Clinical Characteristics and Surgical Outcomes of Patients Undergoing Pars Plana Vitrectomy for Proliferative Diabetic Retinopathy

OBJECTIVE

To evaluate clinical characteristics impacting surgical outcomes of patients undergoing pars plana vitrectomy (PPV) for complications of proliferative diabetic retinopathy (PDR).

DESIGN

Retrospective consecutive observational case series of patients at a large county hospital in Dallas, Texas, from 2014 to 2019.

SUBJECTS

Seven hundred thirty-two patients (933 eyes) undergoing PPV for PDR complications.

METHODS

Collected data included demographics, surgical indication, adjuvant therapies, intraoperative course, complications, and best corrected visual acuity (BCVA). Patients with < 6 months of follow-up were excluded. Best corrected visual acuity was converted to logarithm of the minimum angle of resolution for analysis. Statistics performed included t test, analysis of variance, and multivariate analyses.

MAIN OUTCOME MEASURES

Postoperative BCVA, primary anatomic success rate, and postoperative complications.

RESULTS

Three hundred ninety-three patients were male (509 eyes; 54.5%) with an average age of 52 years. Postoperative BCVA at 6 months was significantly different among surgical indications: 0.79 versus 0.77 versus 1.20 (P < 0.0001) for vitreous hemorrhage (VH), vitreomacular interface abnormalities, and tractional retinal detachment (TRD), respectively. Adjuvant preoperative therapy with panretinal photocoagulation (PRP) versus no PRP (0.95 vs. 1.25; P < 0.001) and insulin versus no insulin (0.99 vs. 1.17; P < 0.01) were associated with improved vision. Iatrogenic breaks were associated with decreased postoperative vision (1.40 vs. 0.88; P < 0.001). The primary anatomic success rate for TRD was 85% (495 eyes). Combined TRD/RRD (tractional and rhegmatogenous retinal detachment) was associated with a lower success rate compared with macula-on/macula-off TRD, with odds ratios of 0.36, 0.46, and 0.53, respectively. Patients experiencing recurrent detachment postsurgery had worse preoperative visual acuity (VA) (1.93 vs. 1.63; P < 0.01) and were younger (47.6 vs. 50.0; P = 0.02). Postoperative complications occurred in 699 eyes (75%), with VH (498 eyes, 53%), cataract (465, 50%), and elevated intraocular pressure (149, 16%) being the most common. Two hundred thirty-six eyes (25%) required a second PPV operation. Endophthalmitis (1 eye; <1%) and choroidal detachment (5 eyes; <1%) were rare.

CONCLUSIONS

In this retrospective series analyzing surgical outcomes among patients with complications from PDR, vitrectomy led to improved vision on average, with a meaningful proportion of patients receiving additional surgical intervention. Surgical indication, presenting VA, age, and adjuvant therapies appeared to impact outcomes.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Rates of diabetic retinopathy among cluster analysis-identified type 2 diabetic mellitus subgroups

PURPOSE

To determine whether phenotypic clustering of patients with diabetes mellitus (DM) is associated with more advanced diabetic retinopathy (DR).

METHODS

Retrospective cohort study of 495 patients with no prior DR treatment seen at a tertiary care clinic 2014-2020. Four previously identified clusters from Ahlqvist's 2018 paper were reproduced utilizing baseline hemoglobin A1c, body mass index, and age at DM diagnosis. Age-adjusted Cox proportional hazard ratios were used to compare clusters with reference as the lowest risk cluster.

RESULTS

All four type 2 DM clusters were replicated with our cohort. There was a significant difference in racial distribution among clusters (p = 0.018) with severe insulin-resistant diabetes (SIRD) having the higher percentage of Caucasians and lower percentage of Hispanics compared to other groups and a higher percentage of African Americans comprising the severe insulin-deficient diabetes (SIDD) cluster than other groups. Rates of proliferative diabetic retinopathy were higher in mild obesity-related diabetes (MOD) (28%), SIDD (24%), mild age-related diabetes (MARD) (20%), and lowest in SIRD (7.9%), overall p = 0.004. Rates of vitreous hemorrhage were higher in MOD (p = 0.032) and MARD (0.005) compared to SIRD.

CONCLUSION

Baseline clinical measures may be useful in risk stratifying patients for progression to retinopathy requiring intervention.

Proliferative diabetic retinopathy: Role of bevacizumab in decreasing the occurrence of vitreous hemorrhage after panretinal photocoagulation

PURPOSE

To investigate the beneficial effect of bevacizumab injection one week prior to panretinal photocoagulation (PRP) on the occurrence of vitreous hemorrhage (VH) following PRP in high-risk proliferative diabetic retinopathy (PDR).

METHODS

This was a case-control pilot study conducted on two groups: an anti-VEGF treatment group, treated with bevacizumab injection one week prior to the first PRP session, and a control group of treatment-naive PDR patients who underwent PRP treatment and were not given an intravitreal bevacizumab injection, consecutively recruited. In both groups, a complete ophthalmological examination was conducted prior to PRP and at 4, 9, and 16 weeks following treatment. The primary endpoint studied was the occurrence of VH.

RESULTS

The control group included 69 patients (mean age 63±12.3 years) with high-risk PDR who received PRP treatment only, and the anti-VEGF treatment group included 67 patients (mean age 63.13±10.3 years). None of the demographic variables or comorbidities showed any significant difference between the two groups. The number of PRP sessions was not significantly correlated to the occurrence of VH in either of the groups (P=0.167). Vitreous hemorrhage within 16 weeks following laser treatment occurred in 10 patients (14.5%) in the control group and in only 3 patients (4.5%) in the anti-VEGF group (P=0.047).

CONCLUSION

Our case-control pilot study demonstrates that a bevacizumab injection preceding the initial PRP session might be beneficial in reducing the occurrence of VH in the first 16 weeks following PRP.

Long-term longitudinal retinal changes after conventional and pattern scan laser panretinal photocoagulation in diabetic retinopathy

PURPOSE

Comparison the effect of conventional and pattern scan laser (PASCAL) panretinal photocoagulation (PRP) on macula and optic disk in diabetic retinopathy (DR).

METHODS

This retrospective study included 57 patients. In the conventional laser group, PRP was completed using the LightMed LightLas 532 laser device in accordance with the ETDRS protocol. In the pattern laser group, it was completed in a single session using PASCAL device with 20 ms pulse duration and multispot pattern. Central macular thickness (CMT) and retinal nerve fiber layer (RNFL) thickness were evaluated before laser treatment and at 1, 6 and 12 months after treatment.

RESULTS

There were 30 eyes in the conventional laser group and 27 eyes in the PASCAL group. There was no significant difference between the groups in terms of age (p = 0.560), sex (p = 0.866), duration (p = 0.498) and stage (p = 0.503) of diabetes, visual acuity (p = 0.104) and intraocular pressure (p = 0.963).In both groups, CMT increased significantly (p ˂0.001), while RNFL thickness decreased significantly (p ˂0.001) at 12 months. While CMT and mean RNFL thickness increased in the first month in both groups, it decreased progressively until the 12th month.

CONCLUSION

Conventional and pattern laser systems used in the treatment of DR................ cause an increase in CMT and thinning of RNFL thickness in the long term. This change is more in the conventional laser group compared to the pattern laser.

Photocoagulation Up to Ora Serrata in Diabetic Vitrectomy to Prevent Recurrent Vitreous Hemorrhage

PURPOSE

To evaluate the role of performing photocoagulation up to ora serrata during vitrectomy in preventing recurrent vitreous hemorrhage (VH) in patients undergoing pars plana vitrectomy (PPV) for proliferative diabetic retinopathy (PDR).

METHODS

This retrospective, nonrandomized study included 60 eyes from 60 patients who had undergone PPV for VH due to PDR. These patients were divided into two groups: group 1, those who underwent photocoagulation up to ora serrata using the scleral indentation technique during surgery; and group 2, those who did not undergo scleral indentation when photocoagulation and underwent photocoagulation up to vortex veins. Their hospital records were analyzed to investigate the recurrence rate of VH, the time until recurrence of VH after surgery, logarithm of the minimal angle of resolution (logMAR) best-corrected visual acuity (BCVA) measured before surgery and at 1, 2, and 3 years after surgery, and the occurrence of complications such as neovascular glaucoma (NVG) during follow-up.

RESULTS

Group 1 exhibited lower recurrence rate of VH (2 of 30 [6.7%] vs. 10 of 30 [33.3%], p = 0.01) and lower occurrence of postoperative NVG (2 of 30 [6.7%] vs. 8 of 30 [26.7%], p = 0.038) compared with group 2. There were no statistically significant differences in logMAR BCVA measured at 1, 2, and 3 years between the two groups (at 1 year: 0.54 ± 0.43 vs. 0.54 ± 0.44, p = 0.954; at 2 years: 0.48 ± 0.47 vs. 0.55 ± 0.64, p = 0.235; at 3 years: 0.51 ± 0.50 vs. 0.61 ± 0.77, p = 0.200). Logistic regression analysis showed that among several factors that could affect recurrence rate of VH, only range of photocoagulation performed was a statistically significant factor (odds ratio, 0.119; 95% confidence interval, 0.022-0.659; p = 0.015).

CONCLUSIONS

Photocoagulation treatment over a wider range with scleral indentation could be a beneficial adjunct procedure for preventing postoperative recurrent VH following diabetic vitrectomy.

intravitreal conbercept

PURPOSE

To compare long-term real-world outcomes of retinal microvasculature changes in proliferative diabetic retinopathy (PDR) treated with panretinal photocoagulation (PRP) vs. intravitreal conbercept (IVC) and to explore the potential factors affecting these changes.

METHODS

This study retrospectively included 96 treatment-naïve PDR eyes of 96 type 2 diabetes mellitus patients [59 PRP and 37 IVC]. Baseline characteristics and treatment details were collected. Optical coherence tomography angiography (OCTA) data of macular vessel density (VD) and optic disc capillary density (CD) at baseline and at the last follow-up were compared between groups. The differences between the baseline and the last follow-up OCTA data in each group were also tested for significance. The correlation between the change in each OCTA parameter from baseline and each baseline characteristic/treatment parameter was investigated in each group.

RESULTS

During a mean follow-up of two years, greater superficial (SCP) (p = 0.004) and deep capillary plexus (DCP) VD (p < 0.001) were observed in the foveal area in the PRP than in the IVC. Compared to the baseline, SCP VD in the foveal area increased in the PRP (p = 0.012), while an increased SCP VD in some sectors in the parafoveal and perifoveal areas (p < 0.05), rather than the foveal area (p = 0.908), was seen in the IVC. For both groups, eyes with a higher VD/CD at baseline tended to develop capillary dropout more intensively (all p < 0.05). In the IVC group, foveal avascular zone (FAZ) area change showed a negative correlation with baseline FAZ area (p = 0.020), and complementary PRP exerted a negative influence on FAZ area change (p = 0.002). In the PRP group, SCP VD change was positively correlated with follow-up frequency, and was negatively correlated with diastolic blood pressure (all p < 0.05); DCP VD change showed a positive correlation with PRP shot number (p = 0.019).

CONCLUSION

The aforementioned microvasculature changes should be considered when PRP or IVC is adopted in PDR long-term management.

Panretinal photocoagulation plus intravitreal conbercept for diabetic retinopathy in real world: a retrospective study

BACKGROUND

To evaluate outcomes of panretinal photocoagulation (PRP) plus intravitreal conbercept (IVC) for diabetic retinopathy (DR) in real world and explore risk factors for patients with poor reactivity and presence of vision-threatening complications after combination treatment.

METHODS

Retrospective review of DR patients received PRP plus IVC over 6 months. The main outcome was improvement ≥ 2 steps in ETDRS diabetic retinopathy severity scale (DRSS) levels. Different strategies for eyes receiving IVC within or over 1 month after PRP were analyzed. For patients with DRSS improvement < 2 steps and presence of vision-threatening adverse events, a binary logistic regression method was used to select risk factors.

RESULTS

Sixty one eyes were involved in this study. After treated with combination therapy with a median number of 3 injections, 44% of eyes improved ≥ 2 steps in DRSS levels. A total of 14 eyes (23%) occurred vision-threatening adverse events. No significant difference was found in eyes receiving conbercept within or over 1 month after PRP. Duration of diabetes (OR 0.849, 95%CI 0.734-0.982, P = 0.027), GFR (OR 0.961, 95%CI 0.933-0.990, P = 0.010) and baseline DRSS levels (OR 3.290, 95%CI 1.483-7.295, P = 0.003) were independent risk factors for DRSS improvement < 2 steps after treatment. Occurrence of vision-threatening complications was only related to high DRSS levels (OR 3.668, 95%CI 1.710-7.868, P = 0.001).

CONCLUSIONS

The combination therapy was effective for most patients with DR in real world. Eyes received PRP combined with earlier or later conbercept was demonstrated no significant difference for outcomes. For patients with poor renal function, high DRSS levels or occurred DR at the early stage of diabetes, follow-up should be strengthened.

Quantification of macular perfusion following panretinal photocoagulation for diabetic retinopathy: An optical coherence tomography angiography study

PURPOSE

To assess the effects of panretinal photocoagulation (PRP) on the microvascular structure of the macula and central thickness of the macula and choroid via optical coherence tomography angiography (OCTA).

METHODS

In this prospective clinical study, 43 eyes of 31 patients with severe non-proliferative diabetic retinopathy or early proliferative diabetic retinopathy were included. Before and at the third and sixth months after PRP, the foveal avascular zone (FAZ) area, acircularity index (AI), foveal density (FD), and vascular density of the superficial capillary plexus (SCP) and deep capillary plexus (DCP) were evaluated using OCTA. The central macular thickness (CMT) and subfoveal choroidal thickness (SCT) were also measured after PRP.

RESULTS

There was no difference between the FAZ area, AI, FD, and vessel density of the SCP and DCP before and at the third and sixth months after PRP (all p>0.05). The CMT value was higher at the third and sixth months than at baseline (p = 0.002 and p = 0.001, respectively). The SCT value was lower at the third and sixth months than at baseline (p = 0.002 and p = 0.001, respectively).

CONCLUSION

PRP is a beneficial and reliable method that supports the integrity of the macular microvascular structure. After PRP, the CMT increases, and the SCT decreases.

Effect of panretinal photocoagulation on retina and choroid in diabetic retinopathy: An optical coherence tomography angiography study

BACKGROUND

To analyze the quantitative changes in both macular, and choroidal thickness, and microvascularization after panretinal photocoagulation (PRP) in eyes with proliferative diabetic retinopathy (PDR) or severe non-proliferative diabetic retinopathy (NPDR) by using optical coherence tomography angiography (OCT-A).

METHODS

The patients diagnosed with severe NPDR or PDR according to the Early Treatment Diabetic Retinopathy Study (ETDRS) and decided to be treated with PRP were included in this prospective and observational study. Ten eyes of 10 patients with PDR and twelve eyes of 12 patients with severe NPDR were examined. Macular scans (6 × 6 mm) were obtained from OCT-A at baseline and at month 6 after PRP. Subfoveal choroidal thickness (SFCT) measurements that were obtained through the foveolar center on a high-definition line scan were recorded.

RESULTS

Best-corrected visual acuity (BCVA) significantly decreased (p = 0.018), central foveal thickness and mean parafoveal thickness significantly increased (p < 0001 and p < 0.001, respectively) six months after PRP. The thickness of all parafoveal retinal quadrants (temporal, superior, nasal, inferior) increased (p = 0.001, p = 0.003, p < 0.001, p < 0.001, respectively) and mean parafoveal, parafoveal temporal, and parafoveal nasal vessel density of the deep capillary plexus (DCP) significantly decreased six months after PRP compared with the baseline values (p = 0.023, p = 0.041, p = 0.018, respectively).

CONCLUSIONS

The parafoveal vessel density of DCP decreased significantly 6 months after PRP in eyes with PDR or severe NPDR. While the difference in SFCT and choroidal flow density was not significant from the baseline; central and parafoveal retinal thickness increased and BCVA decreased significantly 6 months after PRP treatment.

A prediction model for worsening diabetic retinopathy after panretinal photocoagulation

BACKGROUND

As one of the severe complications of diabetes mellitus, diabetic retinopathy (DR) is the leading cause of blindness in the working age worldwide. Although panretinal photocoagulation (PRP) was standard treatment, PRP-treated DR still has a high risk of progression. Hence, this study aimed to assess the risk factors and establish a model for predicting worsening diabetic retinopathy (DR-worsening) within five years after PRP.

METHODS

Patients who were diagnosed with severe non-proliferative diabetic retinopathy or proliferative diabetic retinopathy and treated with PRP were included, and those patients were randomly assigned to either a training or validation cohort. The multivariate logistic regression analysis was used to screen potential risk factors for DR-worsening in the training cohort. Then the model was established after including significant independent risk factors and further validated using discrimination and calibration.

RESULTS

A total of 271 patients were included, and 56.46% of patients had an outcome of DR-worsening. In the training cohort (n = 135), age (odds ratio [OR] = 0.94, 95% confidence interval [CI] 0.90-0.98), baseline best corrected visual acuity (logMAR) (OR = 10.74, 95% CI 1.84-62.52), diabetic nephropathy (OR = 9.32, 95% CI 1.49-58.46), and hyperlipidemia (OR = 3.34, 95% CI 1.05-10.66) were screened out as the independent risk factors, which were incorporated into the predictive model. The area under the receiver operating characteristic curve and calibration slope in the training and validation cohort were 0.79, 0.96 (95% CI 0.60-1.31), and 0.79, 1.00 (95% CI 0.66-1.34), respectively. Two risk groups were developed depending on the best cut-off value of the predicted probability, and the actual probability was 34.90% and 82.79% in the low-risk and high-risk groups, respectively (P < 0.001).

CONCLUSIONS

This study developed and internally validated a new model to predict the probability of DR-worsening after PRP treatment within five years. The model can be used as a rapid risk assessment system for clinical prediction of DR-worsening and identify individuals at a high risk of DR-worsening at an early stage and prescribe additional treatment.

IRVAN syndrome: A case report and a literature review

Introduction and Importance

Idiopathic retinal vasculitis, aneurysms, and neuroretinitis (IRVAN) syndrome is a rare retinal defect. It has a female predominance. The staging of IRVAN was defined depending on ocular criteria.

Case presentations

A 30-year-old female patient presented with floaters in the left eye. One year later, it was diagnosed with Fluorescein fundus angiography (FFA) at stage Ⅲ of IRVAN syndrome. After one year, the right eye was affected, diagnosed at stage Ⅱ, and successfully treated with heavy Pan-Retinal Photocoagulation (PRP).

Clinical discussion

IRVAN Syndrome is an extremely rare retinal defect which has female predominance. The etiology of this syndrome still idiopathic. The most encountered symptoms are blurred vision and vision loss. FFA is the best diagnostic investigation to reveal the retinal abnormalities. Many suggested protocols were mentioned to treat IRVAN Syndrome. Our experience suggests IRVAN Syndrome a differential diagnosis for patients with floaters, and assures that PRP is an affective curement for late stages of IRVAN Syndrome.

Conclusions

Heavy PRP was used successfully for stage II and III. The case emphasizes the importance of early diagnosis to assert the complications. Furthermore, IRVAN syndrome should be considered as a differential diagnosis in patients with floaters. Therefore, heavy PRP is highly recommended as a suitable treatment for IRVAN syndrome.

Review of the management of sight-threatening diabetic retinopathy during pregnancy

Diabetes mellitus (DM) is a noncommunicable disease reaching epidemic proportions around the world. It affects younger individuals, including women of childbearing age. Diabetes can cause diabetic retinopathy (DR), which is potentially sight threatening when severe nonproliferative DR (NPDR), proliferative DR (PDR), or sight-threatening diabetic macular oedema (STDME) develops. Pregnancy is an independent risk factor for the progression of DR. Baseline DR at the onset of pregnancy is an important indicator of progression, with up to 10% of women with baseline NPDR progressing to PDR. Progression to sight-threatening DR (STDR) during pregnancy causes distress to the patient and often necessitates ocular treatment, which may have a systemic effect. Management includes prepregnancy counselling and, when possible, conventional treatment prior to pregnancy. During pregnancy, closer follow-up is required for those with a long duration of DM, poor baseline control of blood sugar and blood pressure, and worse DR, as these are risk factors for progression to STDR. Conventional treatment with anti-vascular endothelial growth factor agents for STDME can potentially lead to foetal loss. Treatment with laser photocoagulation may be preferred, and surgery under general anaesthesia should be avoided. This review provides a management plan for STDR from the perspective of practising ophthalmologists. A review of strategies for maintaining the eyesight of diabetic women with STDR with emphasis on prepregnancy counselling and planning, monitoring and safe treatment during pregnancy, and management of complications is presented.

Laser Therapy in the Treatment of Diabetic Retinopathy and Diabetic Macular Edema

PURPOSE OF REVIEW

This review highlights indications and evidence on laser therapy in the management of diabetic retinopathy and diabetic macular edema. Particular focus is placed upon the benefits and limitations of conventional laser photocoagulation versus more modern laser photocoagulation techniques, as well as the role of laser photocoagulation in treatment of diabetic retinopathy and diabetic macular edema with the frequent utilization of pharmacologic, including anti-vascular endothelial growth factor (VEGF), therapy.

RECENT FINDINGS

Laser photocoagulation remains the gold-standard therapy for the effective, definitive treatment of PDR, and also is highly effective in the management of DME. However, numerous recent studies have demonstrated the clinical efficacy and improved functional and anatomic outcomes of combination therapy with pharmacologic treatment. Continuing innovations in laser technology and improved understanding of laser-retinal interactions and pathophysiology demonstrate that laser therapy will continue to play a critical role in the treatment of diabetic retinopathy and diabetic macular edema for many years to come.

Management of Complications and Vision Loss from Proliferative Diabetic Retinopathy

PURPOSE OF REVIEW

Diabetes can be associated with profound visual loss due to several mechanisms. As the duration of diabetes and blood glucose levels increase, these changes become more severe. The proliferation of new blood vessels, vitreous hemorrhage, and tractional retinal detachments may ultimately result and can be devastating to visual function. New advances, including anti-vascular endothelial growth factor (VEGF) medications and innovative microsurgical instruments, have provided additional methods for the management of diabetic retinopathy in the clinic and in the operating room, leading to improved outcomes.

RECENT FINDINGS

Advances in earlier treatment of proliferative diabetic retinopathy, especially with anti-VEGF injections, allow for a reduction in severity, improved vision, and more controlled and successful surgery. Modern surgical techniques and instrumentation have also allowed for improved patient outcomes. Future research into sustained delivery and release of anti-VEGF, reducing the need for frequent in-office injections, may prove to be additionally beneficial. Over the last decade, anti-VEGF has become an increasingly common treatment modality for the management of proliferative diabetic retinopathy, vitreous hemorrhages, and tractional retinal detachments. Further research is needed to determine the ideal method of delivery and timing of the treatment.

Observation of retinal neovascularization using optical coherence tomography angiography after panretinal photocoagulation for proliferative diabetic retinopathy

Background

To describe the longitudinal changes in retinal neovascularization elsewhere (NVE) as observed on optical coherence tomography angiography (OCTA) in proliferative diabetic retinopathy (PDR) treated by panretinal photocoagulation (PRP).

Methods

Each patient included in this prospective clinical study was newly diagnosed with PDR and NVE confirmed by both fundus fluorescein angiography (FFA) and OCTA. They received four sessions of PRP using a multiwavelength laser. Best-corrected visual acuity (BCVA) and OCTA images of the NVE were obtained before each PRP session and at 1 month, 3 months, and 6 months after the PRP treatment. Generalized estimating equations (GEE) was used to investigate the differences between the BCVA and NVE areas before and after PRP.

Results

Thirty-two eyes of 32 patients with a mean age of 50.56 ± 7.05 years were included. We found a statistically significant reduction in the NVE area at all time points compared with the baseline except at 6 months (all P < 0.05). Further analysis demonstrated no statistically significant change in the NVE area between two adjacent timepoints except from baseline to post-1st PRP (P < 0.05). BCVA at 3 months showed a statistically significant improvement compared with baseline (P < 0.05), but no significant changes in BCVA were observed during the other visits.

Conclusions

We found an overall regression in the NVE area following PRP starting as early as 1 week after the 1st session and lasting up to 3 months. OCTA provides quantitative information on vascular changes and could be a practical method for the longitudinal evaluation of neovascularization.

Panretinal laser photocoagulation decreases large foveal avascular zone area in non-proliferative diabetic retinopathy: A prospective OCTA study

PURPOSE

To analyze the macular microvascular changes after panretinal photocoagulation (PRP) in patients with non-proliferative diabetic retinopathy (NPDR) and a large foveal avascular zone area, using optical coherence tomography angiography.

METHODS

Twenty-four eyes of 24 patients with peripheral ischemia, superficial foveal avascular zone (FAZ) area of larger than 0.350 mm², naive severe NPDR, and no clinically significant diabetic macular edema were included in this prospective study. The PRP was applied in 360-degree in a single session. The main outcome measures of the study were the difference in best-corrected visual acuity, central macular thickness, superficial and deep vascular plexus vessel densities, FAZ features, choroidal and outer retinal flow areas at the baseline versus at one and six months after PRP treatment.

RESULTS

The study group consisted of 13 men and 11 women with a mean age of 68.11 ± 6.47 years. The baseline FAZ area was higher than at one and six months after PRP (0.416 ± 0.70, 0.399 ± 0.065 and 0.407 ± 0.066 mm²; p = 0.001 and p = 0.002, respectively). At one month after PRP, deep capillary plexus vascular density in perifoveal region was statistically significantly lower than at six months after PRP and the baseline. (45.43 ± 4.27, 47.91 ± 4.26 and 49.04 ± 5.64 %; p = 0.001 and p = 0.001, respectively).

CONCLUSION

The PRP effects retinal microvascular morphology in patients with NPDR and a large FAZ area.

Panretinal photocoagulation after or prior to intravitreal conbercept injection for diabetic macular edema: a retrospective study

Background

Panretinal photocoagulation treatment (PRP) have been known as a standard treatment for proliferative diabetic retinopathy (PDR) or severe nonproliferative diabetic retinopathy (sNPDR). However, there is no consensus on when PRP should be administrated if anti-VEGF treatment is needed for the concurrent diabetic macular edema (DME). This study is to evaluate the difference between two groups of PRP prior to, or after intravitreal conbercept (IVC) for patients with PDR or sNPDR combined with DME.

Methods

This was a retrospective study. Fifty-eight eyes with DME secondary to PDR or sNPDR were divided into two groups; the PRP after (PRP-after group), or prior to (PRP-prior group), IVC. Changes in number of IVC injections, best corrected visual acuity (BCVA), and central subfield macular thickness (CSMT) were compared after 4 weeks, 12 weeks, 1 year, and 2 years from the first IVC injection.

Results

The mean number of injections in PRP-after group was 4.8 (1 year) and 6.4 (2 year), lower than 6.4 (1 year) and 8.5 (2 year) in PRP-prior group (both p = 0.002). There was no significant difference in change in BCVA and CSMT between two groups after each follow-up.

Conclusion

PRP after IVC requires less injections but also yields similar visual and anatomic outcome comparing with PRP prior to IVC in patients with diabetic retinopathy combined with DME.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-01920-8.

Retrospective study of aflibercept in combination therapy for high-risk proliferative diabetic retinopathy and diabetic maculopathy

PURPOSE

To evaluate whether anti-vascular endothelial growth factor (VEGF) therapy combined with panretinal photocoagulation could reverse diabetic retinopathy (DR).

METHOD

Fifty-two patients (72 eyes) with high-risk proliferative DR who were diagnosed and treated from June 2018 to May 2019 were divided into the laser group (16 cases, 32 eyes) and combination group (36 cases, 40 eyes) according to a review of the medical records.

RESULTS

Within-group comparison: There were no significant differences in best-corrected visual acuity (BCVA), central foveal thickness (CFT), and microaneurysms in the laser group before and after treatment, but there were statistically significant improvements in the combination group. After the treatment, the BCVA of the patients in the combination group was 0.44 ± 0.17, which was significantly better than 0.70 ± 0.18 before treatment; the CFT after treatment was 266.51 ± 33.28 μm, which was significantly lower than 382.37 ± 54.03 μm at baseline; the MA after treatment was 56.12 ± 23.29, which was significantly lower than 121.44 ± 40.35. There was a statistically significant decrease in hard exudates area in both two groups before and after treatment. Comparison between groups: The difference in BCVA, CFT, MA and between the two groups was statistically significant (all P < 0.05), and the area of retinal neovascularization between the two groups was no significant difference, but decreased more rapidly in the combination group than that in the laser group.

CONCLUSION

Using intravitreal injection of anti-VEGF drugs combined with panretinal photocoagulation to treat DR might morphologically and functionally reverse retinal changes caused by diabetes mellitus.

Photocoagulation for retinal vein occlusion

The role of photocoagulation in retinal vein occlusion (RVO) has been studied since 1974. The most serious complications of central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO) are: (i) visual deterioration, most commonly due to macular edema, and (ii) the development of ocular neovascularization (NV), particularly neovascular glaucoma (NVG), with hazardous consequences for vision and even the eye itself. Before discussing the role of photocoagulation in the management of NV and macular edema in RVO, it is crucial to gain a basic scientific understanding of the following relevant issues: classification of RVO, ocular NV in RVO, and the natural history of macular edema and visual outcome of RVO. These topics are discussed. In CRVO, ocular NV is a complication of ischemic CRVO but not of nonischemic CRVO. Photocoagulation has been advocated to prevent and/or treat the development of ocular NV and NVG. Since NVG is the most dreaded, intractable and blinding complication of ischemic CRVO, the role of photocoagulation and its management are discussed. Findings of three randomized, prospective clinical trials dealing with photocoagulation in ischemic CRVO are discussed. The role of photocoagulation in the management of ocular NV and macular edema in BRVO, and three randomized, prospective clinical trials dealing with those are discussed. Recent advent of intravitreal anti-VEGF and corticosteroid therapies has drastically changed the role of photocoagulation in the management of macular edema and NV in CRVO and BRVO. This is discussed in detail.

Comparison of efficacy of combination therapy of an Intravitreal injection of bevacizumab and photocoagulation versus Pan Retinal Photocoagulation alone in High risk Proliferative Diabetic Retinopathy

Objective:

To compare efficacy of intravitreal bevacizumab augmented with Panretinal photocoagulation versus Panretinal photocoagulation alone in high risk proliferative diabetic retinopathy.

Methods:

This is Randomized clinical control trial study conducted at ISRA University Hospital, Hyderabad from July 2018 to December 2018. A total of 76 eyes were randomized into two groups, 38 eyes undergone PRP plus intravitreal bevacizumab, while 38 eyes had PRP alone. Status of neovessels was assessed before and after treatment with the help of fundus fluorescein angiography. Neovessels at disc (NVD’s) and neovessels elsewhere (NVE’s) were assessed with the disc surface diameter.

Results:

Seventy-six eyes were enrolled in this randomized clinical trial into two groups consecutively, that all completed the six months follow-up. In the PRP group mean BCVA (logMAR) worsened significantly from mean 0.30±0.07 to mean 0.40±0.04 at a 30^th day and mean 0.40±0.04 at day 90. While BCVA become improved from 0.30±0.05 to 0.1±0.03 at week four and 0.1±0.02 at week 12 in PRP-Plus group. There was significant change in regression of NVES in PRP only group at week 4 is 2.25±0.75 (p=0.00004) and at 12 weeks 2.00±0.50 (p=0.00002), while in PRP + intravitreal bevacizumab group at 4^th week was 1±0.5 (p =0.0001) and at 12^th week was 0.75±0.25 (p=0.0001).

Conclusion:

Intravitreal Bevacizumab augmented with PRP is more effective in early regression of neovessels in high risk PDR patients.

Choroidal Detachment Following Multi-spot Double Frequency Nd-YAG Retinal Photocoagulation - A Case Report

Introduction: Panretinal photocoagulation (PRP) remains the gold standard treatment for severe non-proliferative and proliferative diabetic retinopathy (PDR), as it reduces the risk of severe visual loss by more than 50%. In the conventional single-spot laser, the procedure involves the application of moderate-intensity burns of 200-500 microns, placed one spot-size apart to achieve a total of 1200-2000 applications in 2 or 3 sessions. The more advanced retina lasers like the Pattern Scan Laser (PASCAL) and the VITRA multi-spot laser are 532 nm frequency-doubled (Nd: YAG) solid-state lasers. These modern lasers enable the application of multiple laser burns in a rapid pre-determined sequence with reduced pulse duration (10-20 ms) to facilitate the PRP to be completed in a single sitting with lesser collateral tissue damage. Case Report: Though multi-spot lasers have significantly reduced the adverse events when compared with the conventional single-spot lasers, we report a case of rare adverse events (serous choroidal detachment) following PRP with the VITRA multi-spot double frequency NdYAG (532 nm) laser. Conclusion: Most of the serious choroidal detachments following PRP are self-limiting. We recommend complete retinal evaluation post laser procedure even with modern multisport laser to look for such adverse events.

Intravitreal Aflibercept injection with Panretinal photocoagulation versus early Vitrectomy for diabetic vitreous hemorrhage: randomized clinical trial

Background

To compare efficacy and safety of intravitreal aflibercept (IVA) injection with panretinal photocoagulation (PRP) versus early vitrectomy for diabetic vitreous hemorrhage (VH).

Methods

Prospective, randomized study that included 34 eyes with diabetic VH. They were divided into two groups, Group Ι (17 eyes) received three successive IVA injections followed by PRP and group ΙΙ (17 eyes) for whom early vitrectomy was done. Follow up was carried out after one, two, three, six and nine months. The primary outcome measure was change in the mean best corrected visual acuity (BCVA) after nine months, secondary outcome measures were mean duration of clearance of VH and rate of recurrent hemorrhage with any additional treatment in both groups. Complications were reported.

Results

There was no statistically significant difference regarding initial demographic criteria between both groups. The mean final log MAR BCVA was statistically better than the initial BCVA in both groups (0.51 ± 0.20, 1.17 ± 0.48 for group I and 0.48 ± 0.18, 1.44 ± 0.44 for group II, P < 0.001). There was no statistically significant difference between both groups regarding the mean final Log Mar BCVA (0.51 ± 0.20 for group I, 0.48 ± 0.18 for group II, p ≥ 0.05), the mean duration of clearance of VH was 7.8 ± 1.8 weeks, 5 days for group I and II respectively. PRP was completely done for all eyes in group I after three months. The difference in the recurrence rate between group I (29.4%) and group II (11.8%) was statistically significant (p < 0.05). Vitrectomy was done for three eyes (17.6%) due to recurrent non-resolving VH in group I. late recurrent VH occurred in two eyes (11.8%) in group II, IVA was given with complete clearance of the hemorrhage. No vision threatening complications were reported in both groups.

Conclusion

Both intravitreal injection of aflibercept followed by PRP and early vitrectomy are effective and safe modalities for treatment of diabetic vitreous hemorrhage. Early vitrectomy leads to faster vision gain with less incidence of recurrence than intravitreal injection.

Trial registration

Randomized clinical trial under the number of NCT04153253 on November 6, 2019 “Retrospectively registered”.

19th EURETINA Congress Keynote Lecture: Diabetic Retinopathy Today

In the last decades, significant changes have been taking place regarding the pathogenesis of diabetic retinopathy (DR) and the complex mechanisms that eventually lead to the various manifestations of the disease, including diabetic macular edema (DME). DR was first considered a pure microvascular disease, due to the evident capillary structural changes (microaneurysms), fluid extravasation, and lipid exudation. With the advent of fundus fluorescein angiography, the concept of ischemia and the correlation between peripheral nonperfusion and neovascularization has been introduced, which was eventually followed by the advent of new therapeutic strategies, such as peripheral photocoagulation. Nowadays, thanks to more advanced imaging techniques, namely optical coherence tomography (OCT), OCT angiography, and wide-field imaging (imaging up to 200° of the retina in a single shot), it became clear that other elements participate in the occurrence of DR and DME, including inflammation and neurodegeneration. In the future, integration of standard investigations with new diagnostic devices would allow the prompt recognition of DR even before clinical signs of the disease are ophthalmoscopically evident, and the development of personalized treatment for both retinopathy and DME will be available.

Intravitreal ziv-aflibercept in diabetic vitreous hemorrhage

Background

To evaluate the safety and efficacy of intravitreal ziv-aflibercept (IVZ) in the management of vitreous hemorrhage (VH) in eyes with previously lasered proliferative diabetic retinopathy (PDR).

Methods

In a prospective multicenter study, previously lasered eyes who had dense VH from PDR underwent intravitreal injection of ziv-aflibercept (IVZ) (1.25 mg aflibercept). Demographic characteristics of the patients, baseline and final logMar visual acuity, number of injections, VH clearance time, and need for vitrectomy were recorded.

Results

Twenty-seven eyes of 21 patients were included in the study. Mean age of study patients was 61.3 ± 14.1 years with mean duration of diabetes mellitus of 22.6 ± 7.8 years. Mean logMAR BCVA at baseline was 1.41 ± 1.26 (Snellen equivalent 20/514) and at the last visit 0.55 ± 0.61 (Snellen equivalent 20/70) with a mean gain of 0.86 EDTRS line (paired student t test = 5.1; p ≤ 0.001). Mean number of IVZ 2.4 ± 1.6 (range 1–6). The mean follow-up time was 11.7 ± 11.1 months (range 1–34). Mean time for visual recovery and/or VH clearance was 5.7 ± 3.3 weeks. Eyes, which required multiple injections, the interval period between injections for recurrent VH was 6.4 ± 5.2 months. No subject required vitrectomy. No ocular or systemic adverse effects were noted.

Conclusions

IVZ injections had good short-term safety and efficacy for the therapy of new or recurrent VH in previously lasered eyes with PDR reducing somewhat the need for vitrectomy.

Trial registration: NCT02486484

Comparison of navigated laser and conventional single-spot laser system for induced pain during panretinal photocoagulation

To compare the panretinal photocoagulation (PRP)-induced pain response between novel navigated laser (Navilas) and conventional single-spot laser. The eyes were randomly assigned to Navilas or conventional laser. Contralateral eyes underwent PRP with the other system with 30 min resting interval. Pulse duration was 100 ms in conventional laser and 30 ms or 100 ms in Navilas and power setting was enough to create gray-white light burn on both devices. Pain response was evaluated by verbal scale (VS) (0-4) and visual analog scale (VAS) (0-10) after each PRP application. The mean age of 70 patients (140 eyes) was 62.52 ± 9.49 years. Mean power and spot numbers for Navilas and conventional laser were 291.9 ± 85.3 mW vs 368.4 ± 72.0 mW, and 375.4 ± 108.4 vs 374.2 ± 105.0 (p < 0.001 and p = 0.53, respectively). Pain scores for Navilas and conventional laser were 1.19 ± 0.73 and 1.99 ± 0.84 for VS and 2.41 ± 1.65 and 4.74 ± 2.17 for VAS (p < 0.001 and p < 0.001). More comfortable PRP is achieved with Navilas system in comparison with conventional single-spot laser system. However, small number of patients treated with same pulse duration and different contact lenses used for two systems should be taken into consideration. Besides, we did not report comparative clinical efficiency of either laser system.

Near reading speed changes after panretinal photocoagulation in diabetic retinopathy patients: a prospective study using an iPad application for the measurement of reading speed

PURPOSE

To investigate the changes in the near reading speed after panretinal photocoagulation (PRP) in diabetic retinopathy patients.

METHODS

This non-randomized, prospective, clinical study enrolled diabetic retinopathy patients who underwent PRP from January 2016 to June 2017. The near reading speed was measured before and 1 week, 1 month, and 4 months after PRP by using an iPad application for the assessment of reading speed; near best-corrected visual acuity (BCVA) and subfoveal choroidal thickness (SFCT) were also analyzed. The reading speed of age-matched healthy individuals was compared with that of diabetic retinopathy patients.

RESULTS

Forty-seven patients were enrolled in this study. The baseline near reading speed of diabetic retinopathy patients was significantly slower than that of age-matched healthy controls. The near reading speed was reduced at 1 week after PRP, but recovered at 1 and 4 months after PRP. Near BCVA showed a similar pattern after PRP. SFCT increased at 1 week after PRP and significantly decreased at both 1 and 4 months after PRP.

CONCLUSION

The near reading speed of diabetic patients was significantly slower than that of age-matched healthy controls. The speed was temporarily reduced at 1 week after PRP, potentially due to short-term impairment of parasympathetic nerve innervation.

The Diabetic Retinopathy Clinical Research Network (DRCR.net) and Its Contributions to the Treatment of Diabetic Retinopathy

Over the past two decades, the Diabetic Retinopathy Clinical Research Network (now known as the DRCR Retina Network) has contributed to multiple and substantial advances in the clinical care of diabetic eye disease. Network studies helped establish anti-vascular endothelial growth factor (VEGF) agents as an effective alternative to panretinal photocoagulation for eyes with proliferative diabetic retinopathy (PDR) and as first-line therapy for eyes with visual impairment for diabetic macular edema (DME), defined treatment algorithms for the use of intravitreal medications in these conditions, and provided critical data to understand how to better evaluate the diabetic eye using optical coherence tomography and other imaging modalities. Ongoing DRCR.net studies will address whether anti-VEGF therapy is effective at preventing vision-threatening complications in eyes with severe non-proliferative diabetic retinopathy, if photobiomodulation has a beneficial effect in eyes with DME, and whether initiation of DME treatment with bevacizumab and rescue with aflibercept can provide visual outcomes as good as those achieved with aflibercept alone. Future plans for the Network also include the expansion into non-diabetic eye disease in areas such as age-related macular degeneration.

Effects of panretinal photocoagulation on retinal vasculature and foveal avascular zone in diabetic retinopathy using optical coherence tomography angiography: A pilot study

Purpose

To evaluate the optical coherence tomography angiography (OCTA) parameters in patients with diabetic retinopathy following panretinal photocoagulation (PRP).

Methods

Eleven eyes of 6 patients with very severe nonproliferative diabetic retinopathy (NPDR) or early proliferative diabetic retinopathy (PDR) were recruited in this prospective interventional pilot study. All patients underwent OCTA imaging at baseline, and choroidal flow, foveal avascular zone (FAZ), retinal thickness, and vascular density were measured at baseline. Three months after treatment, OCTA was repeated, and the alteration in variables was analyzed.

Results

The FAZ area remained unchanged following treatment, (P = 0.75). Retinal thickness increased along (P = 0.02) with an increase in vascular density in the superficial and deep foveal area and the macular temporal sector (P = 0.007, 0.03 and 0.049, respectively). Choroidal flow surface area was unchanged (P = 0.10).

Conclusion

In this study, foveal vascular density increased and FAZ remained unchanged after PRP for diabetic retinopathy.

Bilateral methamphetamine-induced ischemic retinopathy

Purpose

To describe the multimodal imaging and treatment of a 37-year-old male presenting with bilateral ischemic retinopathy induced by methamphetamine abuse.

Observations

A 37-year-old male presented with progressively deteriorating vision and was found to have branch retinal artery occlusion and central retinal vein occlusion in both eyes along with secondary vitreous hemorrhage in the left eye following seven years of intermittent intranasal methamphetamine abuse. Fundus fluorescein angiography and optical coherence tomography angiography revealed large areas of non-perfusion in the peripheral retina along with peripapillary neovascularization. Systemic evaluation revealed ischemic foci scattered in the deep brain on magnetic resonance angiography scanning. Based on the retinal findings, the patient was diagnosed with methamphetamine-induced ischemic retinopathy. He received panretinal photocoagulation, which improved the vision in the right eye and vitreous hemorrhage in the left eye. The vision in the left eye remained stable.

Conclusions and importance

This case highlights that intranasal methamphetamine abuse is associated with bilateral simultaneous central retinal vein occlusion and branch retinal artery occlusion. To our knowledge, extensive bilateral ischemic retinopathy has not been documented previously with newer modalities. In addition, PRP may be considered for the treatment of ischemic retinopathy induced by methamphetamine abuse.

Diabetic Nephropathy in Type 2 Diabetic Retinopathy Requiring Panretinal Photocoagulation

PURPOSE

To investigate the risk factors of diabetic nephropathy in patients with diabetic retinopathy requiring panretinal photocoagulation (PRP) and the visual prognosis.

METHODS

A retrospective review of electronic medical records was conducted at Seoul St. Mary's Hospital, comprising 103 patients with type 2 diabetes mellitus and diabetic retinopathy who underwent PRP from 1996 to 2005. Patients with type 1 diabetes mellitus, non-diabetic renal disease, non-diabetic retinal disease, visually significant ocular disease, high-risk proliferative diabetic retinopathy, and advanced diabetic retinopathy were excluded. The patients were divided into three groups: no nephropathy (group 1, n = 45), microalbuminuria (group 2, n = 16), and advanced nephropathy (group 3, n = 42). Duration of diagnosis of retinopathy and nephropathy, glycosylated hemoglobin, visual acuity, complications, and treatment history were investigated.

RESULTS

The mean glycosylated hemoglobin of group 3 (8.4 ± 1.2) was higher than that of group 1 (7.7 ± 1.0) or group 2 (7.7 ± 1.0) (p = 0.04). Mean interval from PRP to diagnosis of nephropathy was 8.8 ± 6.0 years in group 2 and 8.7 ± 4.9 years in group 3. The significant decrease in visual acuity in group 3 (28 eyes, 35.9%) was significantly higher than that in group 1 (15 eyes, 18.1%, p = 0.01) or group 2 (6 eyes, 20.7%, p = 0.03). Only vitreous hemorrhage showed a significantly higher incidence in groups 2 and 3 than in group 1 (p = 0.02). Multivariate regression analysis revealed that female sex and lower glycosylated hemoglobin were significantly associated with a protective effect on development of nephropathy.

CONCLUSIONS

In the clinical setting, many patients with PRP-requiring diabetic retinopathy develop nephropathy an average of 8 to 9 years after PRP. Male sex and higher glycosylated hemoglobin could be risk factors of nephropathy.

Sickle cell retinopathy. A focused review

PURPOSE

To provide a focused review of sickle cell retinopathy in the light of recent advances in the pathogenesis, multimodal retinal imaging, management of the condition, and migration trends, which may lead to increased prevalence of the condition in the Western world.

METHODS

Non-systematic focused literature review.

RESULTS

Sickle retinopathy results from aggregation of abnormal hemoglobin in the red blood cells in the retinal microcirculation, leading to reduced deformability of the red blood cells, stagnant blood flow in the retinal precapillary arterioles, thrombosis, and ischemia. This may be precipitated by hypoxia, acidosis, and hyperosmolarity. Sickle retinopathy may result in sight threatening complications, such as paracentral middle maculopathy or sequelae of proliferative retinopathy, such as vitreous hemorrhage and retinal detachment. New imaging modalities, such as wide-field imaging and optical coherence tomography angiography, have revealed the microstructural features of sickle retinopathy, enabling earlier diagnosis. The vascular growth factor ANGPTL-4 has recently been identified as a potential mediator of progression to proliferative retinopathy and may represent a possible therapeutic target. Laser therapy should be considered for proliferative retinopathy in order to prevent visual loss; however, the evidence is not very strong. With recent development of wide-field imaging, targeted laser to ischemic retina may prove to be beneficial. Exact control of intraoperative intraocular pressure, including valved trocar vitrectomy systems, may improve the outcomes of vitreoretinal surgery for complications, such as vitreous hemorrhage and retinal detachment. Stem cell transplantation and gene therapy are potentially curative treatments, which may prevent retinopathy.

CONCLUSIONS

There is lack of evidence regarding the optimal management of sickle retinopathy. Further study is needed to determine if recent progress in the understanding of the pathophysiology and diagnosis of sickle retinopathy may translate into improved management and outcome.

PASCAL laser platform produces less pain responses compared to conventional laser system during the panretinal photocoagulation: a randomized clinical trial

Background

Most of patients experience pain during the panretinal photocoagulation(PRP). Laser photocoagulation delivery has advanced with the introduction of pattern-scanning laser systems (PASCAL). Shorter pulse duration and less choroidal penetration believed to reduce pain during the laser treatment.

Objectives

To compare the severity of expressed pain scores in patients with PDR who underwent PRP either with PASCAL laser or conventional laser.

Methods

A total of 28 patients with a diagnosis of PDR who were scheduled for bilateral PRP therapy were enrolled into the prospective study. Both eyes were treated within the same session and while one eye was treated with PASCAL the other was treated with conventional laser randomly. Pulse duration was adjusted to 100-ms in conventional laser and 30 ms in PASCAL. The severity of pain was graded using a verbal scale and a visual analog scale (VAS).

Results

Mean age was 61.36±9.10 years. Mean verbal and VAS scores were 1.32±0.47 and 2.86±1.21 in the PASCAL laser and 2.39±0.49 and 5.75±1.35 in the conventional laser group, respectively. Differences between expressed pain scores obtained by both two scales were statistically significant (p<0.001).

Conclusion

PASCAL laser significantly alleviates pain levels possibly due to the shorter laser pulse duration and lower intensity.

Comparison of 577-nm Multispot and Standard Single-Spot Photocoagulation for Diabetic Retinopathy

OBJECTIVE

To compare two different laser strategies of panretinal photocoagulation for diabetic retinopathy.

METHODS

Single-center, randomized study including 41 eyes treated with 577-nm multispot laser with a 20-ms pulse duration (group 1) or a 532-nm single-spot laser with a 100-ms pulse duration (group 2). The outcomes included best-corrected visual acuity (BCVA) and imaging changes at baseline, 6 and 12 months, laser parameters, and results of subjective pain analysis.

RESULTS

At 12 months, the treatments did not differ significantly in BCVA, central retinal thicknesses (CRTs), improved macular edema, vitreomacular interface changes, patient-reported pain scores, or angiographic responses. Group 1 had significantly fewer treatment sessions but used more laser spots (p < 0.001).

CONCLUSION

The multispot laser required fewer applications with more spots delivered to compensate for lower fluency, showing similar patient tolerance to single-spot laser. Both groups maintained the initial visual acuities and CRTs; about 50% of cases had vitreomacular interface changes and improved macular edema, with similar angiographic improvements after 12 months.

Progression of diabetic retinopathy severity after treatment with dexamethasone implant: a 24-month cohort study the 'DR-Pro-DEX Study'

PURPOSE

Intravitreal anti-vascular endothelial growth factor agents have been shown to reduce diabetic retinopathy (DR) progression; data on the effects of intravitreal corticosteroids on modifying disease severity are limited. This study evaluates the long-term effect of intravitreal dexamethasone implant (DEX) on the severity and progression of non-proliferative DR (NPDR).

METHODS

This was a retrospective cohort study. Sixty eyes from 60 consecutive patients with NPDR and diabetic macular edema (DME) treated with dexamethasone implant (DEX group) and 49 eyes from consecutive 49 patients without DME requiring observation only. Fundus angiography images from baseline and after 24 months were graded by two masked assessors into mild, moderate and severe NPDR and PDR, according to the ETDRS classification. Patients were followed up 1-3 and 4-6 months after each DEX implant. Re-treatment with DEX implant was on a pro re nata basis. Records were reviewed for performance of panretinal photocoagulation. Main outcome was as follows: change of DR ≥ 1 grade and progression to proliferative diabetic retinopathy (PDR).

RESULTS

Three eyes (5%) in the DEX group and 43 (87.8%) eyes in the control group progressed to PDR (P < 0.0001). Twenty-five eyes (41.7%) in the DEX group but none in the control group demonstrated an improvement in DR severity (P < 0.0001).

CONCLUSION

This study provides the first long-term evidence that DEX implant has the potential to not only delay progression of DR and PDR development, but may also improve DR severity over 24 months. Better understanding of the effects of corticosteroids will help guide its use in the treatment pathway of DR.

Serous retinal detachment after panretinal photocoagulation for proliferative diabetic retinopathy: a case report

BACKGROUND

Proliferative diabetic retinopathy is a major cause of visual impairment in working-age adults worldwide. Panretinal photocoagulation is a cornerstone in its management; however, it may include a range of side effects and complications, one of these being serous retinal detachment. To the best of our knowledge, this is the first report of the use of intravitreal injection of bevacizumab for serous retinal detachment after panretinal photocoagulation.

CASE PRESENTATION

A 24-year-old Saudi man with poorly controlled type 1 diabetes presented with bilateral progressive proliferative retinopathy in spite of several sessions of panretinal photocoagulation. After one additional such session, he developed bilateral serous retinal detachment and vision loss, which was managed with a single bilateral intravitreal bevacizumab injection. The serous retinal detachment subsided with partial recovery of vision.

CONCLUSIONS

Serous retinal detachment after panretinal photocoagulation for proliferative diabetic retinopathy is a rare complication nowadays. In this case, it seems that excessive photocoagulation exceeded the energy-absorbing capacity of the retinal pigment epithelium, leading to a disruption of the blood-retinal barrier. A single injection of bilateral intravitreal bevacizumab was sufficient to control the serous retinal detachment. This effect may have been due to a reduction of vascular leakage resulting from the mechanism of action of this drug. No complications were noted from the injection. Caution should be exerted when attempting bilateral panretinal photocoagulation.

Intraocular Inflammation in Diabetic Populations

PURPOSE OF REVIEW

The purpose of this review is to determine the prevalence of uveitis in the diabetic population, the clinical features of the uveitis and diabetes when coexisting and pathophysiology of a possible correlation. We also aim to review the cases of diabetes and uveitis in the literature.

RECENT FINDINGS

The basis of an association between uveitis and diabetes mellitus (DM) is the common pathophysiology of inflammation. There are several reports on a DM-related uveitis, defined as idiopathic anterior uveitis in the presence of poorly controlled DM, but causation has not been established. There are conflicting results in the literature regarding an association between uveitis and DM. More studies are needed to determine if an association truly exists.

Changes in choroidal thickness in patients with diabetic retinopathy

PURPOSE

To investigate the changes in choroidal thickness (ChT) following panretinal photocoagulation (PRP) for diabetic retinopathy (DR) and compare ChT in relation to DR severity.

METHODS

Thirty-two eyes [19 eyes with proliferative DR (PDR) and 13 eyes with severe nonproliferative DR (NPDR)] for which PRP was necessary were analyzed. ChT was measured before PRP and at 1, 3, and 6 months after PRP using the swept-source optical coherence tomography. ChT of the 61 eyes matched with the PDR patients for the mean age and axial length was also measured and statistically compared in relation to severity.

RESULTS

The central field ChT before PRP treatment was 268.6 ± 104.5 µm (mean ± standard deviation) and was significantly decreased at 1, 3, and 6 months after PRP (254.5 ± 105.3, 254.2 ± 108.2, and 248.1 ± 101.8 µm, respectively, P < 0.0001). The central field ChT of severe NPDR (323.2 ± 61.3 µm) was significantly thicker than that of normal (248.3 ± 70.7 µm) and mild to moderate NPDR (230.0 ± 70.3 µm, P = 0.0455 and 0.0099, respectively). Moreover, the central field ChT of PDR (307.3 ± 84.1 µm) was significantly thicker than of mild to moderate NPDR (P = 0.0169).

CONCLUSION

ChT significantly decreased after PRP, which continued for at least 6 months after treatment. ChT of severe NPDR and PDR was significantly thicker than that of mild to moderate NPDR. ChT of patients with DR was changed according to the treatment and severity of DR.

Extended targeted retinal photocoagulation versus conventional pan-retinal photocoagulation for proliferative diabetic retinopathy in a randomized clinical trial

PURPOSE

To determine the clinical efficacy of extended targeted retinal photocoagulation (ETRP) compared to conventional panretinal photocoagulation (CPRP) in proliferative diabetic retinopathy (PDR).

METHODS

In a single-masked randomized clinical trial, 270 eyes of 234 patients with naïve early or high-risk PDR were randomly assigned to receive either CPRP or ETRP (135 eyes, each treatment arm). Best-corrected visual acuity (BCVA) measurement, fundus examination, wide-field fluorescein angiography (WFFA) and optical coherence tomography were carried out before and 3 months after retinal photocoagulation. Primary outcome was early PDR regression, specified as reduction in retinal neovascularization based on WFFA at 3 months. Secondary outcomes were BCVA and central macular thickness (CMT) changes.

RESULTS

There were significantly more high-risk PDR eyes in ETRP group compared to CPRP (109 and 94 eyes, respectively, P = 0.04). Early PDR regression occurred in 71.9 and 64.4% of eyes in the ETRP and CPRP groups, respectively (P = 0.19). The mean number of applied laser spots in the ETRP was significantly fewer than CPRP (1202 vs. 1360, respectively, P < 0.001). Mean BCVA at baseline and 3 months post-laser were 0.37 ± 0.26 and 0.47 ± 0.19 logMAR in the ETRP arm, respectively. In the CPRP arm these values were 0.40 ± 0.27 and 0.47 ± 0.24 logMAR, respectively. Although mean BCVA decreased significantly in both treatment arms (ETRP P < 0.001, CPRP P = 0.009), the difference was not significant between arms (P = 0.68). CMT increased significantly in both groups (ETRP 41.08 μm, P < 0.001, CPRP 33.31 μm, P < 0.001). Nevertheless, the difference between the groups was not significant (P = 0.26).

CONCLUSIONS

ETRP with fewer number of laser spots may be an appropriate alternative to CPRP in PDR regression at least through 3 months.

CLINICAL TRIAL

GOV REGISTRATION NUMBER

NCT01232179.

Treatment of diabetic retinopathy: Recent advances and unresolved challenges

Diabetic retinopathy (DR) is the leading cause of blindness in industrialized countries. Remarkable advances in the diagnosis and treatment of DR have been made during the past 30 years, but several important management questions and treatment deficiencies remain unanswered. The global diabetes epidemic threatens to overwhelm resources and increase the incidence of blindness, necessitating the development of innovative programs to diagnose and treat patients. The introduction and rapid adoption of intravitreal pharmacologic agents, particularly drugs that block the actions of vascular endothelial growth factor (VEGF) and corticosteroids, have changed the goal of DR treatment from stabilization of vision to improvement. Anti-VEGF injections improve visual acuity in patients with diabetic macular edema (DME) from 8-12 letters and improvements with corticosteroids are only slightly less. Unfortunately, a third of patients have an incomplete response to anti-VEGF therapy, but the best second-line therapy remains unknown. Current first-line therapy requires monthly visits and injections; longer acting therapies are needed to free up healthcare resources and improve patient compliance. VEGF suppression may be as effective as panretinal photocoagulation (PRP) for proliferative diabetic retinopathy, but more studies are needed before PRP is abandoned. For over 30 years laser was the mainstay for the treatment of DME, but recent studies question its role in the pharmacologic era. Aggressive treatment improves vision in most patients, but many still do not achieve reading and driving vision. New drugs are needed to add to gains achieved with available therapies.

Metamizole versus placebo for panretinal photocoagulation pain control: a prospective double-masked randomized controlled study

BACKGROUND

Diabetic retinopathy is one of most common and threatening ocular diseases. Many of these patients need to be submitted to panretinal photocoagulation (PRP), experiencing a significant level of pain. The purpose of this study is to evaluate the effectiveness of oral metamizole in reducing pain during PRP in patients with proliferative diabetic retinopathy (PDR) and very severe non-proliferative diabetic retinopathy (VSNDR).

METHODS

Patients from a single center with PDR or VSNDR and indication of bilateral PRP were recruited for a double-masked, controlled, prospective study. The treated eyes were randomly assigned in two groups, and each patient had one eye assigned per group. Group A received 1000 mg of metamizole and group B received a placebo pill 40 min before the laser treatment. The groups were switched for the treatment of the fellow eye. Each patient scored the pain sensation immediately after each PRP section using Scott's visual analogue scale (VAS). The paired Student t test was used to measure the significance between the two groups VAS scores, with significance level adopted of p < 0.05.

RESULTS

Twenty-one patients were recruited. The level of pain was significantly lower when submitted to PRP after oral metamizole treatment compared to placebo (p = 0.002). The mean pain scores for groups A and B were 4.72 ± 1.708 and 5.89 ± 1.967, respectively. The minimum/maximum scores within groups A and B were 1/8 and 1/10, respectively.

CONCLUSIONS

The use of 1000 mg of metamizole 40 min before PRP significantly reduces the pain associated with the procedure in patients with PDR or VSNDR.

Severe ischemic retinopathy in a patient with systemic lupus erythematosus without antiphospholipid syndrome: A case report

Systemic lupus erythematosus (SLE) is a chronic, autoimmune, multisystem disease which may affect the eyes and/or visual system in up to a third of patients. Severe retinal vaso-occlusive diseases have been rarely reported as manifestation in patients with SLE. We report the case of a 35-year-old female treated for systemic lupus erythematosus for 6 months, presented a sudden loss of vision. Fundus examination and fluorescein angiography revealed severe retinal vascular occlusion. This has motivated the search for antiphospholipid antibody syndrome and this was confirmed without the presence of anticardiolipin antibodies. And the treatment consisted in a laser therapy. The purpose of this case report is to demonstrate that an ocular vascular event can reveal the disease and that its diagnosis is important because this disease generally affects young people and may endanger ocular and vital prognosis.

Bilateral Hypertensive Retinopathy Complicated with Retinal Neovascularization: Panretinal Photocoagulation or Intravitreal Anti-VEGF Treatment?

PURPOSE

To present the case of a patient with bilateral hypertensive retinopathy complicated with retinal neovascularization who received anti-VEGF intravitreal injection in one eye and panretinal photocoagulation (PRP) in the fellow eye.

METHODS

A 33-year-old male patient presented with gradual visual loss in both eyes for the last 5 months. At that time, he was examined by an ophthalmologist and occlusive retinopathy due to malignant systematic hypertension was diagnosed. He was put on antihypertensive treatment but no ophthalmic treatment was undertaken. At presentation, 5 months later, best-corrected visual acuity (BCVA) was 0.1 in the right eye (RE) and 0.9 in the left eye (LE). Fundus examination was compatible with hypertensive retinopathy complicated with retinal neovascularization. Fluorescein angiography (FFA) revealed macular ischemia mainly in the RE and large areas of peripheral retinal ischemia and neovascularization with vascular leakage in both eyes. The patient was treated with two anti-VEGF (ranibizumab) injections with 2 months interval in the RE and PRP laser in the LE.

RESULTS

Follow-up examination after 12 months showed mild improvement in BCVA, and FFA documented regression of retinal neovascularization in both eyes.

CONCLUSION

Hypertensive retinopathy can be rarely complicated with retinal neovascularization. Treatment with PRP can be undertaken. In our case, the use of an intravitreal anti-VEGF agent seemed to halt its progression satisfactorily.

INITIAL EXPERIENCE WITH TRANSPUPILLARY DIODE LASER PHOTOCOAGULATION FOR RETINAL DISEASES

BACKGROUND

Lasers are an invaluable treatment modality for the management of some retinovascular diseases. One of these lasers is the diode laser which is easy to procure and maintain.

AIM

To review the outcomes of diode laser photocoagulation in patients with a variety of retinal conditions.

PATIENTS & METHODS

A retrospective case series of all patients who had retinal laser photocoagulation between July 2012 and June 2014 with the semiconductor infrared diode laser was performed. Demographic and clinical data collected included age, sex, eye involved, visual acuity, diagnosis, associated systemic and ocular diseases, intra and post treatment findings, laser treatment parameters and follow up.

RESULTS

A total of 22 eyes of 15 patients had diode laser treatment during the period under review comprising 8(53.3%) males and 7(46.7%) females with a mean age at presentation of 53.4±8.9 years. The indications for treatment were proliferative diabetic retinopathy in 18(81.8%) eyes of 11 patients, retinal vein occlusion in 2(9.1%) eyes of 2 patients and retinal breaks with lattice in 2(9.1%) eyes of 2 patients with fellow eye retinal detachment. Visual acuity in eyes with diabetic retinopathy improved in 9(50%) eyes, worsened in 3(16.7%) eyes and was unchanged/ stable in 6(33.3%) eyes. Regression of neovascularization was achieved in 2(100%) eyes with retinal vein occlusion. The retina of the 2(100%) eyes with breaks following retinopexy remained attached during the follow up period. The follow up period ranged from 2 days to 2 years with a mean duration of 13.5±15.8 months.

CONCLUSION

The diode laser is an effective and beneficial treatment modality in the management of proliferative retinopathies and some retinal diseases.

Analgesic effects of tramadol during panretinal photocoagulation

Purpose

To evaluate the effectiveness of tramadol for the reduction of pain in panretinal photocoagulation (PRP).

Methods

A double-masked randomized controlled study was performed. Fifty-eight eyes in 29 patients with proliferative diabetic retinopathy were enrolled. The eyes of the patients were randomized into two groups. Group A received an empty capsule. Group B received an oral intake of 100 mg tramadol. The capsule used in Group A had the same appearance as that used in Group B. Pain during PRP was assessed using a visual analog scale. Vital signs, including blood pressure and heart rate, were measured.

Results

The mean pain scores for groups A and B were 4.80±2.10 and 3.83±1.82 (p=0.09). There were no significant differences in the mean pain scores between the two groups. More patients in group A complained of greater pain than moderate intensity (visual analogue scale=4). Systemic blood pressure increased significantly in group A after laser treatment. However, there were no significant differences in the diastolic blood pressure changes between the two groups. We found no statistical correlation in the heart rate changes.

Conclusions

We failed to prove that tramadol is effective for pain relief because of the small sample size. However, tramadol was effective for the relief of more severe pain. It was also found to stabilize vital sign changes, such as systolic blood pressure during PRP.

Effects of an intravitreal bevacizumab injection combined with panretinal photocoagulation on high-risk proliferative diabetic retinopathy

Purpose

To investigate the short-term effects of panretinal photocoagulation (PRP) combined with an intravitreal injection of Avastin® (bevacizumab) as an adjuvant to high-risk proliferative diabetic retinopathy (PDR).

Methods

The data was collected retrospectively from the eyes of high-risk PDR patients, which were divided into two groups. One eye was treated with only PRP (PRP only group) and the fellow eye of same patient was treated with both PRP and intravitreal bevacizumab injection (Adjuvant group). Best corrected visual acuity (BCVA), IOP (intraocular pressure), and new vessel (NV) size in fluorescein angiography were recorded immediately and at the six-week follow-up visit. Adverse events associated with intravitreal injection were investigated.

Results

Of 12 patients with high-risk PDR, five were male and seven were female. There were no statistically significant BCVA or IOP changes after treatment in either group (p=0.916, 0.888). The reduction of NV size was found in both groups, but NV size in the adjuvant group showed a greater decrease than that of the PRP only group (p=0.038). Three patients had adverse events after intravitreal injection. Two patients had mild anterior uveitis and one patient had a serious complication of branched retinal artery obstruction (BRAO).

Conclusions

Intravitreal bevacizumab injection with PRP resulted in marked regression of neovascularization compared with PRP alone. One serious side effect, BRAO, was noted in this study. Further studies are needed to determine the effect of repeated intravitreal bevacizumab injections and the proper number of bevacizumab injections as an adjuvant.

Intravitreal bevacizumab for the treatment of neovascular glaucoma associated with central retinal artery occlusion

We report three cases of neovascular glaucoma secondary to central retinal artery occlusion (CRAO) which were effectively managed with intravitreal bevacizumab (IVB) followed by panretinal photocoagulation (PRP). Neovascular glaucoma without peripheral anterior synechiae developed between one and five weeks following CRAO onset. All patients received 0.75 mg (0.03 ml) IVB. In all patients, complete regression of the iris and anterior chamber angle neovascularization was confirmed within one week. PRP was applied two weeks after the injection. The follow-up period was four to seven months (average, five months). Intraocular pressure was controlled in all patients using topical antiglaucoma medications alone. However, one patient experienced a recurrence of neovascularization three months after the initial combination treatment. This patient received another IVB injection and additional PRP, and the recurrent neovascularization resolved. There were no local or systemic adverse events in any patients. Therefore, intravitreal bevacizumab may be an effective adjunct in the treatment of neovascular glaucoma associated with CRAO.

Peripapillary retinal nerve fiber layer thickness change after panretinal photocoagulation in patients with diabetic retinopathy

Purpose

To examine the effect of panretinal photocoagulation (PRP) on the retinal nerve fiber layer (RNFL) thickness in patients with diabetic retinopathy.

Methods

Subjects included 118 eyes for a treatment group and 164 eyes for a control group. The peripapillary RNFL thickness was measured before and 6 months after PRP in treatment group. In control group, the peripapillary RNFL thickness was measured at baseline and 6 months later. The relationships between changes in RNFL thickness and the number of laser burns, duration of diabetes, HbA1c level, and vision change were analyzed.

Results

After 6 months, the RNFL thickness decreased an average of 2.12 µm and 0.93 µm in the treatment and control groups. However, the changes between the two groups were not statistically significant. The relationship between the number of laser burns and changes in RNFL thickness was not significant. No differences were found between changes in the RNFL thickness and the duration of diabetes in either group. However, in the treatment group a higher HbA1c level was correlated with a greater decrease in post-PRP RNFL thickness. This relationship was not observed in the control group. The difference in the change of the RNFL thickness between the two groups was statistically significant. Vision increased an average of 0.02 and 0.01 after 6 months in the treatment and control groups, respectively. However, this difference was not statistically significant.

Conclusions

Although a decrease in peripapillary RNFL thickness was observed in the treatment group after 6 months, it was not statistically significant compared to control group. However, the decrease was greater when the blood HbA1c level was higher.