Macular Laser Research Articles

Regenerative Retinal Laser and Light Therapies (RELITE): Proposal of a New Nomenclature, Categorization, and Trial Reporting Standard.

Numerous laser and light therapies have been developed to induce regenerative processes in the choroid/retinal pigment epithelium (RPE)/photoreceptor complex, leaving the neuroretina undamaged. These therapies are applied to the macula for the treatment of various diseases, most prominently diabetic maculopathy, retinal vein occlusion, central serous chorioretinopathy, and age-related macular degeneration. However, the abundance of technologies, treatment patterns, and dosimetry protocols has made understanding these therapies and comparing different approaches increasingly complex and challenging. To address this, we propose a new nomenclature system with a clear categorization that will allow for better understanding and comparability between different laser and light modalities. We propose this nomenclature system as an open standard that may be adapted in future toward new technical developments or medical advancements. A systematic literature review of reported macular laser and light therapies was conducted. A categorization into a standardized system was proposed and discussed among experts and professionals in the field. This paper does not aim to assess, compare, or evaluate the efficacy of different laser or dosimetry techniques or treatment patterns. The literature search yielded 194 papers describing laser techniques, 50 studies describing dosimetry, 272 studies with relevant clinical trials, and 82 reviews. Following the common therapeutic aim, we propose "regenerative retinal laser and light therapies (RELITE)" as the general header. We subdivided RELITE into four main categories that refer to the intended physical and biochemical effects of temperature increase (photothermal therapy, PTT), RPE regeneration (photomicrodisruption therapy, PMT), photochemical processes (photochemical therapy, PCT), and photobiomodulation (photobiomodulation therapy, PBT). Further, we categorized the different dosimetry approaches and treatment regimens. We propose the following nomenclature system that integrates the most important parameters to enable understanding and comparability: Pattern-Dosimetry-Exposure Time/Frequency, Duty Cycle/Irradiation Diameter/Wavelength-Subcategory-Category. Regenerative retinal laser and light therapies are widely used for different diseases and may become valuable in the future. A precise nomenclature system and strict reporting standards are needed to allow for a better understanding, reproduceable and comparable clinical trials, and overall acceptance. We defined categories for a systematic therapeutic goal-based nomenclature to facilitate future research in this field.

Application of optical coherence tomography angiography in the assessment of diabetic macular edema staging and laser photocoagulation efficacy

ObjectiveThis study aimed to analyze the effect of optical coherence tomography angiography (OCTA) on diabetic macular edema (DME) staging and assess the efficacy of laser photocoagulation. MethodsEighty-six patients (141 eyes) with suspected DME who visited our hospital from August 2019 to March 2022 were selected and underwent fundus angiography and OCTA. The two examination methods were compared in terms of their efficacy in macular edema staging. Subsequently, the sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of OCTA in diagnosing DME were assessed using fundus angiography as the gold standard. In patients with clinically significant macular edema (CSME) treated with laser photocoagulation, the central concave non-perfused zone (FAZ), vascular density (VD), central macular retinal thickness (CRT), whole retinal blood flow density (FD-300), superficial capillary plexus (SCP), and deep capillary plexus (DCP) were measured using the OCTA 3 mm × 3 mm mode before treatment, at 3 months after treatment, and at 6 months after treatment. SCP, deep capillary plexus (DCP), blood flow density (VD), best corrected visual acuity (BCVA), and central retinal thickness (CRT) were recorded before treatment, 3 months after treatment, and 6 months after treatment. The correlation between BCVA and pre-treatment OCTA parameters at 6 months after treatment was analyzed using Pearson's correlation. ResultsFundus angiography was performed in 86 patients (141 eyes) with suspected DME. Of the 141 eyes, 44 had no leakage, 52 had diffuse edema, 40 had focal macular edema, and 5 had eyes ischemia. A total of 97 eyes showed CSME on fundus angiography. Using fundus angiography as the gold standard, OCTA exhibited a sensitivity of 97.94 %, a specificity of 63.64 %, and an accuracy of 87.23 % in diagnosing CSME. The Kappa value between OCTA and fundus angiography was 0.674. The receiver operating characteristic curve revealed that the area under the curve (AUC) of OCTA in diagnosing CSME was 0.808 (95 % confidence interval: 0.717–0.899). The BCVA was higher, while the CRT was lower in CSME patients at 3 and 6 months after treatment (P<0.05). No significant difference was observed in the OCTA parameters in CSME patients at 3 months after treatment compared with that before treatment (P>0.05). Similarly, no significant difference was found in the FD300 of CSME patients at 6 months after treatment compared with that before treatment (P>0.05). However, the FAZ area, DCP-VD (overall, central concave, and paracentral concave), and SCP-VD (overall, central concave, and paracentral concave) were higher in CSME patients at 6 months after treatment compared with that before treatment (P<0.05). Pearson's correlation showed that BCVA was positively correlated with pre-treatment FAZ area, DCP-VD, and SCP-VD (r>0, P<0.05), and negatively associated with CRT (r<0, P<0.05). ConclusionOCTA exhibited high sensitivity and specificity in diagnosis and staging DME. It adeptly captures the microvascular and visual changes in the central macular recess before and after laser photocoagulation therapy, which can quantitatively guide the follow-up treatment of DME.

The Treatment of Diabetic Retinal Edema with Intravitreal Steroids: How and When.

Diabetic macular edema (DME) is a common complication of diabetes mellitus and a leading cause of visual impairment worldwide. It is defined as the diabetes-related accumulation of fluid, proteins, and lipids, with retinal thickening, within the macular area. DME affects a significant proportion of individuals with diabetes, with the prevalence increasing with disease duration and severity. It is estimated that approximately 25-30% of diabetic patients will develop DME during their lifetime. Poor glycemic control, hypertension, hyperlipidemia, diabetes duration, and genetic predisposition are recognized as risk factors for the development and progression of DME. Although the exact pathophysiology is still not completely understood, it has been demonstrated that chronic hyperglycemia triggers a cascade of biochemical processes, including increased oxidative stress, inflammation, activation of vascular endothelial growth factor (VEGF), cellular dysfunction, and apoptosis, with breakdown of the blood-retinal barriers and fluid accumulation within the macular area. Early diagnosis and appropriate management of DME are crucial for improving visual outcomes. Although the control of systemic risk factors still remains the most important strategy in DME treatment, intravitreal pharmacotherapy with anti-VEGF molecules or steroids is currently considered the first-line approach in DME patients, whereas macular laser photocoagulation and pars plana vitrectomy may be useful in selected cases. Available intravitreal steroids, including triamcinolone acetonide injections and dexamethasone and fluocinolone acetonide implants, exert their therapeutic effect by reducing inflammation, inhibiting VEGF expression, stabilizing the blood-retinal barrier and thus reducing vascular permeability. They have been demonstrated to be effective in reducing macular edema and improving visual outcomes in DME patients but are associated with a high risk of intraocular pressure elevation and cataract development, so their use requires an accurate patient selection. This manuscript aims to provide a comprehensive overview of the pathology, epidemiology, risk factors, physiopathology, clinical features, treatment mechanisms of actions, treatment options, prognosis, and ongoing clinical studies related to the treatment of DME, with particular consideration of intravitreal steroids therapy.

Intravitreal injection of methotrexate in persistent diabetic macular edema: a 6-month study.

Diabetic macular edema (DME) affects approximately 10% of patients with diabetes mellitus. This condition can cause blurred or distorted vision, which significantly affects the quality of life of these patients. We evaluated the therapeutic effects of intravitreal methotrexate (MTX) injections on persistent DME. This prospective interventional case series included patients with confirmed persistent DME that was unresponsive to previous standard treatments. The patients underwent comprehensive eye examinations and macular imaging with optical coherence tomography (OCT). A single intravitreal MTX injection (400 µg MTX in 0.16 mL solution) was administered, followed by patient assessments at 1, 3, and 6 months after injection. Best-corrected distance visual acuity (BCDVA), intraocular pressure (IOP), macular thickness (MT), and central subfield thickness (CST) were measured at baseline and post-injection to evaluate treatment efficacy. We included 33 eyes of 30 patients with a mean (standard deviation [SD], range) age of 62.7 (8.3, 44 to 77) years, of whom 17 (56.7%) were men and 13 (43.3%) were women. All participants had type 2 diabetes mellitus, with a mean (SD, range) duration of 17.0 (6.8, 10 to 31) years. Most participants (n = 27 eyes, 81.8%) had non-proliferative diabetic retinopathy, and six eyes (18.2%) had regressed proliferative diabetic retinopathy. Four eyes (12.1%) had undergone prior macular laser photocoagulation. The mean (SD) number of prior intravitreal bevacizumab injections was 3.4 (0.8), and 29 eyes (87.8%) had received one intravitreal triamcinolone injection. During the study period, a statistically significant difference was observed in CST (P < 0.05); however, no statistically significant differences were observed in BCDVA, MT, or IOP (P > 0.05). Pairwise comparison revealed a significant decrease in CST at 6 months post-injection compared to the baseline value (P < 0.05). During the investigation period, no side effects of MTX, such as macular edema, retinal tears, vitreous hemorrhage, endophthalmitis, or vision loss, were observed. A single intravitreal MTX injection significantly reduced CST in patients with persistent DME, without relevant safety concerns. However, no significant improvement in functional outcomes was observed. Therefore, there is no strong evidence to recommend its use as a treatment for pDME. Further studies, preferably randomized clinical trials with long-term follow-ups, are warranted to assess the long-term efficacy, safety, and potential benefits of intravitreal MTX for the treatment of persistent DME.

Long-term Longitudinal Analysis of Subfoveal Choroidal Thickness Following Sulodexide Treatment in Diabetic Retinopathy Patients

Purpose: To evaluate the two-year longitudinal changes in subfoveal choroidal thickness (CT) following sulodexide treatment in patients with diabetic retinopathy.Methods: Thirty-eight eyes from patients with diabetic retinopathy, followed for a minimum of two years after sulodexide administration, were included. Subfoveal CT, measured using optical coherence tomography, was analyzed prospectively. Variables including age, sex, duration of diabetes mellitus, HbA1c, blood pressure, sulodexide treatment duration, refractive error, axial length, central macular thickness (CMT), visual acuity, laser photocoagulation, and intravitreal anti-vascular endothelial growth factor injections were evaluated for potential effects on CT. CMT, subfoveal CT, and choroidal vascularity index were compared at baseline and at 6, 12, and 24 months after sulodexide.Results: Of the 38 eyes, 10 belonged to males and 28 to females. The mean data were as follows: age, 67.18 ± 8.87 years; duration of diabetes, 18.11 ± 7.57 years; HbA1c, 8.76 ± 1.60 mmol/L; systolic blood pressure, 134.69 ± 14.68 mmHg; diastolic blood pressure, 73.72 ± 11.90 mmHg; duration of sulodexide, 25.79 ± 3.17 months; refractive error, 0.22 ± 2.19 diopters (D); and axial length, 23.32 ± 0.89 mm. During the observation period, 15 eyes underwent laser photocoagulation and 17 eyes received intravitreal anti-vascular endothelial growth factor injections. The mean subfoveal CT was 216.00 ± 64.23 μm before sulodexide administration and increased to 223.87 ± 62.18 μm, 225.53 ± 62.02 μm, and 225.76 ± 63.62 μm at 6, 12, and 24 months, respectively (&lt;i&gt;p&lt;/i&gt; = 0.0377, &lt;i&gt;p&lt;/i&gt; = 0.0159, &lt;i&gt;p&lt;/i&gt; = 0.0135). The CMT was 318.14 ± 102.28 μm initially and changed to 313.08 ± 77.47 μm, 314.97 ± 88.32 μm, and 320.03 ± 97.36 μm at the aforementioned intervals, with no significant variation (&lt;i&gt;p&lt;/i&gt; = 0.904, &lt;i&gt;p&lt;/i&gt; = 0.736, &lt;i&gt;p&lt;/i&gt; = 0.892).Conclusions: Sulodexide administration led to a significant rise in subfoveal CT over a 2-year follow-up. This change in CT was not mirrored in the CMT.

Adjunct Nondamaging Focal Laser Reduces Intravitreal Injection Burden in Diabetic Macular Edema.

This study aims to determine the impact of adjunct nondamaging focal laser therapy on the number of anti-vascular endothelial growth factor (anti-VEGF) injections and visual acuity (VA) and imaging in patients with diabetic macular edema (DME). A retrospective analysis of 18 eyes of 14 patients with DME treated with a single session of the PASCAL 532 nm Synthesis Photocoagulator with Endpoint Management was conducted. Demographic data, VA, imaging, laser parameters, and anti-VEGF injection burden six months before and after treatment were collected. Wilcoxon Signed-rank tests were used to assess changes in VA and injection burden before and after treatment. The mean number of intravitreal injections in the six-month period prior to laser treatment was 3.39 ± 2.57 injections compared to 2.33 ± 2.40 injections following laser treatment (p = 0.02). There was no significant difference between the mean VA on the day of treatment logMAR VA of 0.38 ± 0.27 (approx. Snellen equivalent 20/50) and the visual acuity on the most recent follow-up 6 months after laser logMAR VA of 0.35 ± 0.32 (approx. Snellen equivalent 20/40) (p = 0.34). There was also no significant difference in OCT central macular thickness before (311 μm) compared to 6 months after (301 μm, p = 0.64). Adjunct focal macular laser therapy is associated with a statistically and clinically significant decrease in the number of intravitreal injections required in the six-month period immediately following treatment, without compromising visual acuity or macular thickness. Nondamaging focal laser has the potential to alleviate the burden of injections for both patients and clinics.

Management of macular oedema due to retinal vein occlusion: An evidence-based systematic review and meta-analysis.

Central retinal vein occlusion and branch retinal vein occlusion are common causes of visual loss due to associated macular oedema. The aim of this review was to assess the effectiveness of interventions improving vision and treating macular oedema in central retinal vein occlusion and branch retinal vein occlusion. Medical search engines and clinical trial registries were systematically searched. Randomised clinical trials with ≥90 eyes and real-world outcome studies with ≥100 eyes each with ≥6 months follow-up were included. There were 11 randomised controlled trials evaluating treatments for central retinal vein occlusion which met the inclusion criteria and 10 for branch retinal vein occlusion. There were 10 real world outcome studies of central retinal vein occlusion and 5 real world outcome studies of branch retinal vein occlusion. Meta-analysis was performed on studies that met the defined inclusion criteria. Main outcomes were change in visual acuity at 6-, 12-, 24- and 36 months by treatment. Intravitreal anti-vascular endothelial derived growth factor is recommended as first line treatment over intravitreal corticosteroid due to its effectiveness and lower rate of ocular adverse events. Best outcomes are achieved when intravitreal treatment is started early. Macular laser may have an adjunctive role in branch retina vein occlusion but not central retinal vein occlusion.

Optical Coherence Tomography Angiography After Macular Laser Treatment for Diabetic Macular Edema

Optical Coherence Tomography Angiography After Macular Laser Treatment for Diabetic Macular Edema

Diabetic macular edema treatment with subthreshold micropulse laser - five-year long monitoring.

The objective of this study was to evaluate the efficacy of diabetic macular edema (DME) therapy using subthreshold micropulse laser (SMPL) with a wavelength of 577 nm during a long-term monitoring period of 5 years. The cohort included the total number of 52 eyes of 34 patients with DME. All underwent the standard laser treatment for the diabetic retinopathy outside the macula and DME treatment with SMPL. Subsequent check-ups were followed every 3 months in the first year of treatment, and every 4 to 6 months in the following years. The treatment was combined neither with focal macular laser nor with anti-VEGF therapy. The mean central retinal thickness (CRT) was 345.9 µm SD 122.6 µm at the beginning of the monitoring. At the end of the follow-up period five years after treatment it was 256.4 µm SD 98.4 µm. The mean CRT decreased by 89.5 µm SD 153.6 µm during 5 years. At the beginning of the monitoring, before treatment with SMPL, the best corrected visual acuity (BCVA) was 70.0, SD 10.1 ETDRS letters. One year after therapy, BCVA was 72, SD 10.0 letters, two years later it was 71.4, SD 10.4 letters and decreased to 66.9, SD 12.1 letters after 5 years. The mean BCVA decreased by merely 3.1, SD 10.9 letters during 5 years. Based on our long-term observations, the DME treatment with SMPL appears to be an effective method for reducing DME and protecting BCVA against rapid worsening.

Diabetic macular edema

AbstractThe main diabetic macular edema (DME) treatment options include intravitreal injections of anti‐VEGF agents and intravitreal injections of corticosteroids. In the past, macular laser photocoagulation (LP) was a standard of DME treatment, however, now it is utilized as an additional treatment. Two most important techniques of LP in patients with DME include focal photocoagulation and the grid laser. According to European Society of Retina Specialists (EURETINA) guidelines focal or grid laser should be utilized mainly for non‐center involving DME. In recent years anti‐VEGFs were found superior over typical laser treatment in DME patients. However, new tissue‐sparing technique, subthreshold micropulse laser (SML), avoids protein coagulation and prevents retinal scars, allowing retinal anatomic and functional preservation. It helps to improve or stabilize visual function and decrease macular thickness in treatment of DME.Corticosteroids are often used as an alternative therapy for eyes with insufficient response to anti‐VEGF treatment because they act on different targets than anti‐VEGF agents leading to by inflammation reduction, decrease in the disruption of the blood‐retinal barrier, and retinal angiogenesis. The major steroids used in the treatment of DME include triamcinolone acetonide (TA), dexamethasone (DEX) and fluocinolone acetonide (FA). It is known, however, that steroids frequently increase the intraocular pressure, and are related with the risk of cataract development.

Retrospective analysis of the efficacy of early switching from bevacizumab to aflibercept or ranibizumab in diabetic macular edema.

The study aimed to compare the anatomical and functional gains of switching to ranibizumab or aflibercept in eyes with treatment-naive diabetic macular edema (DME) which has an inadequate response to three consecutive bevacizumab injections. This observational, retrospective, comparative study presented 12-month results of 80 patients with DME. One eye of each patient was enrolled, and bevacizumab was switched as aflibercept (40 eyes) or ranibizumab (40 eyes). DME was diagnosed based on a fundoscopic examination, fundus fluorescein angiography (FFA), central macular thickness (CMT), and best-corrected visual acuity (BCVA). Forty-one patients (51.2%) were male, and 39 (48.8%) were female, with a mean age of 62.3 ± 6.7 years. At the end of the study, the mean number of intravitreal injections was 8.1 ± 1.8 in the aflibercept group, whereas 8.9 ± 1.4 in the ranibizumab (p = 0.091). The mean CMT decreased from 449.2 ± 69.3 µm to 311.0 ± 48.9 µm in the aflibercept group, and from 444.9 ± 109.2 µm to 316.3 ± 54.5 µm in the ranibizumab group (for both, p < 0.0001). The mean BVCA increased from 49.2 ± 11.1 ETDRS letters to 62.5 ± 9.9 in the aflibercept group (p < 0.0001) and from 49.9 ± 12.0 ETDRS letters to 61.1 ± 9.1 in the ranibizumab group (p < 0.0001). Macular laser treatment was required in 17.5% of the aflibercept group and 22.5% of the ranibizumab group (p = 0.781). Significant improvement was observed with ranibizumab and aflibercept treatments in initial bevacizumab-resistant DME. Early switching therapy may contribute to better visual and anatomical outcomes.

Ischemia and laser photocoagulation in retinal vein occlusion

Retinal vein occlusions (RVO) are associated with retinal ischemia to ahighly variable extent. An ischemic retina may lead to the development of neovascularization and further to secondary complications such as neovascular glaucoma, vitreous hemorrhage or tractional retinal detachment. Numerous factors such as vascular endothelial growth factor (VEGF) and other cytokines are produced in the ischemic area, which cause macular edema. Before the introduction of intravitreal drug injections (IVI), retinal laser photocoagulation was the leading form of treatment. Macular laser photocoagulation was applied in the form of focal laser or grid laser in patients with branch retinal vein occlusion (BRVO) to treat macular edema. In patients with ischemic RVO, panretinal laser photocoagulation (PRP) was recommended for treatment of secondary neovascular complications. The value of laser treatment in the management of patients with RVO changed after the introduction of IVI treatment. This article presents a review of the current study results and the recommendations for performing laser photocoagulation of the central and peripheral retina in patients with RVO. Conventional focal or grid laser photocoagulation has been replaced by IVI treatment in the management of macular edema secondary to BRVO; however, macular laser treatment can still be considered in patients with BRVO if the macular edema persists despite the use of available IVI drugs. The use of central laser photocoagulation in these cases is based on the findings of fluorescein angiography. Disseminated panretinal laser photocoagulation is still indicated in RVO patients who have large areas of nonperfusion, have developed neovascularization and/or late complications. Targeted laser photocoagulation of the peripheral areas of nonperfusion has recently been recommended by several authors and is expected to improve not only the visual outcome of IVI treatment, but more importantly to also reduce the duration of treatment and the number of re-injections needed. Clear evidence for targeted laser treatment is not yet available and is afocus of currently ongoing prospective randomized studies.

Outcomes of Over 40,000 Eyes Treated for Diabetic Macula Edema in Routine Clinical Practice: A Systematic Review and Meta-analysis.

We investigated effectiveness and safety outcomes of diabetic macula edema (DME) treatment in routine clinical practice. A literature search was conducted of peer-reviewed articles published from January 2011 to September 2021. Studies of DME treatment in real-world practice of at least 6months with at least 50 eyes at baseline were included. Randomized controlled trials (RCTs) were excluded. The primary outcome for this meta-analysis was change in visual acuity (VA) 12months after starting treatment. Of 3034 initially identified studies, 138 met selection criteria, representing more than 40,000 eyes. The mean 12-month VA gain was 4.6 letters (95%CI 3.7, 5.4; baseline 58.6) for vascular endothelial growth factor inhibitors (anti-VEGF), 4.4 (2.5, 6.3; baseline 54.2) for steroids, and 2.1 (-1.2, 5.3; baseline 63.6) for macular laser. Australian and New Zealand studies had better baseline VA when initiating treatment compared with Asia, Europe, and North America, translating to better VA at 12months. Fewer anti-VEGF injections were delivered in real-world practice than registrational RCTs. Neither systemic nor ocular safety was consistently reported. Intravitreal anti-VEGF or steroids for DME generally led to visual gains in real-world practice but these were less impressive than RCTs, with undertreatment and differences in baseline characteristics likely contributing factors.

Laser Treatment Modalities for Diabetic Retinopathy

Diabetes is a chronic progressive metabolic disorder that is caused by the body's inability to regulate blood glucose levels. If uncontrolled, it can lead to various complications. Among its various complications, long-term diabetes leads to diabetic retinopathy (DR). It is a disease involving blood vessels and the destruction of retinal nerves. It is usually classified into two types: proliferativediabetic retinopathy (PDR) and nonproliferative diabetic retinopathy (NPDR). It progresses and causes loss of vision. The leading cause of loss of vision is diabetic macular edema (DME). The argon laser is used as a modality in the management of PDR. There are various types of laser photocoagulation, such as peripheral retinal laser photocoagulation,focal macular laser photocoagulation, and grid photocoagulation. DR results in various adverse consequences such as vitreous hemorrhage, fibrosis, traction, detachment of the retina, and glaucoma. To assess DR, a detailedfundus examination with a slit lamp biomicroscopeneeds to be done. Seven-standard field stereoscopic-color fundus photography needs to be done for documentation and follow-up. Patients with diabetesmellitus (DM) type 1 have a greater risk of suffering fromDR. Another major complication of the condition is DME, which is characterized by an increase in the permeability of vessels and the thickening of the central part of the retina along with the accumulation of hard exudates on the macula. This article discussesvarious laser therapy modalities for the treatment of DR, their types, mechanisms, and aims. Clinical features of DR include abnormal dilatation of capillaries, and outpouchings in the form of microaneurysm from the capillary wallareone of the earliest and most dangerous changes; later, non-perfusion of the retina occurs, which is associated with cotton wool spots and blot hemorrhages. In patients suffering from PDR and maculopathy, peripheral retinal laser photocoagulation is used as a mode of intervention.

Decision-making support system for the personalization of retinal laser treatment in diabetic retinopathy

In this work, we propose a decision-making support system for automatically mapping an effective photocoagulation pattern for the laser treatment of diabetic retinopathy. The purpose of research to create automated personalization of diabetic macular edema laser treatment. The results are based on analysis of large semi-structured data, methods and algorithms for fundus image processing. The technology improves the quality of retina laser coagulation in the treatment of diabetic macular edema, which is one of the main reasons for pronounced vision decrease. The proposed technology includes original solutions to establish an optimal localization of multitude burns by determining zones exposed to laser. It also includes the recognition of large amount of unstructured data on the anatomical and pathological locations' structures in the area of edema and data optical coherent tomography. As a result, a uniform laser application on the pigment epithelium of the affected retina is ensured. It will increase the treatment safety and its effectiveness, thus avoiding the use of more expensive treatment methods. Assessment of retinal lesions volume and quality will allow predicting the laser photocoagulation results and will contribute to the improvement of laser surgeon's skills. The architecture of a software complex comprises a number of modules, including image processing methods, algorithms for photocoagulation pattern mapping, and intelligent analysis methods.

Therapeutic Effects of Combination Therapy and Photobiomodulation Therapy on Retinal Regeneration.

Introduction: Many systemic and ocular diseases cause macular edema (ME). Macular edema is seen in two primary forms; the first is diffuse thickening of the macula, and the other is a macula with a distinct petaloid (cloverleaf) appearance called cystoid macular edema. Macular edema has a known role in the reduction of visual equity, and many options have been proposed for the reversal of this condition. Methods: Articles on the effects of macular laser grid photocoagulation on diabetic macular edema (DME) or cystoid macular edema published between 2000 and 2022 were collected from PubMed, Google Scholar, and Web of Science. The following keywords were used for the search: "macular laser photocoagulation", "macular edema", "cystoid macular edema", "intravitreal pharmacotherapies", and "antivascular endothelial growth factor". Two hundred nineteen articles were found in google scholar and 165 articles in PubMed, and a total of 58 articles were included in the study after applying the exclusion criteria. Results: We investigated the effects of various lasers photocoagulation such as Focal and/or grid macular laser, subthreshold micropulse laser (SMPL), as well as intravitreal pharmacotherapies with triamcinolone acetonide, and fluocinolone, and extended released intraocular implants such as Ozurdex, Retisert, Iluvien, and anti-vascular endothelial growth factors such as bevacizumab (Avastin), Eyela, and Lucentis. Corticosteroids were more effective than lasers, although some researchers have found that lasers and combined lasers and corticosteroids are more effective. In addition, some studies have shown that the frequency and concentrations of intravitreal pharmacotherapies are effective in increasing visual outcomes. Conclusion: The results of the studies showed that the combined intravitreal corticosteroids are much more effective in improving visual acuity (VA) than a single corticosteroid, and the low concentration of the drug is safer. Still, corticosteroids have side effects such as increased intraocular pressure and glaucoma. Therefore, combining the medication with a laser is much more reasonable than each alone. Also, the subthreshold photocoagulation laser (670 nm) is better at reducing the central macular thickness (CMT) and improving VA than the micro pulse yellow laser and pan-retinal photocoagulation (PRP).

Management of Diabetic Macular Edema: Guidelines from the Emirates Society of Ophthalmology.

In the United Arab Emirates, retinopathy has been shown to be present in 19% of the diabetic population, with diabetes identified in up to 40% of individuals aged over 55 years. Despite the prevalence of diabetic retinal diseases, there are no unified national guidelines on the management of diabetic macular edema (DME). These published guidelines are based on evidence taken from the literature and published trials of therapies, and consensus opinion of a representative expert panel with an interest in this condition, convened by the Emirates Society of Ophthalmology. The aim is to provide evidence-based, clinical guidance for the best management of different aspects of DME, with a special focus on vision-threatening diabetic retinopathy. Treatment should be initiated in patients with best-corrected visual acuity 20/30 or worse, and/or features of DME as seen on optical coherence tomography (OCT) with central retinal thickness (CRT) of at least 300 μm or in symptomatic patients with vision better than 20/25, and/or CRT less than 300 μm where there are OCT features consistent with center-involving macular edema. The treatment of DME is effective irrespective of glycated hemoglobin (HbA1c) level, and treatment must not be denied or delayed in order to optimize systemic parameters. All ophthalmic treatment options should be discussed with the patient for better compliance and expectations. Non-center-involving DME can be initially observed until progression toward the center is documented. Macular laser no longer has a primary role in center-involving DME, and anti-vascular endothelial growth factor (anti-VEGF) therapy should be considered as first-line treatment for all patients, unless contraindicated. If anti-VEGF is contraindicated, a steroid dexamethasone implant can be considered for first-line treatment. Recommendations for the treatment of DME in special circumstances and in relapsing and refractory DME are also discussed.

Correlation of Change in Macular Thickness With Change in Visual Acuity in Diabetic Macular Edema: Post Hoc Analysis of VISTA and VIVID Trials.

Purpose: To assess the correlation between the change in central subfield thickness (CST) and change in best-corrected visual acuity (BCVA) in eyes with diabetic macular edema (DME) treated with fixed-dosing intravitreal aflibercept injection (IAI). Methods: This post hoc analysis of the VISTA and VIVID randomized controlled clinical trials, in which 862 eyes with central-involved DME were randomly assigned to IAI 2 mg every 4 weeks (2q4; 290 eyes), IAI 2 mg every 8 weeks after 5 initial monthly doses (2q8; 286 eyes), or macular laser (286 eyes) and followed through 100 weeks. Correlations between the change in CST and change in BCVA from baseline to weeks 12, 52, and 100 were assessed using the Pearson correlation. Results: The respective correlations (r [95% CI]) at weeks 12, 52, and 100 were -0.39 (-0.49 to -0.29), -0.27 (-0.38 to -0.15), and -0.30 (-0.41 to -0.17) in the 2q4 arm and -0.28 (-0.39 to -0.17), -0.29 (-0.41 to -0.17), and -0.33 (-0.44 to -0.20) in the 2q8 arm. Linear regression analysis of the correlation at week 100, adjusted for relevant baseline factors, showed CST changes accounted for 17% of the variance in BCVA changes; every 100-µm decrease in CST was associated with a 1.2-letter increase in BCVA (P = .001). Conclusions: Correlations between the change in CST and change in BCVA after 2q4 or 2q8 fixed-dosing IAI for DME were modest. Although a change in CST might be important in determining the need for antivascular endothelial growth factor for DME at follow-up, it was not a good surrogate for VA outcomes.

Visual outcomes of observation, macular laser and anti-VEGF in diabetic macular edema in type 1 diabetes: a real-world study

BackgroundThe treatment for diabetic macular edema (DME) has revolutionized during the last 15 years after the introduction of intravitreal anti-VEGF agents. The aim of the current study is to evaluate the real-world visual outcomes of diabetic macular edema (DME) treatment in patients with type 1 diabetes (T1D) in long-term follow-up.MethodsA real-world, descriptive, population-based cohort and follow-up of all patients with T1D and DME in 2006-2020 in 34 communities of the Northern Ostrobothnia Hospital District. The main outcome measures included age, gender, duration of T1D at the onset of DME, stage of retinopathy, treatment of DME (observation, laser, intravitreal treatments, combination), and visual outcomes.ResultsA total of 304 eyes of 206 T1D patients with DME were included. 75% (n=155) had non-proliferative diabetic retinopathy during the onset of DME. 15% of the cases were observed, 33% had macular laser, 41% intravitreal anti-VEGF and 12% combination of laser and intravitreal injections. Patients in anti-VEGF and in combination groups gained 4.9 and 5.5 ETDRS letters after the initial DME episode (p<0.001 and p<0.001), and the long-term visual improvements were 4.1 and 5.1 ETDRS letters (p<0.001 and p<0.001), respectively. In observation and laser groups the initial gain of 0.1 (p>0.90) and loss of 0.4 ETDRS letter (p=0.61), respectively, was noted. After the follow-up, a 3.7 ETDRS letter decrease was documented in the observation group (p>0.90) and a 1.1 (p=0.14) ETDRS letter decline in the laser group of patients. At the beginning of treatment, eyes subjected to anti-VEGF alone or in combination with laser had lower visual acuity compared to eyes subjected to observation or macular laser. The average of a 6.1±4.8 anti-VEGF injections were needed to dry DME. Visual impairment due to DME decreased from 2.4% to 1.0% during the 15-year period.ConclusionsAnti-VEGF alone or in combination with macular laser seems to be beneficial in terms of visual outcomes and treatment stability in T1D patients with central DME.Moreover, satisfying long-term visual outcomes were achieved with anti-VEGF treatment in a real-world setting.

Proliferative Diabetic Retinopathy Events in Patients With Diabetic Macular Edema: Post Hoc Analysis of VISTA and VIVID Trials.

This work aimed to assess the incidence of proliferative diabetic retinopathy (PDR) events and improvement to mild non-PDR (NPDR) or better after intravitreal aflibercept injection (IAI) or laser treatment (control) in diabetic macular edema (DME). PDR events in the VISTA (NCT01363440) and VIVID (NCT01331681) phase 3 clinical trials were evaluated in a combined IAI-treated group (IAI 2 mg every 4 weeks or 2 mg every 8 weeks after 5 initial monthly doses; n = 475) and a macular laser control group (n = 235) through week 100 in eyes without PDR at baseline (Diabetic Retinopathy Severity Scale [DRSS] score ≤ 53). Improvement in the DRSS score to 35 or better was evaluated in those with a baseline DRSS score of 43 or greater. A lower proportion of eyes in the IAI group than in the laser group developed a PDR event through week 100 (4.4% vs 11.1%; adjusted difference, -6.7%; 97.5% CI, -11.7 to -1.6; nominal P = .0008). All PDR events occurred in eyes with a baseline DRSS score of 43, 47, or 53 and not in those with a score of 35 or less. A greater proportion of eyes in the IAI group than in the control group achieved a DRSS score of 35 or less (20.0% vs 3.8%; nominal P < .0001). Fewer eyes with NPDR and DME treated with IAI than eyes treated with a laser had a PDR event. More eyes treated with IAI improved to mild NPDR or better (DRSS score ≤ 35) through 100 weeks.