections in both groups. In the IVB group, visual acuity and central macular thickness changed less as the intraretinal fluid became more turbid. In the IVTA group, visual acuity underwent less change while central macular thickness had a greater reduction (r = -0.675, p = 0.001) as the intraretinal fluid was more turbid. Conclusions IVB and IVTA injections were effective in reducing central macular thickness and improving visual acuity in DME patients. Further, fluid turbidity, which was detected by SD-OCT may be one of the indexes that highlight the influence of the steroid-dependent pathogenetic mechanism.
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The role of inflammation in the pathogenesis of macular edema secondary to retinal vascular diseases. Mediators Inflamm 2014; 2014:432685. [PMID: 25152567 PMCID: PMC4134827 DOI: 10.1155/2014/432685] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2014] [Revised: 07/05/2014] [Accepted: 07/09/2014] [Indexed: 12/17/2022] Open
Abstract
Macular edema (ME) is a nonspecific sign of numerous retinal vascular diseases. This paper is an updated overview about the role of inflammatory processes in the genesis of both diabetic macular edema (DME) and ME secondary to retinal vein occlusion (RVO). We focus on the inflammatory mediators implicated, the effect of the different intravitreal therapies, the recruitment of leukocytes mediated by adhesion molecules, and the role of retinal Müller glial (RMG) cells.
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Nitta F, Kunikata H, Aizawa N, Omodaka K, Shiga Y, Yasuda M, Nakazawa T. The effect of intravitreal bevacizumab on ocular blood flow in diabetic retinopathy and branch retinal vein occlusion as measured by laser speckle flowgraphy. Clin Ophthalmol 2014; 8:1119-27. [PMID: 24959068 PMCID: PMC4061168 DOI: 10.2147/opth.s62022] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background This study evaluated the effect of intravitreal injection of bevacizumab (IVB) on macular edema associated with diabetic retinopathy (DME) or branch retinal vein occlusion (BRVOME) using laser speckle flowgraphy. Methods A comparative interventional study of 25 eyes from 22 patients with macular edema (DME group: 12 eyes; BRVOME group: 13 eyes) who underwent IVB. Mean blur rate (MBR) was measured in the retinal artery, retinal vein, optic nerve head (ONH), and choroid before and after IVB. Results In the BRVOME group, there was no significant change in MBR in the retinal artery, retinal vein or ONH, but choroidal MBR decreased significantly (P=0.04). In the DME group, the MBR in the retinal artery, retinal vein, ONH, and choroid decreased significantly (P=0.02, P=0.04, P<0.001, and P=0.04, respectively). In the DME group, pre-IVB MBR in the ONH was significantly correlated with post-IVB foveal thickness (R= −0.71, P=0.002). There was no such correlation in the BRVOME group in the ONH. Conclusion IVB had a suppressive effect on circulation in eyes with DME but not in those with BRVOME. This suggests that this noninvasive and objective biomarker may be a useful part of pre-IVB evaluations and decision-making in DME.
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Affiliation(s)
- Fumihiko Nitta
- Department of Ophthalmology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroshi Kunikata
- Department of Ophthalmology, Tohoku University Graduate School of Medicine, Sendai, Japan ; Department of Retinal Disease Control, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Naoko Aizawa
- Department of Ophthalmology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kazuko Omodaka
- Department of Ophthalmology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yukihiro Shiga
- Department of Ophthalmology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masayuki Yasuda
- Department of Ophthalmology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toru Nakazawa
- Department of Ophthalmology, Tohoku University Graduate School of Medicine, Sendai, Japan ; Department of Retinal Disease Control, Tohoku University Graduate School of Medicine, Sendai, Japan ; Department of Advanced Ophthalmic Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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Abu El-Asrar AM. Evolving strategies in the management of diabetic retinopathy. Middle East Afr J Ophthalmol 2014; 20:273-82. [PMID: 24339676 PMCID: PMC3841944 DOI: 10.4103/0974-9233.119993] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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.
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Affiliation(s)
- Ahmed M Abu El-Asrar
- Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Abu El-Asrar AM, Al-Mezaine HS, Ola MS. Pathophysiology and management of diabetic retinopathy. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/eop.09.52] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Kang S, Chang YS, Kim JW, Kim CG, Lee TG, Kim JH. Influence of Image Compression on the Interpretation of Optical Coherence Tomography in Diabetic Macular Edema. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2014. [DOI: 10.3341/jkos.2014.55.9.1320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Sunah Kang
- Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, Seoul, Korea
| | - Young Suk Chang
- Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, Seoul, Korea
| | - Jong Woo Kim
- Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, Seoul, Korea
| | - Chul Gu Kim
- Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, Seoul, Korea
| | - Tae Gon Lee
- Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, Seoul, Korea
| | - Jae Hui Kim
- Department of Ophthalmology, Kim's Eye Hospital, Konyang University College of Medicine, Seoul, Korea
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Kim BS, Chung IY, Park JM, Han YS. Comparison of Intravitreal Bevacizumab Alone Injection and Intravitreal Combination Low-Dose Bevacizumab-Triamcinolone Injection or Diabetic Macular Edema. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2014. [DOI: 10.3341/jkos.2014.55.8.1155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Byoung Seon Kim
- Department of Ophthalmology, Gyeongsang National University School of Medicine, Jinju, Korea
| | - In Young Chung
- Department of Ophthalmology, Gyeongsang National University School of Medicine, Jinju, Korea
- Gyeongsang Institute of Health Science, Gyeongsang National University, Jinju, Korea
| | - Jong Moon Park
- Department of Ophthalmology, Gyeongsang National University School of Medicine, Jinju, Korea
- Gyeongsang Institute of Health Science, Gyeongsang National University, Jinju, Korea
| | - Yong Seop Han
- Department of Ophthalmology, Gyeongsang National University School of Medicine, Jinju, Korea
- Gyeongsang Institute of Health Science, Gyeongsang National University, Jinju, Korea
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Kriechbaum K, Prager S, Mylonas G, Scholda C, Rainer G, Funk M, Kundi M, Schmidt-Erfurth U. Intravitreal bevacizumab (Avastin) versus triamcinolone (Volon A) for treatment of diabetic macular edema: one-year results. Eye (Lond) 2013; 28:9-15; quiz 16. [PMID: 24336297 DOI: 10.1038/eye.2013.242] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 08/09/2013] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The objective was to compare retinal morphology and function following intravitreal injections of bevacizumab (Avastin) or triamcinolone (Volon A) in patients with early diabetic macular edema (DME). PATIENTS AND METHODS The study was planned as a randomized, prospective, interventional clinical trial. A total of 30 diabetic patients with treatment-naïve, clinically significant macular edema were included in this study and randomized to two equal groups. One group initially received three injections of 2.5 mg bevacizumab in monthly intervals. The second group received a single injection of 8 mg triamcinolone, followed by two sham interventions. Functional and anatomic results were evaluated monthly using ETDRS vision charts and spectral-domain optical coherence tomography. According to the study protocol, retreatment after 3 months was dependent on functional and anatomic outcome in a PRN regimen. RESULTS Baseline best corrected visual acuity (BCVA) was 0.30 logMAR and central retinal subfield thickness (CSRT) was 505 μm in the bevacizumab group and 0.32 logMAR and 490 μm CSRT in the triamcinolone group. After 3 months, BCVA improved to 0.23 logMAR (bevacizumab) and 358 μm CRST and 0.26 logMAR (triamcinolone) and 308 μm CSRT. After 12 months, BCVA further recovered in the bevacizumab group (0.18 logMAR) but slightly decreased in the triamcinolone group (0.36 logMAR). CONCLUSION Intravitreal bevacizumab and triamcinolone are both equally effective in reducing CSRT in early DME. After 6 months, rehabilitation of vision was comparable in both treatment arms, whereas at the final follow-up at month 12, BCVA was superior in the bevacizumab than in the triamcinolone sample. This may be related to cataract development following steroid treatment, as well as to substance-specific mechanisms within the angiogenic versus the inflammatory cascade.
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Affiliation(s)
- K Kriechbaum
- Department of Ophthalmology, Medical University of Vienna, Vienna, Austria
| | - S Prager
- Department of Ophthalmology, Medical University of Vienna, Vienna, Austria
| | - G Mylonas
- Department of Ophthalmology, Medical University of Vienna, Vienna, Austria
| | - C Scholda
- Department of Ophthalmology, Medical University of Vienna, Vienna, Austria
| | - G Rainer
- Department of Ophthalmology, Medical University of Vienna, Vienna, Austria
| | - M Funk
- Department of Ophthalmology, Medical University of Vienna, Vienna, Austria
| | - M Kundi
- Department of Public Health, Medical University of Vienna, Vienna, Austria
| | - U Schmidt-Erfurth
- Department of Ophthalmology, Medical University of Vienna, Vienna, Austria
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Visual outcome after intravitreal bevacizumab depends on the optical coherence tomographic patterns of patients with diffuse diabetic macular edema. Retina 2013; 33:740-7. [PMID: 23222391 DOI: 10.1097/iae.0b013e31826b6763] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the effectiveness of intravitreal bevacizumab (IVB) on the reduction of diffuse diabetic macular edema in patients with different optical coherence tomography patterns. DESIGN Prospective interventional case series. METHODS One hundred and forty-three eyes with diffuse diabetic macular edema, without a history of any previous treatment, were classified according to their optical coherence tomography patterns: sponge-like diffuse retinal thickening (SDRT) (n = 50), cystoid macular edema (CME) (n = 38), serous retinal detachment (SRD) (n = 25), and the combination of all patterns (FULL: n = 30). All the participants received a single dose (1.25 mg in 0.05 mL) of IVB. The foveal thickness obtained with optical coherence tomography images and logarithm of the minimum angle of resolution visual acuity were assessed before receiving IVB and subsequently every 2 weeks for 12 weeks. RESULTS After IVB, the foveal thickness in all the groups was reduced but the reduction ratio in the SDRT (29.6 ± 15.6%) and CME (27.1 ± 20.5%) groups was significantly greater than in the SRD group (16.4 ± 17.7%) (P < 0.001). Similarly, improvement of visual acuity in the SDRT (-0.21 ± 0.16) and CME (-0.17 ± 0.24) groups was significantly greater than in the SRD (-0.12 ± 0.15) and FULL (-0.11 ± 0.13) (P = 0.047) groups. Interestingly, the efficacy of IVB for regression of diffuse diabetic macular edema was dependent on the duration of diabetes in the SDRT and CME groups but not in the SRD or FULL groups. CONCLUSION The effectiveness of IVB on diffuse diabetic macular edema was dependent on the optical coherence tomography pattern (SDRT ≥ CME >> SRD), indicating that vascular endothelial growth factor plays a critical role in the pathogenesis of SDRT and CME, and was greater in patients having diabetes for a shorter duration of time.
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Nepomuceno AB, Takaki E, Paes de Almeida FP, Peroni R, Cardillo JA, Siqueira RC, Scott IU, Messias A, Jorge R. A prospective randomized trial of intravitreal bevacizumab versus ranibizumab for the management of diabetic macular edema. Am J Ophthalmol 2013; 156:502-510.e2. [PMID: 23795985 DOI: 10.1016/j.ajo.2013.04.026] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Revised: 04/16/2013] [Accepted: 04/18/2013] [Indexed: 11/19/2022]
Abstract
PURPOSE To compare visual acuity and spectral-domain optical coherence tomography (SDOCT) outcomes associated with intravitreal (IV) bevacizumab vs IV ranibizumab for the management of diabetic macular edema (DME). DESIGN Prospective randomized trial. METHODS Forty-eight patients (63 eyes) with center-involved DME were randomly assigned to receive 1.5 mg (0.06 cc) IV bevacizumab or 0.5 mg (0.05 cc) IV ranibizumab at baseline and monthly if central subfield thickness was greater than 275 μm. RESULTS Forty-five patients (60 eyes) completed 48 weeks of follow-up. At baseline, mean ± standard error best-corrected visual acuity (BCVA) (logMAR) was 0.60 (20/80) ± 0.05 in the IV bevacizumab group and 0.63 (20/85) ± 0.05 in the IV ranibizumab group. A significant improvement in mean BCVA was observed in both groups at all study visits (P < .05); this improvement was significantly greater in the IV ranibizumab group compared with the IV bevacizumab group at weeks 8 (P = .032) and 32 (P = .042). A significant reduction in mean central subfield thickness was observed in both groups at all study visits compared with baseline (P < .05), with no significant difference in the magnitude of macular thickness reduction between groups. The mean number of injections was significantly higher (P = .005) in the IV bevacizumab group (9.84) than in the IV ranibizumab group (7.67). CONCLUSIONS IV bevacizumab and IV ranibizumab are associated with similar effects on central subfield thickness in patients with DME through 1 year of follow-up. IV ranibizumab is associated with greater improvement in BCVA at some study visits, and the mean number of injections is higher in the IV bevacizumab group.
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Affiliation(s)
- Antonio Brunno Nepomuceno
- School of Medicine of Ribeirão Preto, University of São Paulo, Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Ribeirão Preto, Brazil
| | - Erika Takaki
- School of Medicine of Ribeirão Preto, University of São Paulo, Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Ribeirão Preto, Brazil
| | - Felipe Piacentini Paes de Almeida
- School of Medicine of Ribeirão Preto, University of São Paulo, Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Ribeirão Preto, Brazil
| | | | | | - Rubens Camargo Siqueira
- School of Medicine of Ribeirão Preto, University of São Paulo, Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Ribeirão Preto, Brazil
| | - Ingrid Ursula Scott
- Departments of Ophthalmology and Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - André Messias
- School of Medicine of Ribeirão Preto, University of São Paulo, Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Ribeirão Preto, Brazil
| | - Rodrigo Jorge
- School of Medicine of Ribeirão Preto, University of São Paulo, Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Ribeirão Preto, Brazil.
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Zhang XL, Chen J, Zhang RJ, Wang WJ, Zhou Q, Qin XY. Intravitreal triamcinolone versus intravitreal bevacizumab for diabetic macular edema: a meta-analysis. Int J Ophthalmol 2013; 6:546-52. [PMID: 23991395 DOI: 10.3980/j.issn.2222-3959.2013.04.26] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 07/03/2013] [Indexed: 11/02/2022] Open
Abstract
AIM To compare the efficacy of the sole intravitreal triamcinolone (IVT) versus intravitreal bevacizumab (IVB) alone or IVB combined with IVT in the treatment of diabetic macular edema (DME). METHODS Pertinent publications were identified through systematic searches of database and manually searching. Methodological quality of the literatures was valuated according to the Jadad Score. RevMan 5.1.0 was used to do the meta-analysis. Heterogeneity was determined and sensitivity was conducted. RESULTS Six studies were ultimately included in the meta-analysis. The results of our analysis showed IVT had a statistically significant improvement in vision over the IVB at 1 month and 3 months (P<0.01). However, the reduction was not significant regarding central macular thickness (CMT) during the earlier (1 month and 3 months) follow-up period (P=0.12, P=0.41, respectively). At later visit (6 months), IVT had a significant decrease in CMT when compared to IVB (P<0.01) while no significant improvement in visual acuity (VA) was observed (P=0.14). The incidence of intraocular hypertension was 13/102 in IVT group during follow-up period while 0/103 in IVB group. The difference was significant (P<0.01). With regards to IVT versus IVB combined with IVT, there were no significant differences in CMT at 1 month (P=0.86) and 3 months (P=0.06). The incidence of intraocular hypertension was 6/67 in IVT group during follow-up period while 4/66 in IVB+IVT group. But the difference was not significant (P=0.53). CONCLUSION Current evidence shows IVT is superior in improving VA at earlier follow-up (1 month and 3 months) and in reducing CMT at later follow-up (6 months) for DME. At other time, it is in favor of IVT treatment but there are no statistically significances. However, IVT has the side-effect of ocular hypertension. There is no adequate evidence of the benefit adding IVB to IVT in contrast to IVT alone.
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Affiliation(s)
- Xiao-Ling Zhang
- Department of Ophthalmology, the First Affiliated Hospital of Jinan University, Guangzhou 510632, Guangdong Province, China
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Abstract
PURPOSE To describe the current management of diffuse diabetic macular edema (DDME). METHODS Review and discussion of the literature regarding DDME. RESULTS Diffuse diabetic macular edema is a condition that can be managed by means of several treatment options, including focal/grid laser photocoagulation, intravitreal or periocular corticosteroids, intravitreal anti-vascular endothelial growth factor (VEGF), and vitrectomy with or without internal limiting membrane peeling. CONCLUSIONS Even though there is no randomized clinical trial specifically designed to assess the best treatment approach for DDME, new therapeutic approaches based on intravitreal injections of corticosteroid and anti-VEGF molecules offer new hope for its management.
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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 JOURNAL OF OPHTHALMOLOGY 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] [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.
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Affiliation(s)
- Jae Hui Kim
- Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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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] [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.
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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
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Azad R, Sain S, Sharma YR, Mahajan D. Comparison of intravitreal bevacizumab, intravitreal triamcinolone acetonide, and macular grid augmentation in refractory diffuse diabetic macular edema: A prospective, randomized study. Oman J Ophthalmol 2013; 5:166-70. [PMID: 23439853 PMCID: PMC3574512 DOI: 10.4103/0974-620x.106100] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND In spite of laser being the gold standard treatment for Diabetic Macular edema (DME), some patients do not respond to laser. Various treatment modalities are being tried in the management of refractory diffuse DME (DDME). PURPOSE To compare the efficacy of intravitreal bevacizumab (IVB), intravitreal triamcinolone acetonide (IVTA), and macular grid augmentation in the management of refractory DDME. SETTINGS AND DESIGN Prospective randomized study in a tertiary eye care center. MATERIALS AND METHODS SIXTY PATIENTS WITH REFRACTORY DDME WERE RANDOMLY ASSIGNED TO THREE GROUPS: Group 1 received IVB (1.25 mg/0.05 ml), Group 2 received IVTA (4 mg/0.1ml), and Group 3 underwent laser augmentation. Primary outcome measures were best corrected visual acuity (BCVA) and central macular thickness (CMT) at the end of 6 months. STATISTICS Analysis was performed using SPSS 14.0 RESULTS Group 1 and 2 showed significant improvement in mean BCVA from 20/160 at baseline to 20/80 and from 20/125 to 20/63, respectively, at 6 months (P < 0.05). These groups also showed a significant reduction in the mean CMT from 457 ± 151 μ at baseline to 316 ± 136 μ and from 394 ± 61 μ to 261 ± 85 μ, respectively, at 6 months (P < 0.05). Group 3 showed only small improvement in mean BCVA from 20/100 to 20/80 (P = 1.0) while mean CMT increased from 358 ± 89 μ at baseline to 395 ± 127 μ at 6 months (P = 0.191). Eight (40%) eyes in Group 2 had intraocular pressure (IOP) rise and 10 (50%) eyes developed cataract. CONCLUSIONS Both IVB and IVTA may be effective in the treatment of refractory DDME compared with macular grid augmentation. IVTA may be associated with side effects such as IOP rise and cataract formation.
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Affiliation(s)
- Rajvardhan Azad
- Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institue of Medical Sciences, New Delhi, India
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Zhang Y, Ma J, Meng N, Li H, Qu Y. Comparison of Intravitreal Triamcinolone Acetonide with Intravitreal Bevacizumab for Treatment of Diabetic Macular Edema: A Meta-analysis. Curr Eye Res 2013; 38:578-87. [DOI: 10.3109/02713683.2013.767351] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Klaassen I, Van Noorden CJF, Schlingemann RO. Molecular basis of the inner blood-retinal barrier and its breakdown in diabetic macular edema and other pathological conditions. Prog Retin Eye Res 2013; 34:19-48. [PMID: 23416119 DOI: 10.1016/j.preteyeres.2013.02.001] [Citation(s) in RCA: 444] [Impact Index Per Article: 40.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 12/19/2012] [Accepted: 02/01/2013] [Indexed: 12/16/2022]
Abstract
Breakdown of the inner endothelial blood-retinal barrier (BRB), as occurs in diabetic retinopathy, age-related macular degeneration, retinal vein occlusions, uveitis and other chronic retinal diseases, results in vasogenic edema and neural tissue damage, causing loss of vision. The central mechanism of altered BRB function is a change in the permeability characteristics of retinal endothelial cells caused by elevated levels of growth factors, cytokines, advanced glycation end products, inflammation, hyperglycemia and loss of pericytes. Subsequently, paracellular but also transcellular transport across the retinal vascular wall increases via opening of endothelial intercellular junctions and qualitative and quantitative changes in endothelial caveolar transcellular transport, respectively. Functional changes in pericytes and astrocytes, as well as structural changes in the composition of the endothelial glycocalyx and the basal lamina around BRB endothelium further facilitate BRB leakage. As Starling's rules apply, active transcellular transport of plasma proteins by the BRB endothelial cells causing increased interstitial osmotic pressure is probably the main factor in the formation of macular edema. The understanding of the complex cellular and molecular processes involved in BRB leakage has grown rapidly in recent years. Although appropriate animal models for human conditions like diabetic macular edema are lacking, these insights have provided tools for rational design of drugs aimed at restoring the BRB as well as for design of effective transport of drugs across the BRB, to treat the chronic retinal diseases such as diabetic macular edema that affect the quality-of-life of millions of patients.
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Affiliation(s)
- Ingeborg Klaassen
- Ocular Angiogenesis Group, Department of Ophthalmology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Bandello F, Lattanzio R, Zucchiatti I, Del Turco C. Pathophysiology and treatment of diabetic retinopathy. Acta Diabetol 2013; 50:1-20. [PMID: 23277338 DOI: 10.1007/s00592-012-0449-3] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 12/11/2012] [Indexed: 01/07/2023]
Abstract
In the past years, the management of diabetic retinopathy (DR) relied primarily on a good systemic control of diabetes mellitus, and as soon as the severity of the vascular lesions required further treatment, laser photocoagulation or vitreoretinal surgery was done to the patient. Currently, even if the intensive metabolic control is still mandatory, a variety of different clinical strategies could be offered to the patient. The recent advances in understanding the complex pathophysiology of DR allowed the physician to identify many cell types involved in the pathogenesis of DR and thus to develop new treatment approaches. Vasoactive and proinflammatory molecules, such as vascular endothelial growth factor (VEGF), play a key role in this multifactorial disease. Current properly designed trials, evaluating agents targeting VEGF or other mediators, showed benefits in the management of DR, especially when metabolic control is lacking. Other agents, directing to the processes of vasopermeability and angiogenesis, are under investigations, giving more hope in the future management of this still sight-threatening disease.
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Affiliation(s)
- Francesco Bandello
- Department of Ophthalmology, Scientific Institute San Raffaele, University Vita-Salute, Milan, Italy.
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