Macular Laser Research Articles

Topical Interferon Alpha 2b in the Treatment of Refractory Diabetic Macular Edema

PurposeTo report the efficacy of topical interferon alpha 2b in the treatment of refractory diabetic macular edema.MethodsIn this retrospective interventional case series, five eyes of three individuals with diabetic macular edema resistant to multiple intravitreal injections of anti-vascular endothelial growth factor drugs and macular photocoagulation were included.ResultsAll studied eyes had undergone multiple intravitreal injections including bevacizumab, combination of bevacizumab and triamcinolone and aflibercept, and macular laser photocoagulation before being included in this study. Two intravitreal ranibizumab injections had also been performed in both eyes of one patient. Two eyes had undergone pars plana vitrectomy, one for diabetic macular edema and the other for rhegmatogenous retinal detachment. After a discussion regarding the experimental topical interferon alpha 2b treatment, all patients agreed to start interferon alpha 2b drops four times a day. One month after the treatment, optical coherence tomography demonstrated a significant improvement in macular structure and thickness which was stable or improved at the three-month follow-up visit. Visual acuity in all eyes was stable or improved throughout the three-month follow-up period. Conjunctival injection and follicular conjunctivitis were the side effects of topical interferon alpha 2b and were treated with lubrication and steroids.ConclusionThis case series demonstrated the potential efficacy of interferon alpha 2b in the treatment of refractory diabetic macular edema. It might be an option in patients with contraindications for intravitreal injections.

Representativity of macular edema mapping using en face optical coherence tomography, retinal thickness map, and fluorescein angiography

Aim.To study the representativity of macular edema mapping using en face optical coherence tomography (OCT), retinal thickness map, and fluorescein angiography (FA).
 Methods.In this retrospective cross-sectional study, 8 patients (15 eyes) with diabetic macular edema (2 females and 6 males, mean age 66.58.1 years) were included. All patients OCT (retinal thickness map and en face OCT) and FA were performed. En face slab was constructed between inner plexiform layer and retinal pigment epithelium. Thearea of macular edema was measured by two masked graders independently.
 Results.There was no statistically significant difference in the area of macular edema between FA, en face OCT, and retinal thickness maps, 12.78.1, 14.58.4, 10.46.9 mm2, respectively (ANOVA3,p=0.34). Intraclass correlation coefficient for three methods was 0.87 and 0.95, for individual and mean values, respectively.
 Conclusion.En face OCT is an adequate non-invasive alternative for FA in evaluating the area of macular edema and planning of grid macular laser photocoagulation.

Optical coherence tomography angiography assessment of 577 nm laser effect on severe non-proliferative diabetic retinopathy with diabetic macular edema.

To quantitatively evaluate the effect of the combined use of 577-nm subthreshold micropulse macular laser (SML) and multi-point mode pan retinal laser photocoagulation (PRP) on severe non-proliferative diabetic retinopathy (NPDR) with central-involved diabetic macular edema (CIDME) using optical coherence tomography angiography (OCTA). In this observational clinical study, 86 eyes of 86 NPDR patients with CIDME who underwent SML and PRP treatment were included. Images were obtained 1d before laser and post-laser (1d, 1wk, 1, 3, and 6mo) using AngioVue software 2.0. Best corrected visual acuity (BCVA, LogMAR), foveal avascular zone area (FAZ), choriocapillary flow area (ChF), parafoveal vessel density (PVD), capillary density inside disc (CDD), peripapillary capillary density (PCD), macular ganglion cell complex thickness (mGCCT), central macular thickness (CMT), and subfoveal choroidal thickness (ChT) were compared between pre- and post-laser treatment. BCVA remained stable during 6mo post-laser therapy (pre-laser vs 6mo post-laser: 0.53±0.21 vs 0.5±0.15, P>0.05). PVD, ChF, ChT, CMT, and mGCCT significantly increased 1d post-laser therapy [pre-laser vs 1d post-laser: superficial PVD (%), 40.51±3.42 vs 42.43±4.68; deep PVD (%), 42.66±3.67 vs 44.78±4.52; ChF, 1.72±0.21 vs 1.9±0.12 mm2; ChT, 302.45±69.74 vs 319.38±70.93 µm; CMT, 301.65±110.78 vs 320.86±105.62 µm; mGCCT, 105.71±10.72 vs 115.46±9.64 µm; P<0.05]. However, PVD, ChF and ChT decreased to less than baseline level at 6mo post-laser therapy (pre-laser vs 6mo post-laser: superficial PVD (%), 40.51±3.42 vs 36.32±4.19; deep PVD (%), 42.66±3.67 vs 38.76±3.74; ChF, 1.72±0.21 vs 1.62±0.09 mm2; ChT, 302.45±69.74 vs 289.61±67.55 µm; P<0.05), whereas CMT and mGCCT decreased to baseline level at 6mo post-laser therapy (CMT, 301.65±110.78 vs 297.77±90.23 µm; mGCCT, 105.71±10.72 vs 107.05±11.81 µm; P>0.05). Moreover, FAZ continuously increased while CDD and PCD continuously decreased in 6mo after laser therapy. CMT and ChT had a significant positive correlation with ChF and PVD in most post-laser stages. During a 6-month follow-up period after combined use of SML and PRP therapy, BCVA remained stable and there was a decreased trend in macular edema. Blood flow increased at 1d post-laser therapy and reduced at 6mo post-laser therapy.

Anti-vascular endothelial growth factor for macular oedema secondary to branch retinal vein occlusion.

Branch retinal vein occlusion (BRVO) occurs when a retinal vein that drains part of the retina becomes blocked. BRVO can affect approximately four to five people per 1,000 of the population. Known risk factors for BRVO include hypertension, atherosclerosis, high cholesterol, diabetes mellitus, and other inflammatory or autoimmune conditions. In a BRVO the severity of vision loss is related to the extent of macular involvement by haemorrhage, swelling (oedema), and poor blood supply (ischaemia). The most common cause of visual loss in patients with BRVO is macular oedema (MO). Patients with BRVO in one eye are at risk of a venous occlusion in the fellow eye. Untreated, approximately one third of affected eyes will achieve a high level of vision (20/40 or better). Current "gold" standard treatment is laser photocoagulation which has been shown to reduce the risk of visual loss and improve the vision in up to two thirds of individuals with macular oedema secondary to BRVO, however, limitations to this treatment exist and newer modalities have suggested equal or improved efficacy. Recent studies have suggested that an injection of anti-vascular endothelial growth factor (anti-VEGF) in the eye may be of benefit to patients with BRVO. In this review, we appraise and present the level of current evidence for the use of anti-VEGF injections in the treatment of macular oedema after BRVO. In total, we found one randomised controlled trial and one quasi-randomised controlled trial. One study from the USA. had 397 participants and compared anti-VEGF injections with sham injections. It demonstrated a potential benefit of repeated anti-VEGF injections to improve vision (at least 15 letters) at one year. A second study with 30 participants, conducted in Italy, compared anti-VEGF injections with laser photocoagulation and did not demonstrate an improvement in vision (of at least 15 letters) of anti-VEGF injections over laser photocoagulation at one year. Antiangiogenic treatment was well tolerated in these studies, but since the studies were only of one year duration, we were unable to discuss long-term effects. There are several ongoing studies which undoubtedly will add to the evidence available.

Combination of Ranibizumab with macular laser for macular edema secondary to branch retinal vein occlusion: one-year results from a randomized controlled double-blind trial

BackgroundIt is not clear whether macular laser combined with anti-vascular endothelial growth factor (VEGF) can reduce the number of anti-VEGF injections in the treatment of macular edema (ME) secondary to branch retinal vein occlusion (BRVO). Our study aimed to investigate the effects of intravitreal ranibizumab with or without macular laser for ME secondary to BRVO and its associated number of anti-VEGF injections.MethodsThis is a prospective, randomized, double-blind, monocentric trial.80 patients were enrolled and 64 patients fulfilled the study requirements. All patients received a minimum of 3 initial monthly ranibizumab injections, pro re nata (PRN) dosing thereafter VA and CRT stabilization criteria-driven PRN treatment. Laser was given 7 days after third ranibizumab injection in ranibizumab with laser group. The follow-up time of this study was 1 year. Best corrected visual acuity (BCVA) improvement, central retinal thickness (CRT) reduction and number of injections of patients were compared between two groups. T-test, non-parametric Wilcoxon test and chis-square tests were adopted for between-group comparisons.ResultsThirty patients received intravitreal ranibizumab 0.5 mg alone and 34 patients received intravitreal ranibizumab 0.5 mg with macular laser. At 52 week, BCVA increased significantly and CRT decreased significantly in both groups (P < 0.001). However, there was no significant difference in BCVA improvement with baseline BCVA adjusted (p = 0.5226), and in the CRT reduction (P = 0.4552) between two groups after 52 weeks. There was also no significant difference in the number of injections between the two groups. (P = 0.0756). There was also no significant difference between ischemic and non-ischemic groups in BCVA improvement, CRT reduction and number of injections (P > 0.05).ConclusionsOur study suggests that ranibizumab combined with macular laser is effective in the treatment of ME secondary to BRVO after 1 year of treatment with 3 + PRN regimen. However, combination of macular grid photocoagulation showed no beneficial anatomical or functional effect during follow-up period, nor did it reduce the number of ranibizumab injections, either in ischemic group or non-ischemic group. We suggest that there is no need to combine macular grid photocoagulation in the treatment of ME secondary to BRVO in the future.Trial registrationClinical Trials NCT03054766. https://register.clinicaltrials.gov.Prospectively registered.

Real world evidence on 5661 patients treated for macular oedema secondary to branch retinal vein occlusion with intravitreal anti-vascular endothelial growth factor, intravitreal dexamethasone or macular laser

Background/aimsClinical trials suggest anti-vascular endothelial growth factor is more effective than intravitreal dexamethasone as treatment for macular oedema secondary to branch retinal vein occlusion. This study asks if ‘real world’...

Changes in real-world treatment patterns for diabetic macular oedema from 2009 to 2019 and 5-year outcomes: Data from the Fight Retinal Blindness! Registry.

Evaluating the treatment outcomes of diabetic macular oedema (DMO) in routine clinical practice provides data for comparison with those of clinical trials. Phase 3 clinical trials of vascular endothelial growth factor (VEGF) inhibitors for DMO have reported significant improvements in visual acuity (VA) not previously reported with laser and steroid treatments. Retrospective analysis of observational data from routine clinical practice. Eyes receiving treatments for DMO tracked in the Fight Retinal Blindness! Registry. We analysed 510 eyes (347 patients) that started DMO treatment between 2009 and 2014. Changes in DMO treatment patterns and mean change in VA (letters logMAR) and central subfield thickness (CST) 5 years after starting treatment. Treatment choice for DMO changed to predominantly VEGF inhibitors from 2009 to 2014. A total of 238 eyes (47%) were followed for at least 5 years. The mean VA at the start of treatment improved from 2009 (58 letters) to 2014 (68 letters) while mean VA change at 5 years were + 4.5 and + 5.3 letters for eyes starting treatment in 2009 and 2014, respectively. The mean CST dropped from 401 μm at baseline to 314 μm at 5 years. Eyes received a median of four injections in the first, two in the second, third and fourth and three in the fifth years. Changing the treatment of DMO from macular laser and intravitreal triamcinolone to VEGF inhibitors from 2011 onwards was associated with better VA outcomes, part of which were due to better VA at the start of treatment. The outcomes of treatment in eyes in real-world practice were, however, worse than those reported by clinical trials, likely because they were undertreated.

Dramatic Resolution of Recalcitrant Cystoid Macular Edema after Concurrent Intravitreal Injection of Bevacizumab and Triamcinolone

Background: Cystoid macular edema (CME), a common complication of branch retinal vein occlusion (BRVO), is associated with a significant vision loss. Anti-vascular endothelial growth factor (anti-VEGF) therapy is the gold standard of treatment, while grid macular photocoagulation has also been used as an adjuvant in patients with CME secondary to BRVO. More recent efforts were successful by the use of intravitreal triamcinolone acetonide. We proposed a concurrent use of intravitreal triamcinolone acetonide and intravitreal bevacizumab in the treatment of CME secondary to BRVO. Case presentation: We described an 82-year-old female with a BRVO in the right eye who developed associated CME. Repeated injections of intravitreal bevacizumab and modified grid macular laser treatment were ineffective. A concurrent treatment with intravitreal bevacizumab and triamcinolone acetonide resulted in complete and dramatic resolution of CME with a favorable visual outcome. Optical Coherence Tomography (OCT) demonstrated a significant decrease in central subfield thickness (CST) from 764μm to 253μm, without any post-procedure complications or recurrence of macular edema with complete recovery of visual acuity at 6-month follow-up. Conclusion: Early concurrent treatment with intravitreal anti-VEGF therapy (e.g. intravitreal bevacizumab) and intravitreal triamcinolone acetonide is likely to be more effective than intravitreal anti-VEGF agents alone or grid macular photocoagulation in the management of CME associated with BRVO.

Dramatic Resolution of Recalcitrant Cystoid Macular Edema after Concurrent Intravitreal Injection of Bevacizumab and Triamcinolone

Background: Cystoid macular edema (CME), a common complication of branch retinal vein occlusion (BRVO), is associated with a significant vision loss. Anti-vascular endothelial growth factor (anti-VEGF) therapy is the gold standard of treatment, while grid macular photocoagulation has also been used as an adjuvant in patients with CME secondary to BRVO. More recent efforts were successful by the use of intravitreal triamcinolone acetonide. We proposed a concurrent use of intravitreal triamcinolone acetonide and intravitreal bevacizumab in the treatment of CME secondary to BRVO.&#x0D; Case presentation: We described an 82-year-old female with a BRVO in the right eye who developed associated CME. Repeated injections of intravitreal bevacizumab and modified grid macular laser treatment were ineffective. A concurrent treatment with intravitreal bevacizumab and triamcinolone acetonide resulted in complete and dramatic resolution of CME with a favorable visual outcome. Optical Coherence Tomography (OCT) demonstrated a significant decrease in central subfield thickness (CST) from 764μm to 253μm, without any post-procedure complications or recurrence of macular edema with complete recovery of visual acuity at 6-month follow-up.&#x0D; Conclusion: Early concurrent treatment with intravitreal anti-VEGF therapy (e.g. intravitreal bevacizumab) and intravitreal triamcinolone acetonide is likely to be more effective than intravitreal anti-VEGF agents alone or grid macular photocoagulation in the management of CME associated with BRVO.

Long-term outcomes of treat-and-extend ranibizumab with and without navigated laser for diabetic macular oedema: TREX-DME 3-year results

Background/aimsTo evaluate the long-term effects of treat-and-extend dosing of ranibizumab with and without navigated focal laser for diabetic macular oedema (DME).MethodsThis is a multicentre, randomised clinical trial where 150 eyes...

Impact of Systemic Dipeptidyl Peptidase-4 Inhibitor Use in Diabetic Macular Edema

To evaluate impact of baseline systemic dipeptidyl peptidase-4 (DPP-4) inhibitor use in diabetic macular edema (DME). This was a post hoc exploratory analysis of previously completed randomized, controlled clinical trials (VISTA and VIVID) in patients with DME evaluating intravitreal aflibercept injection (IAI) every 4 weeks (2q4) or every 8 weeks (2q8) or macular laser photocoagulation. Overall, a small number of patients (12.2% [n = 35], 9.7% [n = 28], and 15.4% [n = 44]) in the laser control, 2q4, and 2q8 groups reported baseline DPP-4 inhibitor use. There were no differences in changes from baseline in best-corrected visual acuity, central subfield thickness, or rates of 2-or-greater-step improvement in Diabetic Retinopathy Severity Scale score based on DPP-4 inhibitor use within each treatment group. DPP-4 inhibitor use at baseline did not influence the magnitude of visual and anatomic benefit in patients with DME being treated with IAI or laser. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:226-234.].

LONG-TERM RESULTS OF AUTOLOGOUS RETINAL PIGMENT EPITHELIUM AND CHOROID TRANSPLANTATION FOR THE TREATMENT OF EXUDATIVE AND ATROPHIC MACULOPATHIES.

To evaluate the long-term results of autologous retinal pigment epithelium (RPE) and choroid transplantation (RPE-choroid patch) for exudative and atrophic maculopathies. Consecutive chart review of 120 eyes, which underwent RPE-choroid patch, from 2007 to 2017 for RPE atrophy or choroidal neovascular membrane secondary to exudative and hemorrhagic age-related macular degeneration, myopia, angioid streaks, and laser. Eyes were tested with best-corrected visual acuity (BCVA), reading ability, optical coherence tomography, fluorescein angiography and indocyanine green angiography, autofluorescence, and microperimetry. Eighty-eight eyes of 84 patients had complete data, with 2- to 10-year follow-up. Mean age was 71.9 ± 9.06 years. Mean preoperative and postoperative BCVA was 20/320 (1.2 ± 0.2 logMAR) and 20/200 (0.94 ± 0.36 logMAR), respectively (P = 0.009). Reading ability recovered in 43% of cases. Microperimetry showed central fixation. A gain of at least 15 letters was obtained in 40% of eyes. Integrity (P = 0.009) of external limiting membrane and higher preoperative BCVA (P = 0.001) predicted better final BCVA. Complications were retinal detachment (11.4%), macular atrophy (7%), subretinal hemorrhage (4.5%), epiretinal membrane (4.5%), recurrent choroidal neovascular membrane (4.5%), macular hole (3.4%), and cystoid edema (3%). Autologous RPE-choroid patch achieved long-lasting BCVA improvement and central fixation, in eyes with choroidal neovascular membrane and intact external limiting membrane. Atrophic maculopathies only obtained temporary visual benefit.

&lt;p&gt;Intravitreal Aflibercept versus Laser Photocoagulation in Asian Patients with Diabetic Macular Edema: The VIVID-East Study&lt;/p&gt;

PurposeThe prevalence of diabetes and diabetes-related complications, including diabetic macular edema (DME), is increasing in Asia and worldwide.MethodsVIVID-East was a 12-month, double-masked, randomized, active-controlled, Phase 3 trial (NCT01783886) enrolling adult patients (aged ≥18 years) with DME at 25 centers across China, Hong Kong, Republic of Korea, and Russia. Eyes were randomized 1:1:1 to 2 mg intravitreal aflibercept (IVT-AFL) every 4 weeks (2q4; N=127), 2 mg IVT-AFL every 8 weeks (after 5 initial monthly doses from baseline to week 16) with sham injections on nontreatment visits (2q8; N=127), or macular laser photocoagulation at baseline and sham injections at every visit (laser control group; N=124). The primary efficacy endpoint was mean change in best corrected visual acuity (BCVA) from baseline to week 52.ResultsCompared with baseline, at week 52 the mean (SE) BCVA in the 2q4 and 2q8 groups gained +13.6 (0.9) and +13.1 (1.0) letters, respectively, versus −0.5 (1.4) letters in the laser group (P<0.0001 for both). A significantly higher proportion of patients treated with IVT-AFL (2q4 and 2q8) achieved a ≥10-letter or ≥15-letter gain compared with laser (both P<0.0001) (≥10-letter gain: 70.9%, 62.7%, and 23.4%, respectively; ≥15-letter gain: 43.3%, 36.5%, and 12.1%, respectively). Mean reduction in central retinal thickness from baseline to week 52 was significantly greater with IVT-AFL versus laser treatment. Incidence of treatment-emergent adverse events was low and similar across groups; conjunctival hemorrhage (11.8%), retinal hemorrhage (8.7%), retinal aneurysm (7.5%), and retinal exudates (5.5%) being the most frequently reported. Visual and anatomic outcomes in the Chinese subgroup were consistent with the overall population.ConclusionIVT-AFL treatment resulted in significant visual and anatomic improvements in Asian patients with DME. Treatment benefits observed in the overall study population were mirrored in the subgroup of Chinese patients, who made up the largest population group in the study.Study RegistrationNCT01783886.

Visual Outcomes in the Management of Diabetic Maculopathy in Central Australia

ABSTRACT Purpose: In major urban centres and high-resource settings, treatment of diabetic maculopathy with anti-Vascular Endothelial Growth Factor (VEGF) injections has largely displaced laser treatment. However, intravitreal therapy alone requires frequent follow-up, a barrier to adherence in remote Australia. We report vision outcomes of phased diabetic maculopathy treatment in remote Central Australia for maculopathy using laser and, in a subset, supplementary injection treatment. Methods: We audited clinical records of patients undergoing laser treatment for diabetic maculopathy between 2001 and 2013 at an ophthalmology service based at Alice Springs Hospital, a regional hub in remote Australia. All patients receiving macular laser treatment were included, and some required supplementary injection(s). The primary outcome measure was change in best-corrected visual acuity [BCVA] from baseline treatment. Results: Of 338 maculopathy-treated patients, 88% were indigenous and 39% were male. Of 554 maculopathy laser-treated eyes, 118 (21%) received supplementary injection/s. In the laser treatment phase, median BCVA was 78 letters at baseline (interquartile range 62–80) and decreased by a median of two letters at final visit. In the subset who underwent subsequentinjection treatment, BCVA was 60 letters at first injection, with a median five-letter increase by final visit. Overall outcomes were similar in Indigenous and non-Indigenous Australians. Predictors of reduction in BCVA in the macular laser treatment phase were better baseline BCVA, older age, and PRP treatment (all p < .005). Conclusion: Laser treatment for diabetic maculopathy preserved vision in Central Australia, where barriers to follow-up can preclude regular injections. Supplementary injections stabilized vision in the laser-resistant subset.

Cost-effectiveness analysis of intravitreal aflibercept in the treatment of diabetic macular edema in China.

Aim: To evaluate the cost-effectiveness of intravitreal aflibercept compared with macular laser photocoagulation and ranibizumab for diabetic macular edema (DME) in China. Methods: A Markov model was developed to reflect the vision changes in DME patients. Parameters were estimated from VIVID-EAST trial data, published literature and physician surveys. Results: In a 20-year horizon, intravitreal aflibercept was associated with 7.825 quality-adjusted life years (QALYs) and 217,841 Chinese Yuan Renminbi (CNY), laser photocoagulation was associated with 7.189 QALYs and 135,489 CNY, and ranibizumab was associated with 7.462 QALYs and 222,477 CNY. The incremental cost-effectiveness ratios were 129,397 CNY/QALY and -12,774 CNY/QALY for intravitreal aflibercept versus laser photocoagulation and ranibizumab, respectively. Conclusion: Intravitreal aflibercept was considered as a cost-effective strategy for DME when compared with laser photocoagulation; it was considered as a dominant strategy when compared with ranibizumab.

Intravitreal Bevacizumab Alone Versus Combined Bevacizumab and Macular Grid Laser Photocoagulation in Diffuse Diabetic Macular Oedema

Introduction: Diabetes Mellitus (DM) is a common disease with multiple systemic complications. Diabetic macular oedema is the main threat to vision in patients with diabetic retinopathy, which results from the increased permeability of the inner and outer blood-retinal barrier. Macular argon laser photocoagulation was the only treatment of diabetic macular oedema in the past. Now-a-days, both intravitreal anti-Vascular Endothelial Growth Factor (VEGF) and macular grid laser photocoagulation are used in the management of diffuse and focal Diabetic Macular Oedema (DME). Aim: To assess the changes in both visual acuity and Central Macular Thickness (CMT) in patients with DME after intravitreal injection of bevacizumab only or in combination with macular grid laser treatment. Materials and Methods: A prospective longitudinal cohort study included 89 eyes of 52 patients with DME, who were categorised into two interventional groups. The first group received only intravitreal bevacizumab for the first three months, then Pro Re Nata (PRN), while the second group received intravitreal bevacizumab, similar to the first group, in addition to macular grid laser treatment two weeks after the initial injection. Participants were followed-up at 12 months, and the visual acuity, CMT, and the total number of injections were documented. Patients were followed-up but data was gathered on baseline and at the 12th month were compared. Results: In comparison to the initial presentation, a significant decrease in CMT was noticed in both groups (163.47±83.60 μm vs. 126.45±52.45 μm, respectively). Moreover, a significant improvement in visual acuity of both groups (p&lt;0.023 and p&lt;0.016, respectively) and significantly fewer injections being required in the second group were noticed. Conclusion: Combining intravitreal bevacizumab with macular grid laser treatment can lead to stabilisation and improvement of visual acuity with a smaller number of injections which was statistically significant.

Macular laser photocoagulation in the management of diabetic macular edema: Still relevant in 2020?

Macular laser photocoagulation (MLP) is inferior to intravitreal vascular endothelial growth factor (VEGF) inhibitors in the treatment of center-involved diabetic macular edema (DME). Ultra-widefield fluorescein angiography-guided laser photocoagulation to presumed ischemic areas of the peripheral retina or MLP do not reduce the treatment burden nor improve the visual outcomes of eyes treated with anti-VEGF drugs. Destruction of retinal tissue is not necessary to induce a therapeutic response in DME. Modern lasers are capable of producing invisible laser “burns” that do not destroy the targeted tissue using micropulse subthreshold (ST) mode where the laser's duty cycle is modified or alternatively selective retinal therapy (SRT) where ultrashort pulses of continuous wave laser selectively target the RPE. The best results with micropulse ST laser are obtained in eyes with a central macular thickness ≤400 μm. Eyes need to be treated in a continuous manner with no spaces between burns in the edematous area. Micropulse ST-MLP downregulates inflammatory biomarkers produced by activated microglial cells and Müller cells. Micropulse ST-MLP may reduce the anti-VEGF injection burden in DME. In SRT, the diseased RPE is targeted and heated with the laser with the hope that the adjacent RPE migrates and proliferates into these areas to heal the diseased RPE. There is much less experience with SRT, but the results are promising and deserve further study.

Do patients receiving laser treatment for sight threatening diabetic retinopathy and those under the care of a consultant led multidisciplinary diabetes specialist team have better HbA1c value than those that are not under a diabetes specialist?

AbstractPurposeTo evaluate if patients with sight threatening diabetic retinopathy who undergo laser photocoagulation treatment and are under the care of a consultant‐led specialist diabetes team have a better HbA1c value than those that are not under a specialist diabetes team.MethodsRetrospective review of all patients who underwent pan laser photocoagulation (PRP) treatment or macular laser therapy between 1st January 2018 and 31st December 2018 were included in the study.ResultsWe identified 64 patients who underwent laser treatment for diabetic retinopathy in the 12‐month period, 21 female and 43 male. Of these, 36 patients (56%) had type‐2 diabetes, 12 patients (18%) had type‐1 diabetes and in 16 patients (25%), this was undocumented. In terms of type of laser therapy, 50 (78%) underwent PRP and 14 (22%) underwent macular laser. 33 patients (51%) who underwent laser treatment were under the care of a specialist diabetes team within 1 year of receiving treatment. The average HbA1c value of patients who were under a diabetes specialist was 80.9 mmol/mol (9.6%), versus those who were not under a diabetes specialist was 72.7 mmol/mol (8.8%).ConclusionOur study showed that amongst patients who underwent laser treatment for sight threatening diabetic retinopathy, majority underwent pan retinal photocoagulation for proliferative disease rather than macular laser for maculopathy. This observation is expected, as macular laser is less commonly practiced since the advent of anti‐VEGF therapy for diabetic maculopathy. Surprisingly, the HbA1c values on average were better in those who were not under a specialist diabetes team compared to those who were under the care of a specialist. Although this is unexpected, it may be explained by the fact that those under a diabetes team have poorer control of their blood sugars, and/or more advanced diabetes to begin with.

Factors Predicting Treatment Response in Anti-Vascular Endothelial Growth Factor Naïve Diabetic Macular Edema Patients Treated with Intravitreal Bevacizumab.

Purpose: To identify factors that affect the therapeutic response of intravitreal bevacizumab in diabetic macular edema (DMO) and explore the correlation between the functional and anatomical outcomes observed. Methods: A retrospective, noncomparative, consecutive case series design was used. Baseline imaging data and clinical records of 65 eyes with DMO, secondary to type II diabetes mellitus, which received intravitreal bevacizumab for the first time in 2016, were analyzed. The central macular thickness (CMT), macular volume, and best-corrected visual acuity (BCVA), following the initial 3 injection loading phase were recorded. Outcomes were compared to multiple variables including glycemic control, diabetic retinopathy grade, DMO subtype on optical coherence tomography, and use of past macular laser therapy. Results: The participants' age ranged from 46 to 84 of which 63% were men and 37% were women. The mean baseline CMT was 443.21 μm. A mean reduction of 11.23% (P < 0.0005) in CMT was observed following the loading phase. Women exhibited a greater reduction in CMT (P = 0.032). Participants with diffuse retinal thickening (DRT) and with cystoid macular edema (CMO) showed a net reduction in CMT of 17.39% (P = 0.047) and 8.24% (P = 0.04) respectively. Eyes with proliferative diabetic retinopathy demonstrated a mean gain in CMT of 16.86% (P = 0.001). Conclusions: Female patients and DRT demonstrated a positive anatomical response. Patients with CMO and proliferative diabetic retinopathy displayed a negative therapeutic response. Such observations may be considered in clinical decision-making when opting for anti-vascular endothelial growth factor (VEGF) therapy for DMO.

Is there still a role of macular laser treatment in branch retinal vein occlusion in the era of intravitreal injections?

We aimedto evaluate whether macular laser still has a role in the treatment of macular oedema (MO) caused by branch retinal vein occlusion (BRVO) and provide an overview of recent studies on commonly available treatment options. A literature search was last conducted in PubMed on 26 February 2019, limited to human randomized controlled trials published in English since 2008. Seventeen articles addressing 13 trials were included in this assessment. In trials evaluating intravitreal corticosteroid and macular laser, triamcinolone was non-inferior to laser in regard to visual acuity (VA) and central retinal thickness (CRT) outcomes. Combination treatment of dexamethasone and laser resulted in better VA and lower CRT after 6months. In trials evaluating vascular endothelial growth factor (VEGF) inhibitors versus macular laser treatment, or sham and rescue laser, better VA and CRT of VEGF inhibition treatment was consistently reported. Results of combination treatment versus VEGF inhibition monotherapy were inconsistent, with four of six studies reporting comparable outcomes and injection burden. Study comparison was affected by considerable differences in study design and inadequate reporting of laser protocol and rescue laser. Studies evaluating angiostatic treatmentas monotherapy largely report the use of rescue laser, indicating that some patients would benefit from supplemental laser treatment even in the era of intravitreal therapy. Thus, we suggest further studies on optimal design of combination therapy prioritizing longer follow-up time to sufficiently evaluate the delayed effect of laser.