Long-term results of a single injection of intravitreal dexamethasone as initial therapy in diabetic macular edema

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Safety and efficacy profile of intravitreal ranibizumab vs dexamethasone in treatment of naïve diabetic macular edema

PURPOSE

To compare the safety and efficacy parameters of intravitreal ranibizumab vs intravitreal dexamethasone (IVD) in the treatment of patients with naïve diabetic macular edema (DME) in terms of best-corrected visual acuity (BCVA), central macular thickness (CMT), and possible complications like intraocular pressure (IOP) rise and cataract progression.

METHODS

A hospital-based prospective and comparative study of naïve DME patients was conducted between November 2020 and October 2021 with a minimum follow-up (F/U) period of 6 months. Thirty phakic patients received one dose of IVD implant (Group A) and the other 30 (Group B) received three consecutive monthly doses of ranibizumab. The main exclusion criteria were steroid responders and the presence of ocular inflammation.

RESULTS

The mean pre-injection CMT in Group A was 405µ and reduced to 297.07µ at 3 months and 278.35µ at 6 months. Mean increase in logMAR BCVA was 0.55. The mean pre-injection IOP was 16.28 and 17.64 mm of Hg at 6 months. In Group B, the mean pre-injection CMT was 401.07µ and reduced to 276.1µ at 3 months and 292.9µ at 6 months. Mean BCVA increased to 0.37. The mean pre-injection IOP was 17.28 mm Hg and 16.42 mm Hg at 6 months. There was no significant progression of cataract in both groups.

CONCLUSION

The mean decrease in CMT was comparable in both the groups at 6 months F/U with an improvement of BCVA with no significant IOP fluctuation or cataract progression. Hence, IVD appears to be noninferior to ranibizumab in the treatment of naïve DME.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Quantitative Analysis of Retinal Microvascular Perfusion and Novel Biomarkers of the Treatment Response in Diabetic Macular Edema

PURPOSE

We aimed to assess the changes of retinal microvascular parameters using optical coherence tomography angiography (OCTA) between diabetes macular edema (DME) and controls. We assessed the changes between the baseline microvascular parameters and final treatment response in patients with DME, initially treated with intravitreal dexamethasone (DEX) implant followed by antivascular endothelial growth factor (VEGF) injections on an as-needed basis.

METHODS

This retrospective study included 90 DME patients and 24 healthy control subjects. All subjects had their best-corrected visual acuity (BCVA) and central macular thickness (CMT) measured at baseline and after 12 months. Vessel density (VD) in the superficial capillary plexus (SCP) and deep capillary plexus (DCP) and the deep/superficial flow ratio at baseline were analyzed. A subgroup analysis was used to compare the treatment response. A poor-response group was defined by five or more retreatments at 12 months.

RESULTS

BCVA and CMT showed a significant improvement at 12 months (all p < 0.001). The VD in the whole and parafoveal areas of the DCP was significantly reduced in DME patients compared to that in controls (all p < 0.05). The DCP/SCP flow ratio was also significantly reduced in the DME group (1.08 ± 0.03 vs. 1.05 ± 0.02, p = 0.001). In the subgroup analysis, the VD in the foveal and whole DCP areas was significantly lower in the poor-response group than that in the good-response group (p = 0.043 and p = 0.048, respectively). The DCP/SCP flow ratio was also significantly lower in the poor-response group (p = 0.011).

CONCLUSION

DME correlated with significant retinal microvascular impairment in the DCP. A decreased DCP/SCP flow ratio was observed in patients with DME that exhibited a poor treatment response. Retinal microvascular parameters could predict the treatment response in DME and help optimize clinical outcomes.