Laser For Diabetic Macular Edema Research Articles

Randomized Trial of Treat and Extend Ranibizumab with and without Navigated Laser for Diabetic Macular Edema: TREX-DME 1 Year Outcomes

To compare monthly dosing with a treat and extend algorithm using ranibizumab 0.3 mg with and without angiography-guided macular laser photocoagulation for center-involving diabetic macular edema (DME). Multicenter, prospective, randomized clinical trial. A total of 150 eyes from 116 subjects were randomized into 3 cohorts: Monthly (n= 30), TReat and EXtend without macular laser photocoagulation (TREX; n= 60), and treat and extend with angiography-GuIded macular LAser photocoagulation (GILA; n= 60). Monthly cohort eyes received ranibizumab 0.3 mg every 4 weeks. Eyes in the TREX and GILA cohorts received 4 monthly injections of ranibizumab 0.3 mg followed by a treat and extend algorithm based on disease activity. Eyes in the GILA cohort also received angiography-guided macular laser photocoagulation at month 1 and again every 3 months for microaneurysm leakage. Change in mean best-corrected visual acuity (BCVA), mean central retinal thickness (CRT), number of injections from baseline to 1 year, and percentage gaining/losing 2 and 3 lines of vision. Baseline demographics were well balanced among the cohorts. A total of 137 eyes (91%) completed the 1-year end point visit. At 1 year, the mean BCVA improved by 8.6, 9.6, and 9.5 letters in the Monthly, TREX, and GILA cohorts, respectively (P= 0.8). There was no significant difference between the cohorts in the percentage gaining/losing 2 and 3 lines of vision. The CRT improved by 123 μm, 146 μm, and 166 μm in theMonthly, TREX, and GILA cohorts, respectively (P= 0.47). The mean number of macular laser treatments in theGILA cohort at 1 year was 2.9 (range, 1-4). The number of injections was significantly reduced in both the TREX (10.7) and GILA (10.1) cohorts compared with the Monthly cohort (13.1, P < 0.001). There were no cases of endophthalmitis, and the total incidence of Anti-Platelet Trialists' Collaboration events was 4.7%. This prospective, randomized trial found that treat and extend dosing of ranibizumab 0.3 mg with and without angiography-guided macular laser photocoagulation significantly decreased the number of injections given while providing similar visual and anatomic outcomes compared with monthly dosing at 1 year. Adding angiography-guided laser photocoagulation to this dosing algorithm did not significantly improve outcomes at 1 year.

Trends in the Care of Diabetic Macular Edema: Analysis of a National Cohort.

PurposeTo evaluate how the monitoring and treatment for diabetic macular edema (DME) has changed in a national sample.DesignRetrospective cohort study.MethodsSetting: Administrative medical claims data from a large, national U.S. insurer. Study population: Beneficiaries of a U.S. insurance company. Observation procedures: All incident cases of DME were found. Those in years 2002/3, 2006 and 2010 were followed for a 2-year observation period and those from 2009, 2010 and 2011 for a 1-year observation period. Main Outcome Measures: Types and frequencies of treatment were tallied and compared over each of the cohorts.ResultsTwo-year cohorts had 233, 251 and 756 patients in 2002/3, 2006 and 2010 respectively. One-year cohorts had 1002, 1119 and 1382 patients in 2009, 2010 and 2011, respectively. Both percentage of patients receiving therapy and number of treatments given increased across the 2-year cohorts for both focal laser and anti-vascular endothelial growth factor (anti-VEGF) (p<0.001). The highest use of anti-VEGF agents in any of the cohorts was in the 2011 1-year group that only averaged 3.78 injections. Focal laser was used 2.5x as frequently as anti-VEGF injections in the most recent cohorts with only a high of 14.0% of DME patients receiving anti-VEGF therapy in any of the cohorts.ConclusionRegardless of treatment modality (laser or injection) DME patients received vastly fewer treatments than patients in randomized control trials. Despite the proven superior visual outcomes of anti-VEGF agents over focal laser in DME, focal laser was still used more frequently.

Intravitreal Aflibercept Injection in Diabetic Macular Edema Patients with and without Prior Anti–Vascular Endothelial Growth Factor Treatment: Outcomes from the Phase 3 Program

To evaluate visual and anatomic outcomes after intravitreal aflibercept injection (IAI) versus laser in diabetic macular edema (DME) patients with and without prior anti-vascular endothelial growth factor (VEGF) treatment for DME. Post hoc analysis of eyes from 2 similarly designed, phase 3 trials, VISTA and VIVID. Patients (eyes) with DME with central involvement from VISTA (n = 461) and VIVID (n = 404). Eyes received IAI 2 mg every 4 weeks (2q4), IAI 2 mg every 8 weeks after 5 monthly doses (2q8), or macular laser photocoagulation. This study reports exploratory outcomes through week 100. Analyses focused on VISTA because more patients received prior anti-VEGF therapy in VISTA (42.9%) versus VIVID (8.9%). Of 42.9% of patients in VISTA who received prior anti-VEGF treatment, 83.3% to 92.6% received ≥ 1 prior injections of bevacizumab, and 71.4% to 82.4% received bevacizumab only as prior anti-VEGF treatment for a duration ranging from 28 days to 3.9 years. In patients with prior anti-VEGF treatment, mean best-corrected visual acuity (BCVA) changes from baseline in the IAI 2q4, IAI 2q8, and laser groups were +10.4 letters, +10.5 letters, and -0.7 letters at week 52 and +10.9 letters, +10.8 letters, and -0.8 letters at week 100, respectively. Corresponding changes in patients without prior anti-VEGF treatment were +14.1 letters, +11.0 letters, and +0.9 letters at week 52 and +12.0 letters, +11.3 letters, and +2.1 letters at week 100. In patients with prior anti-VEGF treatment, mean reductions in central retinal thickness were 180.2 μm, 192.2 μm, and 90.9 μm at week 52 and 180.1 μm, 196.4 μm, and 94.1 μm at week 100. Corresponding reductions in patients without prior anti-VEGF treatment were 190.3 μm, 175.7 μm, and 61.0 μm at week 52 and 200.0 μm, 186.7 μm, and 76.9 μm at week 100. The most frequent serious ocular adverse event was vitreous hemorrhage (1.3%, 0.7%, and 1.9%, respectively). Visual and anatomic improvements over laser with both IAI regimens were significant and similar through week 100 in subgroups of patients in VISTA with and without prior anti-VEGF treatment for DME.

Clinical efficacy observation of sodium aescinate combined with laser for diabetic macular edema

Clinical efficacy observation of sodium aescinate combined with laser for diabetic macular edema

RANIBIZUMAB PLUS PROMPT OR DEFERRED LASER FOR DIABETIC MACULAR EDEMA IN EYES WITH VITRECTOMY BEFORE ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY.

The approach to managing diabetic macular edema in eyes with previous vitrectomy is based on limited evidence. Therefore, an exploratory post hoc assessment of 3-year data from eyes with and without vitrectomy before randomization in a DRCR.net trial that evaluated ranibizumab + prompt or deferred laser for diabetic macular edema is presented. Visual acuity and optical coherence tomography outcomes were compared between eyes with and without previous vitrectomy. At baseline, eyes with previous vitrectomy (n = 25) had longer duration of diabetes, worse visual acuity, less thickened central subfield measurements on optical coherence tomography and were more apt to have worse diabetic retinopathy severity level or previous treatment for macular edema or cataract surgery than eyes without a history of vitrectomy (n = 335). Analyses adjusted for these baseline imbalances did not identify substantial differences between eyes with and without previous vitrectomy at each annual visit through 3 years for the favorable visual acuity, optical coherence tomography central subfield thickness, or volume outcomes, although optical coherence tomography improvement appeared slower in vitrectomy eyes during the first year. This study provides little evidence that the beneficial clinical outcomes for patients with center-involved diabetic macular edema treated with anti-vascular endothelial growth factor are affected in the long term by previous vitrectomy.

Morphological and functional outcomes following modified early treatment diabetic retinopathy study laser in diabetic macular edema.

Aim:The aim was to report morphological and functional outcomes following modified early treatment diabetic retinopathy study (ETDRS) laser in diabetic macular edema (DME).Materials and Methods:Structural and functional changes using spectral domain optical coherence tomography (OCT) and microperimetry (MP) were studied before and 4 months after laser in 37 eyes with clinically significant macular edema (ME) requiring modified ETDRS laser treatment. Paired t-test was used to compare pre and postlaser outcomes P < 0.05 was considered statistically significant.Results:Central foveal thickness showed a significant reduction after laser P = 0.004. There was a significant reduction in mean retinal thickness (MRT) and retinal volume in all the quadrants of ETDRS except for the temporal and nasal quadrants in outer 6 mm ring. Maximum reduction in MRT was seen in eyes with DME having neurosensory detachment (382.66 μ to 292.61 μ). Retinal sensitivities reduced in all quadrants following laser, however, fixation patterns showed improvements. The change in VA was positively correlated to change in MRT (r = 0.468, P = 0.032).Conclusion:Laser not only causes structural benefits such as reduction of retinal thickness and volume, it also causes improvement of fixation patterns.

RaScaL: A Pilot Study to Assess the Efficacy, Durability, and Safety of a Single Intervention with Ranibizumab plus Peripheral Laser for Diabetic Macular Edema Associated with Peripheral Nonperfusion on Ultrawide-Field Fluorescein Angiography

Background and Objectives: To determine the efficacy, durability, and safety of a single treatment with intravitreal ranibizumab plus peripheral scatter laser (RaScaL) in patients with diabetic macular edema associated with peripheral retinal nonperfusion on ultrawide-field fluorescein angiography (UWFA). Study Design: A 6-month, randomized, controlled, prospective phase I/II study of 30 treatment-naïve eyes of 22 patients (8 bilateral patients) with visual impairment secondary to diabetic macular edema associated with peripheral nonperfusion on UWFA. Patients were randomized to receive ranibizumab plus UWFA-guided peripheral scatter laser (n = 15) or triamcinolone acetonide plus macular laser (n = 15). Results: At 6 months, the RaScaL group patients had fewer recurrences warranting retreatment (33% vs. 80%, p < 0.003). Mean change in final visual acuity and central foveal thickness were not statistically significant between groups. Conclusion: This pilot study suggests the efficacy, safety and durability of the RaScaL treatment regimen in patients with diabetic macular edema associated with peripheral nonperfusion on UWFA.

Laser treatment for diabetic macular edema in the 21st century.

Diabetic macular edema (DME) is the leading cause of blindness in the diabetic population. The diabetes Control and Complications Trial reported that 27% of patients affected by type 1 diabetes develop DME within 9 years of onset. Other studies have shown that in patients with type 2 diabetes, the prevalence increased from 3% to 28% within 5 years of diagnosis to twenty years after the onset. At the present time, despite the enthusiasm for evaluating several new treatments for DME, including the intravitreal therapies for DME (e.g., corticosteroids, and anti-VEGF drugs), laser photocoagulation remains the current gold standard and the only treatment with proven efficacy in a wide range of clinical trials for this condition. Despite being the standard technique for comparison and evaluation of the emerging treatments, we have generally poor understanding of the ETDRS recommendations, and we often forget about the results of laser in DME. The purpose of this review is to update our knowledge on laser photocoagulation for DME with an extensive review of the ETDRS results and discuss the laser techniques. Furthermore, we will describe the new developments in laser systems and review the current indications and results. Finally, we will discuss the results of laser treatments versus the current pharmacological therapies. We conclude by trying to provide a general overview that which laser treatment must be indicated and what types of lasers are currently recommended.

A Randomized Trial to Assess Functional and Structural Effects of Ranibizumab versus Laser in Diabetic Macular Edema (the LUCIDATE Study)

To compare the functional and structural effects of ranibizumab versus macular laser therapy in patients with center-involving diabetic macular edema. Prospective, randomized, single-masked clinical trial. Single center. Thirty-three eyes of 33 patients with center-involving diabetic macular edema, with best corrected visual acuity of 55 to 79 Early Treatment Diabetic Retinopathy Study letters at baseline, completing the 48-week study period. Subjects were randomized 2:1 to 3 loading doses of ranibizumab then retreatment every 4weeks as required; or macular laser therapy at baseline, repeated as required every 12weeks. Exploratory Outcome Measures: Structural imaging studies included greatest linear dimension and area of foveal avascular zone, perifoveal capillary dropout grade, and presence of morphologic features of diabetic macular edema on Spectralis optical coherence tomography (Heidelberg Engineering GmbH, Heidelberg, Germany). Functional measures: Visual acuity, retinal sensitivity in the central 4 and 12 degrees on microperimetry, color contrast sensitivity protan and tritan thresholds, pattern and full-field electroretinogram amplitudes and implicit times, and multifocal electroretinogram amplitude distribution. These were reported at 12, 24, and 48weeks. Ranibizumab-treated subjects gained 6.0 vs 0.9 letters lost for laser, demonstrated improved tritan and protan color contrast thresholds, and improved retinal sensitivity. Electrophysiologic function also improved after ranibizumab therapy. No safety issues were evident. Better retinal thickness reduction and structural improvement in optical coherence tomography features of diabetic macular edema were seen with ranibizumab therapy than in the laser group. There was no evidence of progressive ischemia with ranibizumab therapy. Ranibizumab therapy in the treatment of diabetic macular edema seems to improve retinal function and structure as demonstrated by this evaluation of different assessment methods.

Yellow micropulse laser in diabetic macular edema: a short-term pilot study.

To evaluate the effects of yellow micropulse laser in eyes with diabetic macular edema (DME). In this retrospective interventional case series, 22 eyes of 17 patients with visual impairment secondary to persistent DME received one single session of yellow micropulse laser. Patients were divided into 2 groups: group 1, naive eyes; and group 2, previously treated eyes. Main outcome measures included changes in central retinal thickness (CRT) and best-corrected visual acuity (BCVA). Possible atrophic changes of the retinal pigment epithelium as a result of yellow micropulse laser application were evaluated with fundus autofluorescence. At baseline, the mean logMAR BCVA was 0.39 ± 0.18 and the mean CRT was 361.8 ± 70.95. The mean BCVA improved to 0.31 ± 0.19 (p = 0.0091) and 0.31 ± 0.19 (p = 0.0078) at 3 and 6 months of follow-up, respectively. The mean CRT improved to 331.3 ± 48.46 (p&lt;0.0001) and 328.1 ± 53.25 (p&lt;0.0001) at 3 and 6 months of follow-up. Subgroup analysis showed that only in naive eyes was there a beneficial effect on visual acuity and central macular thickness. In eyes with DME, yellow micropulse laser produces a statistically significant improvement in BCVA and CRT in the short term.

LOCALIZED CHANGES IN RETINAL VESSEL CALIBER AFTER FOCAL/GRID LASER TREATMENT IN PATIENTS WITH DIABETIC MACULAR EDEMA

To compare retinal vessel caliber changes at the macula region and surrounding the optic disk after focal/grid laser treatment for diabetic macular edema. The study included 69 eyes from 46 patients treated with focal/grid laser for diabetic macular edema. Retinal photographs were taken <6 months before and 2 months and 12 months after focal/grid photocoagulation treatment. The diameters of retinal vessels around macula and the optic disk were measured separately before and after treatment. Optic disk and macular diameters were summarized into central retinal arteriolar and venular equivalent and macular retinal arteriolar and venular equivalent. Median age and duration of diabetes was 60 years and 13 years. There was a statistically significant decrease in diameter of the macular arterioles (macular retinal arteriolar equivalent 73.5 vs. 72.0 μm, P = 0.04) and venules (macular retinal venular equivalent 63.5 vs. 62.4 μm, P = 0.02) after treatment but no difference in central retinal arteriolar equivalent or central retinal venular equivalent before and after treatment. Retinal vascular calibers in control eyes did not change throughout the study. The diameters of macular vessels decreased after focal/grid laser treatment in most eyes. In contrast, vessel calibers at the optic disk did not change. Quantitative measurement of macular vessels may allow physicians to monitor the progress and success of diabetic macular edema treatment.

Matched pairs analysis of retinal navigated laser versus conventional laser

AbstractPurpose To compare clinical outcome and retreatment rate of a novel computer navigated laser versus conventional slit‐lamp‐microscope laser treatment of diabetic macular edemaMethods Focal laser for diabetic macular edema (DME) in 46 consecutive patients was digitally planned on fundus images and performed utilizing retinal navigation (Navilas® Laser System, OD‐OS GmbH, Teltow / Berlin, Germany). We investigated the number of retreat‐ments and monitored visual acuity (VA) over 6 months and compared to 119 patients treated with a conventional laser via a slit‐lamp‐microscope.To match control group and Navilas pa‐tients propensity score matching was performed with STATA based on the nearest neighbour method.Results The propensity score algorithm for age, gender, baseline VA and number of laser spots yielded 28 patients for the matched control group. All baseline characteristics were comparable, VA was 0.48 +/‐0.37 Log MAR for Navilas and 0.43 +/‐0.36 Log MAR for conventional laser. Visual outcome at 3 and 6 months follow‐up was better for the Navilas group, but did not reach statistical significance. The Laser retreatment rate using Kaplan‐Meier analysis showed separation of the survival curves after 2 months. For the first 6 months the cumulative retreatment rate was 18% in the Navilas and 31% in the conventional laser group (p=0.02)Conclusion Lower retreatment rates were observed with navigated laser treatment compared to conventional laser within 6 months after treatment, indicating a more sustained effect and faster stabilization using navigated laser, hence, reducing the treatment burden for the patient. Commercial interest

Treatment accuracy and patient pain compared in Retinal Navigated Laser (Navilas®) versus conventional laser in diabetic macular edema

AbstractPurpose Treatment accuracy and patient pain were evaluated using a novel navigating laser (NAVILAS) compared to conventional laser treatment in clinically significant macular edema (CSME).Methods Focal Navilas laser was performed in 42 patients. On color images (CI) and OCT laser spots were analyzed regarding accuracy spot placement compared to planning. Treatment pain was quantified on a visual‐analogue‐scale (VAS) and compared to a matched control. Up to one year clinical follow‐up investigated retreatment and visual acuity compared to a control of 113 patients treated by conventional laser.Results 79% of laserspots were visible on CI, of which 96% were within 100µm from the planned target. OCT confirmed that laser effects were limited to the outer retina . The number of laser spots per patient was 115+/‐97 with Navilas, (43+/‐36) with conventional laser. Pain on VAS was mean 1.6 (SD 1.0), 4.4 (SD 1.8) for the control. Kaplan‐Meier analysis showed separation of the retreatment curves after 4‐5 months with less retreatments for Navilas.Conclusion Compared to conventional laser, significantly more laserspots were placed with Navilas, patient reported pain was significantly lower. the tendency for lower retreatment rates tend with Navilas may be important when considering possible combination laser and anti‐VEGF drug therapy. Commercial interest

RANDOMIZED TRIAL EVALUATING SHORT-TERM EFFECTS OF INTRAVITREAL RANIBIZUMAB OR TRIAMCINOLONE ACETONIDE ON MACULAR EDEMA AFTER FOCAL/GRID LASER FOR DIABETIC MACULAR EDEMA IN EYES ALSO RECEIVING PANRETINAL PHOTOCOAGULATION

To evaluate 14-week effects of intravitreal ranibizumab or triamcinolone in eyes receiving focal/grid laser for diabetic macular edema and panretinal photocoagulation. Three hundred and forty-five eyes with a visual acuity of 20/320 or better, center-involved diabetic macular edema receiving focal/grid laser, and diabetic retinopathy receiving prompt panretinal photocoagulation were randomly assigned to sham (n = 123), 0.5-mg ranibizumab (n = 113) at baseline and 4 weeks, and 4-mg triamcinolone at baseline and sham at 4 weeks (n = 109). Treatment was at investigator discretion from 14 weeks to 56 weeks. Mean changes (±SD) in visual acuity letter score from baseline were significantly better in the ranibizumab (+1 ± 11; P < 0.001) and triamcinolone (+2 ± 11; P < 0.001) groups compared with those in the sham group (-4 ± 14) at the 14-week visit, mirroring retinal thickening results. These differences were not maintained when study participants were followed for 56 weeks for safety outcomes. One eye (0.9%; 95% confidence interval, 0.02%-4.7%) developed endophthalmitis after receiving ranibizumab. Cerebrovascular/cardiovascular events occurred in 4%, 7%, and 3% of the sham, ranibizumab, and triamcinolone groups, respectively. The addition of 1 intravitreal triamcinolone injection or 2 intravitreal ranibizumab injections in eyes receiving focal/grid laser for diabetic macular edema and panretinal photocoagulation is associated with better visual acuity and decreased macular edema by 14 weeks. Whether continued long-term intravitreal treatment is beneficial cannot be determined from this study.

Expanded 2-Year Follow-up of Ranibizumab Plus Prompt or Deferred Laser or Triamcinolone Plus Prompt Laser for Diabetic Macular Edema

To report expanded 2-year follow-up of a previously reported randomized trial evaluating intravitreal 0.5 mg ranibizumab or 4 mg triamcinolone combined with focal/grid laser compared with focal/grid laser alone for treatment of diabetic macular edema (DME). Multicenter, randomized clinical trial. A total of 854 study eyes of 691 participants with visual acuity of 20/32 to 20/320 (approximate Snellen equivalent) and DME involving the fovea. Continuation of procedures previously reported for the randomized trial. Best-corrected visual acuity and safety at the 2-year visit. At the 2-year visit, compared with the sham + prompt laser group, the mean change in the visual acuity letter score from baseline was 3.7 letters greater in the ranibizumab + prompt laser group (95% confidence interval adjusted for multiple comparisons [aCI], -0.4 to +7.7), 5.8 letters greater in the ranibizumab + deferred laser group (95% aCI, +1.9 to +9.8), and 1.5 letters worse in the triamcinolone + prompt laser group (95% aCI, -5.5 to +2.4). After the 1- to 2-year visit in the ranibizumab + prompt or deferred laser groups, the median numbers of injections were 2 and 3 (potential maximum of 13), respectively. At the 2-year visit, the percentages of eyes with central subfield thickness ≥250 μm were 59% in the sham + prompt laser group, 43% in the ranibizumab + prompt laser group, 42% in the ranibizumab + deferred laser group, and 52% in the triamcinolone + prompt laser group. No systemic events attributable to study treatment were apparent. Three eyes in 3 (0.8%) of 375 participants had injection-related endophthalmitis in the ranibizumab groups, whereas elevated intraocular pressure and cataract surgery were more frequent in the triamcinolone + prompt laser group. The expanded 2-year results reported are similar to results published previously and reinforce the conclusions originally reported: Ranibizumab should be considered for patients with DME and characteristics similar to those of the cohort in this clinical trial, including vision impairment with DME involving the center of the macula.

Comparative Evaluation of Pan Anti-VEGF with Selective Anti-VEGF with Laser for Diabetic Macular Edema in Indian Eyes: A Randomized Prospective Study

Background: To evaluate intravitreal 0.5 mg ranibizumab plus laser with 0.3 mg pegaptanib plus laser with focal/ grid laser alone for treatment of diabetic macular edema (DME) Methods: A total of 45 study eyes with DME involving the fovea and visual acuity (VA) of 20/32 or worse were randomized into three groups, ranibizumab 0.5 mg + prompt laser (Group 1), pegaptanib sodium 0.3 mg + prompt laser (Group 2) and laser alone (Group 3) with 15 eyes in each study arm. Retreatment was based on optical coherence tomography measurements and VA changes. Results: The mean VA change (± standard deviation) at 1 year in Groups 1, 2 and 3 were 10.4±2.1, 7.6±2.3 and 2±2.7 letters (p<0.001) respectively on a standardized ETDRS chart. There was no significant difference between the VA gain between Group 1 and 2 at 1 year (p=0.189) however significant difference existed between Groups 1 and 2 when compared to Group 3 (p=0.0001). Conclusions: Ranibizumab and Pegaptanib with prompt focal/grid laser proved to be more effective than prompt focal/grid laser alone in treatment of center involved DME. There was no statistical difference in the visual gain achieved in the two intravitreal groups.

Randomized trial evaluating ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema

Abstract Purpose To evaluate the safety and efficacy of intravitreal ranibizumab combined with prompt or deferred laser or intravitreal triamcinolone combined with prompt laser compared to laser alone for diabetic macular edema (DME). Methods 691 study participants (854 eyes) with center‐involved DME and visual acuity 20/32 to 20/320 were enrolled in a multi‐center randomized clinical trial. Eyes were randomized to Group A: sham injection+prompt laser (n = 293), Group B: 0.5‐mg intravitreal ranibizumab+prompt laser (n = 187), Group C: 0.5‐mg intravitreal ranibizumab+deferred laser (n = 188), or Group D: 4‐mg intravitreal triamcinolone+prompt laser (n = 186). Results The 1‐year mean change in the visual acuity letter score from baseline was significantly greater in Group B (+9, P&lt;0.001) and Group C (+9, P&lt;0.001) but not in Group D (+4, P = 0.31) compared with Group A (+3). Reduction in mean central subfield thickness in Group D was similar to Groups B&amp;C and greater than Group A.. Traction retinal detachment (0.3%) and endophthalmitis (0.8%) occurred infrequently in Groups B&amp;C, while cataract and elevated IOP occurred more often in Group D. Conclusion At 1 year intravitreal ranibizumab with prompt or deferred laser is more effective compared with prompt laser alone for the treatment of center involved DME. Intravitreal triamciolone+ laser did not result in superior visual acuity outcomes compared with laser alone. Ranibizumab as applied in this study, although uncommonly associated with endophthalmitis, should be considered for patients with DME and characteristics similar to those in this clinical trial. Supported through a cooperative agreement from the NEI and the NIDDK, National

Pretreatment with Intravitreal Triamcinolone before Laser for Diabetic Macular Edema: 6-Month Results of a Randomized, Placebo-Controlled Trial

To determine whether pretreatment with intravitreal triamcinolone acetonide (IVTA) before laser photocoagulation is effective in eyes with diabetic macular edema (DME). The study was a prospective, double-masked, placebo-controlled, clinical trial of eyes with DME and impaired vision (<or=20/40) randomized to IVTA 4 mg versus placebo 6 weeks before laser treatment. The main outcome measure was the proportion of eyes with improvement of best-corrected logarithm of minimum angle of resolution (logMAR) visual acuity of >or=5 letters after 6 months. Secondary outcomes were necessity of further treatment, change in central macular thickness, and incidence of adverse events. Eighty-four eyes of 54 participants were entered into the study, with 6-month data available for 81 (96%) of 84 eyes. Improvement of >or=5 logMAR letters was similar in eyes treated with IVTA before laser as placebo (18/42 [43%] IVTA vs. 16/34 [38%] laser alone; P = 0.807), as were retreatment rates at 6 months (22 [56%] IVTA vs. 21 [53%] laser alone; P = 0.727). Mean central macular thickness decreased by 50 microm (95% confidence interval, 10-96 microm) more in the IVTA treatment group than in the laser-alone group after 6 months (P = 0.016). Glaucoma therapy was necessary more frequently in IVTA-treated eyes than in those treated with laser alone (19/42 [45%] vs. 7/42 [17%]; P = 0.005). Visual results and the need for further laser treatment at 6 months were no better in the IVTA group than in the laser-alone group, despite a better anatomic outcome reflected by reduction in mean central macular thickness. This study found no evidence of a synergistic effect of IVTA and laser photocoagulation for DME. (ClinicalTrials.gov number, NCT00148265).

When and how to do a grid laser for diabetic macular edema.

Macular edema is a common feature of posterior segment diseases. It is an expression of abnormal permeability in either retinal vessels (inner blood-retinal barrier) or in the retinal pigment epithelium (outer blood-retinal barrier). It occurs in either a diffuse pattern where the macula appears generally thickened or, in more severe cases, as cystoid edema with the typical petaloid appearance. Grid laser treatment may be useful to reduce macular edema. Spots of 100-250 micrometers in diameter are applied to the whole posterior pole, one to two groups apart. The foveal avascular zone remains untouched. In patients treated bilaterally, areas temporal and nasal to the macula must be spared to prevent the development of deep scotomas. The mechanism yielding positive results with the grid technique is still debated. Among the most reliable hypotheses are: Proliferation of pigment epithelial cells, followed by and improved efficiency of the outer blood-retinal barrier; proliferation of endothelial cells in retinal capillaries followed by an improved efficiency of the inner blood-retinal barrier; improvement of the retinochoroidal exchanges, and finally, release by coagulative necrosis of a factor able to improve the efficiency of the blood-retinal barriers. Lasers with long wavelengths, such as krypton red and diode, are the most appropriate ones to perform grid treatment.

Subretinal Neovascularization after Focal Argon Laser for Diabetic Macular Edema

The authors reviewed four cases of iatrogenic subretinal neovascularization after focal argon green photocoagulation for clinically significant diabetic macular edema. An inappropriate combination of small spot size with a high-power setting is the common feature in each case of iatrogenic subretinal neovascularization. Close follow-up with fluorescein angiography is used to identify iatrogenic subretinal neovascularization at an early, treatable stage. All four patients responded favorably to laser photocoagulation of the subretinal neovascular membrane.