Initial Experience with Intravitreal Faricimab for Retinal Diseases at the University College Hospital, Ibadan

The use of intravitreal corticosteroids in the management of macular oedema has recently gained widespread acceptance. New long-acting steroid preparations and methods of delivery have facilitated the use of these new modalities. This review describes the various types of macular oedema for which this therapeutic option is used and the results.

Intravitreal triamcinolone injection for macular edema secondary to increased retinal vascular permeability.

To investigate the effectiveness of repeated injections of intravitreal triamcinolone acetonide (IVTA) in the treatment of macular oedema caused by central retinal vein occlusion (CRVO). Seventeen pseudophakic or aphakic eyes of 17 patients (10 male, seven female) with macular oedema caused by CRVO received a repeat injection of 4 mg IVTA, 16 weeks after the first injection of the same dose. The examination included measurements of best-corrected visual acuity (BCVA) for distance and central foveal thickness (CFT) by optical coherence tomography (OCT), preoperatively and 1, 2, 3 and 4 months postoperatively. The values were compared by paired-t test. Side-effects were monitored. BCVA and CFT were not significantly different before initial and repeat injections. Transient improvements of BCVA and CFT were achieved after both injections. At the end of follow-up, BCVA and CFT were significantly different compared to pre-injection values in the same group (P = 0.032, 0.049 in the initial-injection group and P = 0.001, 0.008 in the repeat-injection group, respectively). However, compared to the initial injection, BCVA measurements were significantly worse at each time-point (P = 0.043, 0.011, 0.010 and 0.012, respectively) after the repeat injection, as were CFT at 1, 2 and 3 months post-injection (P = 0.040, 0.015 and 0.025, respectively). The achieved maximum mean intraocular pressures were 20.00 [standard deviation (SD) 2.06] mmHg and 18.56 (SD 3.65) mmHg after the first and repeat injections, respectively. These values were not significantly different (P = 0.467). No other significant adverse events were noted during the study. A repeat injection of 4 mg IVTA may not be as effective as an initial injection for the treatment of macular oedema caused by CRVO.

To assess the efficacy, duration of effect and safety of one intravitreal injection of bevacizumab in diabetic macular oedema (DMO). Bevacizumab (1 mg/0.04 ml) was injected intravitreally into eyes with DMO (29 with and nine without previous treatments). Best corrected visual acuity (BCVA), intraocular pressure and central retinal thickness (CRT) were measured; slit-lamp examination, macular biomicroscopy, optical coherence tomography and fluorescein angiography were performed before and at 2-4, 8 and 12 weeks post-injection. Best corrected VA and CRT were analysed in both groups. In the non-pretreated group, mean BCVA improved from 0.76 +/- 0.33 (baseline) to 0.57 +/- 0.30 and 0.54 +/- 0.27 at 2-4 weeks and 8 weeks post-injection, respectively (p = 0.02, p = 0.014, paired t-test). Mean CRT decreased from 632.4 +/- 196.0 microm (baseline) to 392.3 +/- 113.6 microm and 370.4 +/- 141.7 microm at the same time-points, respectively (p = 0.01, p = 0.01). There was no difference in BCVA or CRT at 12 weeks. In the pretreated group, mean BCVA improved from 0.62 +/- 0.30 (baseline) to 0.53 +/- 0.33 at 2-4 weeks post-injection (p = 0.01), and mean CRT decreased from 583.9 +/- 180.7 microm (baseline) to 404.1 +/- 197.9 microm at 2-4 weeks post-injection (p < 0.001). Mean BCVA was unchanged at 8 weeks and 12 weeks post-injection, although mean CRT remained lower at 8 weeks (p = 0.004). No ocular or systemic side-effects developed during follow-up. One intravitreal injection of bevacizumab for DMO seems to be effective and safe in both eyes that have been treated previously and eyes that have not. The therapeutic effect is temporary and repeat treatment may be needed.

Intravitreal triamcinolone acetonide (IVTA) has increasingly been applied as treatment for various intraocular neovascular and oedematous diseases. Comparing the various diseases with respect to effect and side-effects of the treatment, the best response in terms of gain in visual acuity (VA) has been achieved for intraretinal oedematous diseases such as diffuse diabetic macular oedema, branch retinal vein occlusion, central retinal vein occlusion and pseudophakic cystoid macular oedema. In eyes with various types of non-infectious uveitis, including acute or chronic sympathetic ophthalmia and Adamantiadis-Behcet's disease, VA increased and the degree of intraocular inflammation decreased. Some studies have suggested that intravitreal triamcinolone may be useful as angiostatic therapy in eyes with iris neovascularization and proliferative ischaemic retinopathies. Intravitreal triamcinolone may possibly be helpful as adjunct therapy for exudative age-related macular degeneration (AMD), particularly in combination with photodynamic therapy. In eyes with chronic, therapy-resistant ocular hypotony, intravitreal triamcinolone can induce an increase in intraocular pressure (IOP) and may stabilize the eye. The complications of intravitreal triamcinolone therapy include: secondary ocular hypertension in about 40% of the eyes injected; medically uncontrollable high IOP leading to antiglaucomatous surgery in about 1-2% of the eyes; posterior subcapsular cataract and nuclear cataract leading to cataract surgery in about 15-20% of elderly patients within 1 year of injection; postoperative infectious endophthalmitis occurring at a rate of about one per 1000; non-infectious endophthalmitis, perhaps due to a reaction to the solvent agent, and pseudo-endophthalmitis with triamcinolone acetonide crystals appearing in the anterior chamber. Intravitreal triamcinolone injection can be combined with other intraocular surgeries, including cataract surgery, particularly in eyes with iris neovascularization. Cataract surgery performed some months after the injection does not show a markedly elevated complication rate. The injection may be repeated if the resultant benefits decrease after the initial IVTA injection. In non-vitrectomized eyes, the duration of the effect and side-effects of a single intravitreal injection of triamcinolone is about 6-9 months for a dosage of about 20 mg, and about 2-4 months for a dosage of 4 mg. So far, it has remained unclear whether the solvent agent should be removed, and if so, how.

To describe two cases of strictly unilateral diabetic retinopathy with macular edema where the precipitating factor appears to have been retinal venous congestion. Retrospective interventional case study. Examination of fundus photographic records demonstrated generalized venous dilation in the affected eyes years in advance of the development of unilateral diabetic macular edema. Relentless progression of edema and visual loss followed despite retinal photocoagulation treatment and ultimately the affected eyes in both patients developed central retinal vein occlusion. The fellow eyes in both patients remained without retinopathy throughout the period of observation. The sequential and strictly unilateral appearance of retinal venous dilation, diabetic macular edema, and central retinal vein occlusion in diabetic patients without fellow-eye retinopathy suggests that venous congestion induced the progression from hyperglycemic insult to vascular injury in the affected eyes. Presumably, diabetes may cause retinal vascular dysfunction that results in little or no vascular damage unless venous congestion is present. This supports that venous congestion and increased sensitivity to congestion are important components of the pathogenesis of diabetic macular edema.

Section I -General Concepts in the pathogenesis of retinal vascular disease: Anatomy of the retinal vasculature. - General concepts in angiogenesis and vasculogenesis. - Cellular interaction in vascular remodeling. - Hematopoietic stem cells in vascular development. - Retinal vascular development.- Retinal vascular leakage. - Inflammation as a stimulus for vascular leakage and proliferation. - Hypoxia and hypoxic signaling in retinal disease. - Genetic approach to retinal vascular disease: the role of vHL. - Retinal blood flow. - Section II - General concepts in the diagnosis and treatment of retinal vascular disease: Angiography. - Optical coherence tomography in the diagnosis of retinal vascular disease. - General concepts in laser treatment for retinal vascular disease. - The role of photodynamic therapy in retinal vascular disease. - Cryopexy. - Vitrectomy in retinal vascular disease. - Pharmacological approaches to retinal vascular disease. - Section III. Pathology, clinical course and treatment of retinal vascular diseases: Non - proliferative diabetic retinopathy.- Proliferative diabetic retinopathy. - Diabetic macular edema. - Hypertensive retinopathy. - Dissiminated intravascular coagulopathy. - Radiation retinopathy. - Central retinal vein occlusion. - Retinal branch vein occlusion. - Arterial obstructions. - Ocular ischemic syndrome. - Retinopathy of prematurity. - Sickle cell retinopathy and hemoglobinopathy. - Vascular abnormalities: Parafoveal teleangiectasi . - Miliary aneurysms. - Macroaneurisms of the retina. - Angiomatosis retinae. - Coats disease. - Familiar exsudative vitreoretinopathy (FEVR). -Inflammatory vascular disease: Morbus Eales. - Rheumatic disorders associated with vasulitis. - Immunosuppression in ocular Sarcoidosis. - Retinal vascular tumours. - Capillary hemangioma. - Racemous hemangioma. - Cavernous hemangioma. - Section IV: Clinical decision making and differential diagnosis: Red dots. - Vitreous bleeding. -Tractional detachment.

To define serous macular detachment in patients with diabetic cystoid macular oedema (CME). This study involved 78 eyes of 58 patients with diabetic CME. The patients underwent complete ophthalmic examination, fluorescein angiography and optical coherence tomography (OCT). Eyes with epiretinal membrane or vitreo-macular traction were not included in the study. Optical coherence tomography-3 was used in all patients and fundi were scanned on the horizontal, vertical and four oblique planes through the centre of the fovea. In all cases the increased thickness of the retina was related primarily to the hyporeflective intraretinal cavities. With OCT, 24 of 78 eyes (31%) had serous macular detachment as shown by retinal elevation over a non-reflective cavity with minimal shadowing of the underlying tissues. Fluorescein angiography did not show serous macular detachment in any patient. Our data showed that the incidence of serous macular detachment in diabetic CME was much higher than previously reported. Optical coherence tomography-3 allows an in vivo cross-sectional observation of very subtle serous macular detachment that is difficult to diagnose at the slit-lamp or by fluorescein angiography in patients with diabetic CME.

Diabetic macular edema (DME) is a leading cause of vision loss in diabetic people. DME can be treated with various medications, including intravitreal injections, laser therapy, and surgery. Early detection and treatment of DME is essential to prevent vision loss. The study aimed to describe patients' demographic and clinical characteristics with DME, optical coherence tomography (OCT) findings, and visual acuity outcomes. A retrospective study reviewed case records of patients with DME between 2017 and 2020. Demographic data, clinical characteristics, and examination results were extracted and analyzed using Microsoft Excel (2013). All patients clinically diagnosed with DME underwent assessment by OCT examination. DME was classified based on OCT findings. Statistical significance was observed at P < 0.05. This retrospective study included 213 eyes of 134 patients, of which 77.6% were male and 22.4% were female. Nonproliferative diabetic retinopathy (NPDR) was present in 51.64% of eyes, and PDR was present in 48.36%. Focal, diffuse, and cystoid macular edema was observed in 68, 31, and 65 eyes, respectively. Tractional macular edema was seen in 16 eyes with posterior hyaloid traction, 13 with epiretinal membrane (ERM), and one with both conditions. DME associated with subretinal fluid (SRF) detachment was seen in 8.92% of eyes. The mean (standard deviation) central retinal thickness was 284.5 (28.9), 434.0 (97.5), 426.5 (27.5), 510.5 (14.1), and 465.5 (280.7) μm in focal, diffuse, cystoid, ERM, and SRF, respectively. Increased central retinal thickness was associated with decreased visual acuity (P < 0.05). The findings of this study suggest that DME is a common and visually significant complication of diabetes. The OCT findings can be used to classify DME into different subtypes, which may help to guide treatment decisions. Focal edema was the most common type of DME with the least central retinal thickness. In NPDR, focal macular edema was the most common; in PDR, cystoid edema was the most common. Cystoid edema was the most common type in the subgroup of patients with recurrent DME following anti-vascular endothelial growth factor injection.

Objective To observe the comparison of the therapeutic efficacy of intravitreal of triamcinolone acetonide (TA) for macular edema caused by retinal vein occlusion (RVO) and diabetic retinopathy (DR). Methods TA was injected inttravitreally in 91 eyes of 91 patients with macular edema secondary to RVO and 73 eyes of 67 patients secondary to DR determined by indirect ophthalmoscope, fundus fluorescent angiography (FFA) and optic coherence tomography (OCT). Among the RVO patients, CRVO were 55 eyes (ischemic type was 11 eyes, and 42 eyes were non-ischemic type). BRVO were 36 eyes (ischemic type was 10 eyes, and 26 eyes were non-ischemic type). Among the DR patients, pre-proliferative diabetic retinopathy (PPDR) were 17 eyes and proliferative diabetic retinopathy (PDR) were 56 eyes. The visual acuity, fundus findings, FFA and the macular thickness under the OCT were recorded and analyzed prior to operation and after operation. Follow-up time was 3 months to 1 years. Results In the group of RVO, visual acuity was improved at the end of follow-up in 48 (52.7%) eyes and decreased or unchanged in 4 (4.40%) eyes and 39 (42.9%) eyes, respectively. 50 (54.9%) eyes showed normal macular thickness after injection of TA on OCT. Improved fundus appearance was seen in 27 (29.7%) eyes on OCT. The fundus was unchanged or even worse in 14 (15.4%) eyes on OCT at the last visit. In the group of DR, visual acuity was improved at the end of follow-up in 25 (34.2%) eyes and decreased or unchanged in 3 (4.11%) eyes and 45 (61.6%) eyes, respectively. 24 (32.9%) eyes showed normal macular thickness after injection of TA on OCT. Improved fundus appearance was seen in 22 (30.1%) eyes on OCT. The fundus was unchanged or even worse in 27 (37.0%) eyes on OCT at the last visit. The difference of two groups was significant. In the group of RVO, intraocular pressure was elevated in 24 eyes. Cataract was in 1 eye and endophthalmitis in 1 eye. 8 eyes were injected two times. In the group of DR, intraocular pressure was elevated in 14 eyes. Cataract was in 2 eyes. 9 eyes were injected two times. Conclusions Intravitreal injection of TA is a safe and effective method to the treatment of macular edema secondary to RVO and DR. The therapeutic efficacy for RVO is better than for DR. Key words: Triamcinolone acetonide; Retinal vein occlusion; Diabetic retinopathy; Macular edema; Optic coherence tomography

&amp;lt;p&amp;gt;Introduction. Intravitreal injection of anti-vascular endothelial growth factor (VEGF) agents has revolutionized the management of age-related macular degeneration (AMD), diabetic macular edema (DME), macular edema in retinal vein occlusions (RVO), and other retinal diseases accompanied by neovascular and macular edema. The aim of the study is to show the efect of switching from bevacizumab to alibercept in patients with recalcitrant wet AMD as the best clinical approach and regimen for patients with neovascular and macular edema accompanied retinal diseases. Methods. All our patients received the intravitreal injections of 1.25 mg (0.1 mL) bevacizumab as the irst treatment option, and we switched to alibercept or triamcinolon acetonid when the therapy including bevacizumab seemed not to be efective enough, according to visual acuity and optical coherent tomography (OCT) indings. Case presentations. We presented four cases: two patients with wet AMD, one patient with macular edema due to central retinal vein occlusion (CRVO) and one patient with DME in non-proliferative diabetic retinopathy (nPDR). The majority of our patients felt visual and anatomical improvement. Some patients felt anatomical improvement although their visual acuity did not improve. Switch to alibercept had prolonged the positive efect of bavacizumab for approximately 2 months. When regular therapy including bevacizumab was reintroduced, the therapeutic efect would be prolonged. The efective clinical approach was not only the switching therapy but the combination therapy as well. Individual treatment approach and pro re nata regimen were most commonly used in our patients. Conclusion. Switching anti-VEGF drug showed positive results in patients with refractory or recurrent wet AMD and macular edema.&amp;lt;/p&amp;gt;

To assess the effect of intravitreal bevacizumab on diabetic macular oedema (DMO) and retinal vessel calibres. We performed a consecutive case series study in which 10 consecutive eyes with diffuse DMO, two of which had not previously been treated, received an intravitreal injection of bevacizumab 1 mg, which was followed by two more injections at 6-week intervals. Fundus photography and optical coherence tomography (OCT) were carried out at baseline immediately before injection and at 1, 2.5 and 4 months after the first injection. Outcome measures were best corrected visual acuity (BCVA) in Early Treatment Diabetic Retinopathy Study letters, macular volume, foveal subfield thickness and vessel diameter measurement. Intravitreal administration of bevacizumab was followed by a mean increase in BCVA of 7.3 +/- 17 (mean +/- standard deviation) letters between baseline and month 4, which was 1 month after the last injection (p < 0.0001). This was accompanied by a reduction in mean macular volume from 9.90 +/- 1.9 mm(3) to 8.96 +/- 2.4 mm(3) (p = 0.002) and in foveal subfield thickness from 447 +/- 117 microm to 388 +/- 117 microm (p = 0.03). Two eyes with early proliferative diabetic retinopathy lost all signs of proliferation without any evidence of fibrosis. Although there was a trend towards vasoconstriction, the changes in vessel diameters (arteries and veins) after 4 months of intravitreal Avastin injection were not statistically significant (p = 0.9 and p = 0.17, respectively). Foveal thickness in non-injected fellow eyes with DMO changed from 428 +/- 153 microm at baseline to 383 +/- 151 microm at 4 months (p = 0.1), which did not reach statistical significance. Intravitreal bevacizumab 1 mg every 6 weeks was followed by a moderate reduction in DMO without normalization of foveal and macular thickness. Our observations suggest that a larger study where patients are examined sooner after injection is needed to elucidate the potential relationship between changes in retinal vessel diameters and thickness changes in DMO.

Shall we use Avastin^® or Lucentis^® for ocular neovascularization?

The purpose of this study was to determine the morphologic patterns of angiographic macular edema using simultaneous colocalization of fluorescein angiography and spectral-domain optical coherence tomography (SD-OCT) images in diabetes, epiretinal membrane, uveitic and pseudophakic cystoid macular edema, and vein occlusion. Eighty-seven consecutive patients (107 eyes) with macular edema from 5 different etiologies were imaged by simultaneous scanning laser ophthalmoscopy/OCT to study the morphologic patterns of edema on SD-OCT and then correlated/colocalized with the fluorescein angiographic patterns of leakage. Statistical analysis was done to analyze the differences in the morphologic OCT pattern by different diseases. Spectral-domain OCT characteristics of macular edema showed a significant difference across different diseases (P = 0.037). Cystic fluid pockets were found to be more commonly seen in patients with diabetic macular edema and retinal vein occlusions, whereas those cases with macular edema secondary to epiretinal membrane showed noncystic changes on OCT. Seventy of the 107 eyes had diffuse angiographic leakage, and the remaining 37 eyes had cystoid leakage on angiography. Of the 70 eyes with diffuse leakage, 24.28% showed microcysts on SD-OCT in the area of edema, and 70% eyes had diffuse thickening or distorted architecture without cyst. All 37 eyes with cystoid leakage showed cysts in the area of edema by SD-OCT. A total of 3.73% of eyes with fluorescein angiographic leakage had no abnormalities on SD-OCT. Eyes with diabetic macular edema and retinal vein occlusions have a significantly higher incidence of cyst formation on SD-OCT. There was no correlation between visual acuity and cyst formation. Diffuse noncystoid angiographic macular edema may show microcysts on SD-OCT, but diffuse edema is more commonly associated with thickening or distortion of the retinal layers without cyst formation. Cystoid leakage on fluorescein angiography is always associated with cystic changes on SD-OCT.

To investigate morphological variations in the macular area with optical coherence tomography (OCT) after vitrectomy for diabetic fibrovascular proliferation. We reviewed 108 cases using OCT 7-15 months after vitrectomy. Of these, 32 received OCT within 3 months postoperatively. Morphological variations were categorized and correlated with visual outcome. Only 24 cases (21.4%) had no obvious abnormalities. The most frequent findings were epiretinal membrane (52.8%), macular thickening (37.0%) and macular cysts (28.7%). Multivariate regression showed that diffuse macular thickening, loss of foveal depression and diffuse retinal thinning were significantly associated with poor visual acuity. Sequential OCT (< 3 and >or= 7 months) revealed that epiretinal membrane and oedema outside of fovea changed significantly between two examinations. OCT may identify diverse morphological changes in the macular area after diabetic vitrectomy for fibrovascular proliferation. Macular appearance may change over time, and certain types of morphological changes may be associated with poor visual function.