Diffuse Diabetic Macular Edema Research Articles

Comparison of the efficacy between an intravitreal and a posterior subtenon injection of triamcinolone acetonide for the treatment of diffuse diabetic macular edema.

To compare the efficacy of an intravitreal injection to a posterior subtenon injection of triamcinolone acetonide for the treatment of diffuse diabetic macular edema. Sixty patients with diabetes mellitus presenting with diffuse diabetic macular edema were recruited for the study. In each patient, one eye received a 4.0 mg (0.1 mL) intravitreal (IVT) injection of TA and the other eye was treated with a 40 mg (1.0 mL) posterior subtenon (PST) injection of triamcinolone acetonide (TA). We measured the visual acuity, the intraocular pressure (IOP) and the thickness of the macula using optical coherence tomography (OCT) before treatment and at one, three and six months after treatment. Eyes treated with PST showed 1-3 lines of improvement in Snellen's acuity from their pre-injection baseline visual status. The eyes in the IVT group showed 1-3 lines of improvement in Snellen's acuity in 80% of the treated eyes, but 20% of the treated eyes did not display any benefit at the end of six months. The difference in acuity between an IVT injection and a PST injection at six months post-treatment was statistically significant (p<0.05). The macular thickness of the eyes treated with an IVT injection was significantly reduced after one (222.7±13.4 μm; p<0.001) and three months (228.1±10.6 μm; p<0.001) of treatment. The eyes treated with a PST injection displayed a slow response and a significant improvement in macular thickness that was observed only after three months (231.3±10.9 μm; p<0.001). The difference between the eyes treated with an IVT injection (385.2±11.3 μm) and those treated with a PST injection (235.4±8.7 μm) was significantly different six months after treatment (p<0.001). The IOP of the eyes treated with an IVT injection was significantly increased after one (17.7±1.1 mm/Hg; p<0.020), three (18.2±1.2 mm/Hg; p<0.003) and six months (18.1±1.320 mm/Hg; p<0.007) when compared to the baseline value (16.1±1.4 mm/Hg). The eyes treated with a PST injection displayed no significant increase in IOP after one (16.4±1.2 mm/Hg; p<0.450), three (16.3±1.1 mm/Hg; p<0.630) and six months (16.2±1.1 mm/Hg; p<0.720) when compared to the baseline value (16.2±1.3 mm/Hg). A PST injection is equally effective and safer than an IVT injection of TA for the management of diffuse DME.

Differential diagnosis (occlusion and unocclusal kind) of complicated and diffuse diabetic macular edema with optical coherence tomography method in patients with diabetes type II

Differential diagnosis (occlusion and unocclusal kind) of complicated and diffuse diabetic macular edema with optical coherence tomography method in patients with diabetes type II

MACULAR LASER GRID ALONE VERSUS COMBINED WITH INTRAVITREAL TRIAMCINOLONE PLUS BEVACIZUMAB FOR DIABETIC MACULAR EDEMA

Diabetic retinopathy is the leading cause of blindness among individuals of working age in advanced societies, most of the vi sion loss resulting from diabetic macula r edema (DME) . Macular laser photocoagulation or i ntravitreal tiamcinolone or anti - vascular endothelial growth factor injection are modalities of therapy for diabetic macular edema. T his study aim was to present the clinical outcomes of 60 eyes of 41 patie nts with diffuse DME who treated with macular laser grid (MLG) alone or combined with intravitreal triamcinolone (IVTA) and intravitreal bevacizumab (IVB) injection. Thirty eyes (group1) treated with MLG and 30 eyes (group 2) treated with MLG + IVB + IVTA. The values of BCVA, central macular thickness ( CMT ) , intraocular pressure ( IOP ) and complications were compared between two groups. At baseline, BCVA was 0.35 ± 0,18 LogMAR (logarithm of the minimum angle of resolution ) in the group 1 and 0.36 ± 0.36 ± 0. 14 logMAR in the group 2. At 6 and 20 months after initial treatment in both groups had no significant improvement in BCVA, whereas had a significan t improvement in CMT (p < 0.001) compared with baseline. An increase in IOP was present in 13 % and cataract was developed in 6.7 % in the group 2. At 6 th and 20 th month , MLG and MLG + IVTA + IVB provided improvement of BCVA and CMT in the both groups . There was no significant difference in BCVA and CMT betwee n two groups. Increased IOP and devel opment of catar act was recorded i n the group 2 secondary to IVTA . MLG may be preffer ed for treatment of DME because of side events of IVTA + IVB.

Impact of intravitreal triamcinolone acetonide versus intravitreal bevacizumab on retrobulbar hemodynamic in patients with diabetic macular edema

Purpose: To evaluate and compare retrobulbar hemodynamic changes measured with color Doppler imaging (CDI) in diabetic patients receiving intravitreal triamcinolone acetonide (IVTA) versus bevacizumab.Methods: Patients with diffuse diabetic macular edema were assessed prospectively by CDI following intravitreal injection of triamcinolone acetonide (group I, 12 eyes) versus bevacizumab (group II, 14 eyes). CDI was used to measure the peak systolic velocity (PSV), end diastolic velocity (EDV) and the resistive index (RI) of the central retinal artery (CRA), ophthalmic artery (OA) and posterior ciliary arteries (PCA) one day preoperatively and one week postoperatively.Results: In group I, EDV of OA and CRA decreased significantly (p = 0.007 and 0.018, respectively). The PSV and RI of PCA decreased significantly (p = 0.035 and 0.002, respectively). In group II, both the PSV and EDV of the CRA decreased significantly (p = 0.000). Comparing the percentage of change in both groups, PSV of the CRA decreased significantly in group II (p = 0.034), while IVTA has more significant effect on the ophthalmic artery hemodynamic parameters as EDV decreased and RI increased significantly (p = 0.045 and 0.043, respectively)Conclusion: Intravitreal injections of triamcinolone acetonide and bevacizumab have a significant effect on the ocular hemodynamic. The effect of bevacizumab is statistically significant on the PSV of CRA compared to IVTA.

Ranibizumab versus bevacizumab for controlling progression of diabetic macular edema with cataract surgery

Purpose To evaluate the effect of an intravitreal injection of ranibizumab or bevacizumab for the management and control of diabetic macular edema (DME) with phacoemulsification. Patients and methods The study population included patients with diffuse DME associated with cataract. Preoperative best-corrected visual acuity (BCVA) was determined and recorded in log MAR and then preoperative assessment by fundus fluorescein angiography and optical coherence topography (OCT) was carried out and recorded. The patients were divided into two groups. For the first group, both phacoemulsification with posterior chamber intraocular lens implantation and an intravitreal injection of ranibizumab were performed, group A, and for the second group, both phacoemulsification with posterior chamber intraocular lens implantation and an intravitreal injection of bevacizumab were performed, group B. Four weeks postoperatively, BCVA in log MAR for each patient in each group was determined and recorded; postoperative fundus fluorescein angiography and assessment of the macular thickness with OCT were performed and recorded. Results This study included 30 eyes, 15 in each group; on the basis of the results, in group A, there was an improvement in macular edema and reduction in central macular thickness (CMT) postoperatively as the mean CMT preoperatively was 397.22±45.43 and improved postoperatively to 328.61±21.64. Also, BCVA improved from 0.96±0.11 to 0.49±0.2. In group B, there was an improvement in macular edema and a decrease in CMT postoperatively as the mean preoperative CMT was 401.8±74.54 and decreased postoperatively to 379.08±78.6; also, BCVA improved from 0.95±0.34 to 0.7±0.1. Conclusion From this study, we concluded that OCT should be performed for all diabetic patients who will undergo cataract surgery preoperatively to assess macular thickness and diagnose the presence of DME; also, both ranibizumab and bevacizumab play an important role in controlling DME with cataract surgery, with higher efficacy for ranibizumab than bevacizumab.

REPEATED INTRAVITREAL BEVACIZUMAB INJECTION WITH AND WITHOUT MACULAR GRID PHOTOCOAGULATION FOR TREATMENT OF DIFFUSE DIABETIC MACULAR EDEMA

To study whether the use of macular grid photocoagulation 3 weeks subsequent to the initial intravitreal bevacizumab (IVB) injection for the treatment of diffuse diabetic macular edema can provide a longer disease-free intervals and reduce the burden of more frequent injections. A prospective pilot study that included 22 patients with bilateral diffuse diabetic macular edema. In each patient, one eye was treated with repeated IVB injections alone (IVB group), while the other eye was treated with repeated IVB injections in addition to macular grid photocoagulation once only 3 weeks after the initial IVB injection (combined group). Before each IVB injection and during the follow-up visits, all patients received a complete ophthalmic examination. The central macular thickness was measured by optical coherence tomography at baseline and during the follow-up examinations. Fundus fluorescein angiography was performed at baseline and before each IVB injection, to detect and assess macular leakage. All patients were followed-up monthly for at least 12 months after the initial IVB injection and for 3 months after the last IVB injection. By the end of the follow-up duration (14.2 ± 1.91 months), the mean number of injections was significantly lower (P < 0.05) in the combined group (2.36 per eye) than in the IVB group (3.27 per eye). The mean duration between the injections was significantly longer in the combined group than in the IVB group (P < 0.05). Within each group, the difference between the mean central macular thickness at the baseline and at the end of the follow-up duration was statistically significant (P < 0.05). The change in the mean best-corrected visual acuity between the baseline and the end of the follow-up period was not statistically significant in both the groups (P > 0.05). There was no statistically significant difference between the 2 groups of the study as regards the number of patients who gained, maintained, or lost vision (P > 0.05). Repeated IVB injection could provide a long-term benefit for the treatment of diffuse diabetic macular edema. Performing macular grid photocoagulation once only 3 weeks subsequent to the initial IVB injection might provide a longer disease-free intervals and reduces the burden of more frequent injections.

Dexamethasone Intravitreal Implant in Combination with Laser Photocoagulation for the Treatment of Diffuse Diabetic Macular Edema

To evaluate Ozurdex (dexamethasone intravitreal implant [DEX implant]; Allergan, Inc, Irvine, CA) 0.7 mg combined with laser photocoagulation compared with laser alone for treatment of diffuse diabetic macular edema (DME). Randomized, controlled, multicenter, double-masked, parallel-group, 12-month trial. Two hundred fifty-three patients with retinal thickening and impaired vision resulting from diffuse DME in at least 1 eye (the study eye) were enrolled. Patients were randomized to treatment in the study eye with DEX implant at baseline plus laser at month 1 (combination treatment; n = 126) or sham implant at baseline and laser at month 1 (laser alone; n = 127) and could receive up to 3 additional laser treatments and 1 additional DEX implant or sham treatment as needed. The primary efficacy variable was the percentage of patients who had a 10-letter or more improvement in best-corrected visual acuity (BCVA) from baseline at month 12. Other key efficacy variables included the change in BCVA from baseline and the area of vessel leakage evaluated with fluorescein angiography. Safety variables included adverse events and intraocular pressure (IOP). The percentage of patients who gained 10 letters or more in BCVA at month 12 did not differ between treatment groups, but the percentage of patients was significantly greater in the combination group at month 1 (P<0.001) and month 9 (P = 0.007). In patients with angiographically verified diffuse DME, the mean improvement in BCVA was significantly greater with DEX implant plus laser treatment than with laser treatment alone (up to 7.9 vs. 2.3 letters) at all time points through month 9 (P ≤ 0.013). Decreases in the area of diffuse vascular leakage measured angiographically were significantly larger with DEX implant plus laser treatment through month 12 (P ≤ 0.041). Increased IOP was more common with combination treatment. No surgeries for elevated IOP were required. There was no significant between-group difference at month 12. However, significantly greater improvement in BCVA, as demonstrated by changes from baseline at various time points up to 9 months and across time based on the area under the curve analysis, occurred in patients with diffuse DME treated with DEX implant plus laser than in patients treated with laser alone. Proprietary or commercial disclosure may be found after the references.

VISUAL OUTCOME AFTER INTRAVITREAL BEVACIZUMAB DEPENDS ON THE OPTICAL COHERENCE TOMOGRAPHIC PATTERNS OF PATIENTS WITH DIFFUSE DIABETIC MACULAR EDEMA

The purpose of this study was to evaluate the effectiveness of intravitreal bevacizumab (IVB) on the reduction of diffuse diabetic macular edema in patients with different optical coherence tomography patterns. Prospective interventional case series. One hundred and forty-three eyes with diffuse diabetic macular edema, without a history of any previous treatment, were classified according to their optical coherence tomography patterns: sponge-like diffuse retinal thickening (SDRT) (n = 50), cystoid macular edema (CME) (n = 38), serous retinal detachment (SRD) (n = 25), and the combination of all patterns (FULL: n = 30). All the participants received a single dose (1.25 mg in 0.05 mL) of IVB. The foveal thickness obtained with optical coherence tomography images and logarithm of the minimum angle of resolution visual acuity were assessed before receiving IVB and subsequently every 2 weeks for 12 weeks. After IVB, the foveal thickness in all the groups was reduced but the reduction ratio in the SDRT (29.6 ± 15.6%) and CME (27.1 ± 20.5%) groups was significantly greater than in the SRD group (16.4 ± 17.7%) (P < 0.001). Similarly, improvement of visual acuity in the SDRT (-0.21 ± 0.16) and CME (-0.17 ± 0.24) groups was significantly greater than in the SRD (-0.12 ± 0.15) and FULL (-0.11 ± 0.13) (P = 0.047) groups. Interestingly, the efficacy of IVB for regression of diffuse diabetic macular edema was dependent on the duration of diabetes in the SDRT and CME groups but not in the SRD or FULL groups. The effectiveness of IVB on diffuse diabetic macular edema was dependent on the optical coherence tomography pattern (SDRT ≥ CME >> SRD), indicating that vascular endothelial growth factor plays a critical role in the pathogenesis of SDRT and CME, and was greater in patients having diabetes for a shorter duration of time.

Characterization of Ischemic Index Using Ultra-widefield Fluorescein Angiography in Patients With Focal and Diffuse Recalcitrant Diabetic Macular Edema

To explore the association of angiographic nonperfusion in focal and diffuse recalcitrant diabetic macular edema (DME) in diabetic retinopathy (DR). A retrospective, observational case series of patients with the diagnosis of recalcitrant DME for at least 2 years placed into 1 of 4 cohorts based on the degree of DR. A total of 148 eyes of 76 patients met theinclusion criteria at 1 academic institution. Ultra-widefield fluorescein angiography (FA) images and spectral-domain optical coherence tomography (SDOCT) images were obtained on all patients. Ultra-widefield FA images were graded for quantity of nonperfusion, which was used to calculate ischemic index. Main outcome measures were mean ischemic index, mean change in central macular thickness (CMT), and mean number of macular photocoagulation treatments over the 2-year study period. The mean ischemic index was 47% (SD 25%; range 0%-99%). The mean ischemic index of eyes within Cohorts 1, 2, 3, and 4 was 0%, 34% (range 16%-51%), 53% (range 32%-89%), and 65% (range 47%-99%), respectively. The mean percentage decrease in CMT in Cohorts 1, 2, 3, and 4 were 25.2%, 19.1%, 11.6%, and 7.2%, respectively. The mean number of macular photocoagulation treatments in Cohorts 1, 2, 3, and 4 was 2.3, 4.8, 5.3, and 5.7, respectively. Eyes with larger areas of retinal nonperfusion and greater severity of DR were found to have the most recalcitrant DME, as evidenced by a greater number of macular photocoagulation treatments and less reduction in SD OCT CMT compared with eyes without retinal nonperfusion. Areas of untreated retinal nonperfusion may generate biochemical mediators that promote ischemia and recalcitrant DME.

INTRAVITREAL BEVACIZUMAB PLUS GRID LASER PHOTOCOAGULATION OR INTRAVITREAL BEVACIZUMAB OR GRID LASER PHOTOCOAGULATION FOR DIFFUSE DIABETIC MACULAR EDEMA

To evaluate the anatomical and functional outcomes at 24 months in patients with diffuse diabetic macular edema treated with primary intravitreal bevacizumab (IVB) plus grid laser photocoagulation (GLP) or primary IVB alone or GLP alone. Retrospective, interventional, comparative, multicenter study. We included in this analysis 141 eyes of 120 patients with diffuse diabetic macular edema treated with primary IVB alone (Group A), 120 eyes of 94 patients with GLP therapy (Group B), and 157 eyes of 104 patients treated with IVB plus GLP (Group C). In all 3 groups, the authors observed improvement of Early Treatment Diabetic Retinopathy Study best-corrected visual acuity from baseline to 24-month follow-up (P < 0.0001). The improvement rate in Group A was statistically significantly better than in Group B (analysis of variance, P = 0.013). The authors also found a decrease in central macular thickness in all groups from baseline to the 24-month follow-up (P < 0.0001). The comparison among 3 groups showed higher central macular thickness decrease in Group A than in Groups B and C (analysis of variance, P < 0.001). The study provides evidence to support the use of primary IVB with or without GLP as treatment of diffuse diabetic macular edema. Primary IVB without GLP seems to be superior to GLP alone to provide stability or improvement in best-corrected visual acuity in patients with diffuse diabetic macular edema at 24 months.

Current status in diabetic macular edema treatments

Diabetes is a serious chronic condition, which increase the risk of cardiovascular diseases, kidney failure and nerve damage leading to amputation. Furthermore the ocular complications include diabetic macular edema, is the leading cause of blindness among adults in the industrialized countries. Today, blindness from diabetic macular edema is largely preventable with timely detection and appropriate interventional therapy. The treatment should include an optimized control of glycemia, arterial tension, lipids and renal status. The photocoagulation laser is currently restricted to focal macular edema in some countries, but due the high cost of intravitreal drugs, the use of laser treatment for focal and diffuse diabetic macular edema (DME), can be valid as gold standard in many countries. The intravitreal anti vascular endothelial growth factor drugs (ranibizumab and bevacizumab), are indicated in the treatment of all types of DME, but the correct protocol for administration should be defined for the different Retina Scientific Societies. The corticosteroids for diffuse DME, has a place in pseudophakic patients, but its complications restricted the use of these drugs for some patients. Finally the intravitreal interface plays an important role and its exploration is mandatory in all DME patients.

Evolving strategies in the management of diabetic retinopathy

Diabetic retinopathy (DR), the most common long-term complication of diabetes mellitus, remains one of the leading causes of blindness worldwide. Tight glycemic and blood pressure control has been shown to significantly decrease the risk of development as well as the progression of retinopathy and represents the cornerstone of medical management of DR. The two most threatening complications of DR are diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR). Focal/grid photocoagulation and panretinal photocoagulation are standard treatments for both DME and PDR, respectively. Focal/grid photocoagulation is a better treatment than intravitreal triamcinolone acetonide in eyes with DME. Currently, most experts consider combination focal/grid laser therapy and pharmacotherapy with intravitreal antivascular endothelial growth factor agents in patients with center-involving DME. Combination therapy reduces the frequency of injections needed to control edema. Vitrectomy with removal of the posterior hyaloid seems to be effective in eyes with persistent diffuse DME, particularly in eyes with associated vitreomacular traction. Emerging therapies include fenofibrate, ruboxistaurin, renin-angiotensin system blockers, peroxisome proliferator-activated receptor gamma agonists, pharmacologic vitreolysis, and islet cell transplantation.

CYTOKINE CONCENTRATION IN AQUEOUS HUMOR OF EYES WITH DIABETIC MACULAR EDEMA

To measure cytokine concentrations in aqueous humor of eyes with diffuse diabetic macular edema. The interventional clinical comparative study included a study group of 23 patients with diffuse diabetic macular edema and a control group of 22 patients undergoing cataract surgery. Cytokine concentrations were measured in aqueous humor samples using a Luminex xMAP suspension array technology. In the study group as compared with the control group, significantly higher concentrations were measured for epidermal growth factor (P < 0.001), human growth factor (P < 0.001), intercellular adhesion molecule-1 (ICAM-1; P < 0.001), interleukin (IL)-1a2 (P = 0.04), IL-6 (P = 0.001), IL-8 (P < 0.001), interferon gamma-induced protein (P = 0.004), monocyte chemoattractant protein-1 (P < 0.001), monokine induced by interferon gamma (P < 0.001), matrix metalloproteinase 1 (P = 0.02), matrix metalloproteinase 9 (P < 0.001), plasminogen activator inhibitor 1 (P < 0.001), placenta growth factor (P < 0.001), tissue growth factor beta (P = 0.003), vascular cell adhesion molecule (P < 0.001), and vascular endothelial growth factor (P < 0.001). Retinal macula thickness was significantly associated with the concentrations of the epidermal growth factor (P = 0.005; ρ = 0.45), ICAM-1 (P < 0.001; ρ = 0.65), IL-3 (P = 0.002; ρ = 0.48), IL-6 (P = 0.003; ρ = 0.47), IL-8 (P < 0.001; ρ = 0.71), monocyte chemoattractant protein-1 (P = 0.001; ρ = 0.53), monokine induced by interferon gamma (P < 0.001; ρ = 0.57), matrix metalloproteinase 9 (P < 0.001; ρ = 0.61), tissue growth factor beta (P = 0.01; ρ = 0.42), placenta growth factor (P = 0.004; ρ = 0.46), vascular cell adhesion molecule (P = 0.006; ρ = 0.44), and vascular endothelial growth factor (P = 0.01; ρ = 0.42). In multivariate analysis, macular thickness remained to be significantly associated with the concentration of ICAM-1 (P = 0.03; r = 0.30). Vascular endothelial growth factor concentrations were correlated with concentration of placenta growth factor (P < 0.001; ρ = 0.78), plasminogen activator inhibitor 1 (P = 0.001; ρ = 0.54), ICAM-1 (P < 0.001; ρ = 0.47), monokine induced by interferon gamma (P = 0.004; ρ = 0.44), monocyte chemoattractant protein-1 (P = 0.003; ρ = 0.43), vascular cell adhesion molecule (P = 0.01; ρ = 0.38), IL-6 (P = 0.02; ρ = 0.35), IL-8 (P = 0.02; ρ = 0.37), epidermal growth factor (P = 0.01; ρ = 0.39), and macrophage migration inhibitory factor (P = 0.01; ρ = 0.37). Numerous cytokines are associated with the presence and the amount of diabetic macular edema. Among these cytokines, ICAM-1 was the most significantly associated with the disease parameters.

Visual acuity and central macular thickness comparison between posterior sub‐Tenon's capsule triamcinolone injection and vitrectomy for diffuse diabetic macular oedema

AbstractPurpose To compare the effect of posterior sub‐Tenon's capsule triamcinolone acetonide injection (STTA) with the surgical outcomes of pars plana vitrectomy (PPV) for diffuse diabetic macular edema (DME).Methods The medical records of 52 patients (52 eyes) with diffuse DME were reviewed. 26 eyes underwent STTA (20mg) and other 26 eyes – vitrectomy combined with cataract surgery. The central macular thickness (CMT) measured by OCT and best‐corrected visual acuity (BCVA) were examined before and 1, 3, and 6 months after treatment. Statistical analysis was performed with student t‐test, Mann‐Whitney U‐test and repeated measured ANOVA.Results Preop BCVA was 0.65±0.4 logMAR units in the STTA group and 0.77±0.3 logMAR units in the PPV group. One, 3 and 6 months postop BCVA were 0.59±0.4, 0.53±0.5 and 0.47±0.4 in the STTA group and 0.77±0.3, 0.59±0.4, and 0.59±0.4 in the PPV group. Preop CMT were 608.1±220μm in the STTA group and 534.4±157μm in the PPV group. One, 3 and 6 months postop CMT were 392.1±193μm, 284.4±101.7μm and 331.4±121μm in the STTA group and 386.8±175μm, 354.2±101.7μm and 354.2±156.4μm in the PPV group. The differences in the BCVA and the CMT between two groups were not significant at any periods before and after treatment.Conclusion Although STTA and PPV can significantly improve the BCVA and reduce the CMT in patients with diffuse DME, the differences in the BCVA and the CMT were not significant. Considering the minor invasion, STTA can be the first choice for the treatment of diffuse DME.

CHANGES IN CILIARY BODY THICKNESS IN PATIENTS WITH DIABETIC MACULAR EDEMA AFTER VITRECTOMY

The purpose of the study to determine whether ciliary body thickness increased in the presence of diabetic macular edema (DME) and whether it changed after pars plana vitrectomy. A DME group consisted of 26 diabetic patients who underwent pars plana vitrectomy for diffuse DME. An epiretinal membrane group, a surgical control group, consisted of 23 nondiabetic patients with epiretinal membrane who underwent pars plana vitrectomy. A healthy control was also included for the comparison of preoperative ciliary body thickness. Ciliary body thickness was measured using ultrasound biomicroscopy, and central macular thickness was determined using optical coherence tomography. The visual acuity, ciliary body thickness, and central macular thickness were compared between groups before and 1, 2, and 4 months after pars plana vitrectomy, and the correlations between the central macular thickness and ciliary body thickness and best-corrected visual acuity were determined. The preoperative ciliary body thickness was increased significantly in the DME group compared with the epiretinal membrane and healthy control groups (both P < 0.001). The ciliary body thickness decreased significantly 1 and 2 months after surgery in the DME group (both P < 0.001) but not in the epiretinal membrane group. In the DME group, the postvitrectomy changes in the ciliary body thickness and central macular thickness showed similar trends and persisted significantly, until 4 months postoperatively (P = 0.027 and P = 0.010, respectively). The correlations between the preoperative central macular thickness and ciliary body thickness and between changes in central macular thickness and ciliary body thickness before and 2 months after surgery were not significant. Ciliary body thickness was increased in patients with DME, and vitrectomy was effective in decreasing ciliary body edema as well as macular edema in those patients during the 4-month follow-up period.

Comparison of intravitreal triamcinolone treatment and intravitreal triamcinolone with grid laser treatment in patients with diffuse diabetic macular edema.

To compare the efficacy of intravitreal triamcinolone acetonide (IVTA) and IVTA plus macular laser grid photocoagulation therapy in diffuse diabetic macular edema (DME). Sixteen patients affected by diffuse DME were retrospectively evaulated. Patients were divided into two groups: control group (IVTA injection) and laser group (IVTA plus grid laser). Main outcomes were best corrected visual aquity (BCVA) and central macular thickness (CMT) at the 3(rd) and 6(th) months of treatment. IVTA associated complications and reinjection necessity were assessed. Our study comprised 18 eyes of 16 patients. The baseline BCVA and CMT were 0.93±0.45 and 530±136μm for the control and 1.02±0.52 and 509±177μm for the laser group respectively. Posttreatment BCVA at the 3(rd) and 6(th) month were 0.73±0.4 and 0.75±0.45 for control and 0.98±0.44 and 1.04±0.4 for laser group respectively (p>0.05 for all). CMT values at the 3(rd) and 6(th) months were 260±174μm (p=0.008) and 362±163 μm (p=0.05) for control and 331±161μm (p=0.05) and 388±215 μm (p>0.05) for laser groups. 55% of control and 66% of laser groups needed reinjection with an avarage of 7±4 months after the first injection. 22% cataract progression and 33% intraocular pressure elevation were noted. Macular grid laser photocoagulation after IVTA does not have beneficial effects for diffuse DME.

SUPRACHOROIDAL DRUG INFUSION FOR THE TREATMENT OF SEVERE SUBFOVEAL HARD EXUDATES

To evaluate the safety, feasibility, and preliminary efficacy of suprachoroidal drug delivery with a microcatheter for the treatment of severe subfoveal hard exudates (SHE) in retinal vasculopathies. Definitive treatments for SHE have not yet been identified and prognosis is unfavorable. In this prospective, interventional pilot study, six eyes of six patients with central or branch retinal vein occlusion or diffuse diabetic macular edema accompanied by massive refractory SHE underwent a single treatment with bevacizumab and triamcinolone administered to the submacular suprachoroidal space via a microcatheter introduced at the pars plana and advanced posteriorly. The main outcome measures included best-corrected visual acuity, vascular leakage, macular thickness, extent of SHE, and complications. Mean follow-up was 12 months. Three eyes had central retinal vein occlusion, one had branch retinal vein occlusion, and two had chronic diabetic macular edema. Best-corrected visual acuity improved by ≥2 lines in 4 eyes and remained stable in 2 eyes. At 1 month to 2 months postprocedure, SHE was almost completely resolved in all eyes and macular edema was significantly reduced. There were no surgical or postoperative complications. Suprachoroidal infusion of drugs can be effective in reabsorbing massive SHE.

Histopathologic analysis of the internal limiting membrane surgically peeled from eyes with diffuse diabetic macular edema

To investigate the pathogenesis of diffuse diabetic maculae edema (DME). Internal limiting membrane (ILM) specimens were surgically peeled from 16 eyes of 15 patients with diffuse DME (diabetic retinopathy (DR) group) and from 12 eyes of 12 patients without diabetes (non-DR group). The specimens were then examined by light microscopy (LM), transmission electron microscopy (TEM), and immunohistochemistry. Examination by LM revealed numerous cells on the inner surface of the ILM specimens in the DR-group, among which five different cell types (glial cell, fibroblast-like cell, macrophages, neutrophils, and lymphocytes) were confirmed. Examination by TEM revealed that the thickness of the peeled ILMs in the DR group was significantly greater, and four types of cellular element (glial, fibroblast-like, macrophages, and lymphocytes) were confirmed on the surface of the vitreous side of the specimens. The existence of glial cells and macrophages was confirmed by immunohistochemistry. In diffuse DME, the ILM is thickened and a variety of cellular elements, especially numerous kinds of inflammatory cell, adhere to the inner surface of the ILM. To attenuate diffuse DME, vitrectomy combined with ILM peeling to remove the inflammatory cells and the physical barrier might be effective.

Study of clinical applications and safety for Pascal® laser photocoagulation in retinal vascular disorders

To establish safe laser parameter standards for 10-30 ms Pascal(®) laser in clinical practice and to evaluate clinical and visual outcomes using this 532-nm multi-spot photocoagulation system. Retrospective observational case series of 313 patients treated between 2006 and 2008. Evaluation of eight groups: A - panretinal photocoagulation (PRP) for proliferative diabetic retinopathy (PDR); B - focal laser treatment for clinically significant diabetic macular oedema; C - grid laser for diffuse diabetic macular oedema; D - sector PRP for ischaemic branch retinal vein occlusions (I-BRVO); E - full PRP for ischaemic central retinal vein occlusions (I-CRVO); F - macular laser treatment for macular oedema secondary to non-ischaemic BRVO; G - full PRP for rubeosis iridis and/or neovascular glaucoma (NVG) secondary to I-BRVO, I - CRVO or PDR; H - laser retinopexy for retinal breaks/degenerations. Mean LogMAR visual acuity for all procedures improved postlaser (p = 0.065), and laser prevented visual loss in 85% eyes. Topical anaesthesia was only required. At mean follow-up of 5 months, 72% procedures had a successful clinical outcome. Significantly higher powers were required for PRP using Pascal(®) compared to conventional laser (p = 0.001) in PDR, I-BRVO, I-CRVO and NVG. Sixty-seven per cent of patients (15/20) were successfully treated with single-session 20-ms PRP using a mean 1952 burns. There were no laser-associated adverse effects or ocular complications associated with multi-spot PRP or macular Pascal(®) arrays. The clinical efficacy using 10- to 30-ms pulse duration Pascal(®) laser is comparable to conventional standard protocols used for the treatment of vascular retinal disorders. Higher power, 10- to 30-ms pulse duration laser may be safely and effectively used in clinical practice.

Concentrations of unbound bevacizumab in the aqueous of untreated fellow eyes after a single intravitreal injection in humans

To determine the concentration of unbound bevacizumab in untreated fellow eyes after contralateral intravitreal injection of bevacizumab. A total of 18 eyes received intravitreal injections of 1.5 mg bevacizumab. Nine probes were obtained in the injected eye and nine in the fellow eye. Each group contained three individual eyes. Aqueous humour samples were obtained during uneventful phacoemulsification at three intervals 1-7 days (group a), 8-12 days (group b) or 13-28 days (group c). In untreated fellow eyes, the concentration of unbound bevacizumab was below the detectable limit of the ELISA (5 ng/ml in all samples). The mean concentration of unbound bevacizumab in the injected eye declined from 28.6 μg/ml (group a), 16.5 μg/ml (group b) to 7.4 μg/ml (group c). There are no pharmacological indications for a significant concentration of unbound bevacizumab in the anterior chamber of contralateral eyes in humans.