Photocoagulation For Proliferative Diabetic Retinopathy Research Articles

Clinical profile, visual outcome and quality of life in patients undergoing pan retinal photocoagulation for proliferative diabetic retinopathy

Introduction Visual outcomes and quality of life of individuals with proliferative diabetic retinopathy following pan-retinal photocoagulation (PRP) have only been briefly documented in a few publications. Improved quality of life experienced by patients as a result of PRP is directly associated with a positive impact on visual outcomes. Aim To determine whether visual outcomes and quality of life after PRP in diabetic patients would result in a better predictive image of the patient as a whole, thus boosting the success rates and efficacy of this treatment method. Methods P.R.P. was performed under topical anesthesia as defined by the early treatment diabetic retinopathy study (E.T.D.R.S.) guidelines. Conclusion This evidence-based analytical observational prospective study could aid in exploring the prognostic value of pan-retinal photocoagulation in proliferative diabetic retinopathy.

Insights Into Visual Rehabilitation: Pan-Retinal Photocoagulation for Proliferative Diabetic Retinopathy.

This review comprehensively explores pan-retinal photocoagulation (PRP) as a pivotal intervention in visually rehabilitating individuals afflicted with proliferative diabetic retinopathy (PDR). The review begins by elucidating the significance of PDR within the spectrum of diabetic retinopathy (DR), emphasizing the progressive nature of the disease and the consequential impact on visual health. A detailed analysis of PRP follows, encompassing its definition, purpose, and historical development, shedding light on the procedural intricacies and mechanisms of action. The postoperative care and follow-up section underscores the necessity of vigilant monitoring for complications, visual recovery, and the importance of regular ophthalmic check-ups. The subsequent discussion delves into patient education and counseling, stressing the need to manage expectations, encourage lifestyle modifications, and highlight the significance of follow-up appointments. The review concludes with insights into future directions, including advancements in laser technology and emerging therapies, offering a glimpse into the evolving landscape of DR management. By addressing ongoing challenges and embracing innovative approaches, this review provides a comprehensive guide for clinicians, researchers, and healthcare practitioners who visually rehabilitate individuals struggling with PDR.

Topical Lidocaine Gel Versus Tetracaine Eye Drops for Panretinal Photo-coagulation in Proliferative Diabetic Retinopathy

Panretinal photocoagulation (PRP) is a treatment for proliferative diabetic retinopathy (PDR). The procedure needs anesthetic agent to overcome the pain. Two widely used anesthetic agents are used in this study which are tetracaine 0.5% eyedrops and lidocaine 2% gel. This study aimed to compare the effectivity and efficacy of both anesthetic agents. A prospective randomized controlled trial was done to 40 eyes divided into two groups, group A was treated with tetracaine 0.5% eyedrop and group B with lidocaine 2% gel. Pain score was obtained subjectively from the patient and recorded during four stages of procedure. The results showed that the mean age was 56.5 years in Group A and 53.20 years in group B. Average procedure duration was 8.7 minutes in group A and 9.35 minutes in group B. Average 5 minutes pain level was 3.05 and 2.10 in group A and B consecutively. Average 10 minutes pain level was 2.65 and 2.45 in group A and B consecutively. Average during procedure pain level was 2.70 and 3.40 in group A and Group B, and average post procedure pain level was 1.20 in Group A and 1.55 in Group B. There was no significant difference between both groups’ parameters. In conclusion, the use of both agents is interchangeable and shows no differences in efficacy and effectivity. Keywords: panretinal photocoagulation; proliferative diabetic retinopathy; anesthetic agent; tetracaine; lidocaine

ASSESSMENT OF QUALITY AND ADEQUACY OF PANRETINAL PHOTOCOAGULATION IN PROLIFERATIVE DIABETIC RETINOPATHY USING ULTRA-WIDEFIELD IMAGING.

To assess the characteristics of completed panretinal photocoagulation (PRP), using ultra-widefield imaging in proliferative diabetic retinopathy. Quantitative assessment of ultra-widefield imaging images of 133 patients with proliferative diabetic retinopathy with completed PRP was made using ImageJ software. The parameters assessed included distance of laser spots from the optic disk, foveal center, superior and inferior arcades, and extent of the maximum width of laser. Areas assessed were total area of the image, area of the inner limit within which laser spots are restricted, minimum areas of unlasered patches, total area lasered, and ideal area to be covered by PRP. Two hundred one images were assessed for the final analysis. The mean distance of laser spots was 4.2 ± 2.4 mm from the optic disk (nasal) and 6.6 ± 2.5 mm from the foveal center (temporal). The mean distance of laser spots from the superior arcade vessel was 3.2 ± 1.9 mm and 6.2 ± 4.4 mm from the inferior arcade. The mean area of the retina that should have been ideally lasered was found to be 900 ± 267 mm 2 , and the actual area lasered was found to be 681 ± 254.4 mm 2 . Approximately one-quarter area of the retina continues to remain ischemic because of the lack of inadequate coverage of PRP. Further longitudinal studies are recommended, using ultra-widefield imaging to objectively assess the adequacy of PRP and its role in modulating the course of progression of the retinopathy.

Incidence and Sequelae of Macular Edema Post Pan-retinal Photocoagulation for Proliferative Diabetic Retinopathy

Purpose To study the incidence and sequelae of macular edema after Panretinal photocoagulation (PRP) for the treatment of proliferative diabetic retinopathy (PDR). Patients and Methods A prospective interventional clinical study included 42 eyes treated by PRP, for proliferative diabetic retinopathy over three sessions on three consecutive weeks. Baseline and 1-month postoperative data were collected including best-corrected visual acuity, detailed fundus examination and Spectral Domain Optical Coherence Tomography Macula (SD-OCT); to assess the Central Subfield Macular Thickness (CSMT) using the ETDRS Map. Results Forty-two eyes of 31 patients were included in the study with mean duration of diabetes of 16.9±5.7 years and mean HbA1c of 9.1±1.4. Mean pre-PRP vision was 0.44±0.2 log units, which improved to 0.41±0.2 log units (P=0.6). Mean pre-laser CSMT was 245.6±25.5 µm, which increased to 265.5±33.5 µm at 1-month follow-up after PRP (P=0.003). Four eyes (9.5%) had CSMT more than 300 µm with intraretinal edema. The mean change and percentage of change from baseline in CSMT between those patients and remaining patient were statistically insignificant (P=0.055 and 0.115 respectively). Changes in CSMT and changes in Log MAR BCVA at 4-week follow-up were inversely correlated. Conclusion Macular edema can be an unavoidable side effect of PRP especially in cases with baseline increased macular thickness. Vision is mostly not affected by PRP, however, changes in vision may be directly affected by macular thickness post-PRP.

Importance of Combination of Intravitreal Bevacizumab and Panretinal Photocoagulation in Proliferative Diabetic Retinopathy

Introduction: Diabetic retinopathy is a vascular condition of the retina that develops due to diabetes mellitus (DM). This study aimed to compare intravitreal bevacizumab, pan-retinal photocoagulation or a combination of both in proliferative diabetic retinopathy.
 Method: In this prospective, randomized interventional study, 180 patients with PDR were enrolled and divided into three equal groups, i.e., Group A patients treated with laser alone and group B- patients treated with anti-VEGF alone and Group C- patients treated with anti-VEGF and laser. The patient’s detailed history and clinical and demographical data were recorded and compared. The examination was done, including visual acuity assessment with Snellen’s chart, slit-lamp biomicroscopic examination, Intraocular pressure and pupillary assessment for optic nerve dysfunction.
 Results: The mean age of group-A, B and C were 57.13 ± 6.88, 55.62 ± 5.97 and 54.86 ± 4.98 were comparable. At the same
 
 time, most of the patients were between the age group of 58–66 years [25(41.67%)]. Majority of the patients were male in all three groups. A significant difference was observed in mean FBS and duration of diabetes. In group A and C, most patients affected eye was left [35(58.33%)] and [34(56.67)], respectively, while in group B right eye was affected [33(55.00%)]. The mean VA Log MAR was found to be significant among the three groups. Mean SNELLENS and IOP were insignificant among the groups. At first, follow up the mean VA LOG MAR, SNELLENS, FFA and OCT were found to significant among the groups. At second follow-up, the mean VA LOG MAR was significant. Intragroup analysis between the treatment of the eye was found insignificant, while the rest of the parameters and characteristics were found significant. Conclusion: The present study suggests that the anti-VEGF + PRP were the best treatment regime, followed by anti-VEGF, and PRP was the least effective.

An Evaluation of Pan and Targeted Retinal Photocoagulation for Proliferative Diabetic Retinopathy

This study evaluates the efficacy of pan retinal and targeted retinal photocoagulation (PRP and TRP) for the treatment of proliferative diabetic retinopathy (PDR). A retrospective review of medical records was conducted of patients with PDR who had undergone PRP or TRP as primary treatment at a tertiary care center. Outcome measures included visual acuity, intraocular pressure, and retinal appearance. Results showed that PRP and TRP were both effective in reducing intraocular pressure and improving visual acuity, with no significant difference between the two. However, PRP was associated with a higher rate of retinal detachment and greater risk of recurrence of PDR. Based on the results, PRP and TRP are both effective treatments for PDR, but PRP may be associated with increased risk of complications.

Observation of retinal neovascularization using optical coherence tomography angiography after panretinal photocoagulation for proliferative diabetic retinopathy

BackgroundTo describe the longitudinal changes in retinal neovascularization elsewhere (NVE) as observed on optical coherence tomography angiography (OCTA) in proliferative diabetic retinopathy (PDR) treated by panretinal photocoagulation (PRP).MethodsEach patient included in this prospective clinical study was newly diagnosed with PDR and NVE confirmed by both fundus fluorescein angiography (FFA) and OCTA. They received four sessions of PRP using a multiwavelength laser. Best-corrected visual acuity (BCVA) and OCTA images of the NVE were obtained before each PRP session and at 1 month, 3 months, and 6 months after the PRP treatment. Generalized estimating equations (GEE) was used to investigate the differences between the BCVA and NVE areas before and after PRP.ResultsThirty-two eyes of 32 patients with a mean age of 50.56 ± 7.05 years were included. We found a statistically significant reduction in the NVE area at all time points compared with the baseline except at 6 months (all P < 0.05). Further analysis demonstrated no statistically significant change in the NVE area between two adjacent timepoints except from baseline to post-1st PRP (P < 0.05). BCVA at 3 months showed a statistically significant improvement compared with baseline (P < 0.05), but no significant changes in BCVA were observed during the other visits.ConclusionsWe found an overall regression in the NVE area following PRP starting as early as 1 week after the 1st session and lasting up to 3 months. OCTA provides quantitative information on vascular changes and could be a practical method for the longitudinal evaluation of neovascularization.

Topographical Response of Retinal Neovascularization to Aflibercept or Panretinal Photocoagulation in Proliferative Diabetic Retinopathy

Eyes with proliferative diabetic retinopathy have a variable response to treatment with panretinal photocoagulation (PRP) or anti-vascular endothelial growth factor agents. The location of neovascularization (NV) is associated with outcomes (eg, patients with disc NV [NVD] have poorer visual prognosis than those with NV elsewhere [NVE]). To investigate the distribution of NV in patients with proliferative diabetic retinopathy and the topographical response of NV to treatment with aflibercept or PRP. This post hoc analysis of the phase 2b randomized clinical single-masked multicenter noninferiority Clinical Efficacy and Mechanistic Evaluation of Aflibercept for Proliferative Diabetic Retinopathy (CLARITY) trial was conducted from November 1, 2019, to September 1, 2020, among 120 treatment-naive patients with proliferative diabetic retinopathy to evaluate the topography of NVD and NVE in 4 quadrants of the retina on color fundus photography at baseline and at 12 and 52 weeks after treatment. In the CLARITY trial, patients were randomized to receive intravitreal aflibercept (2 mg/0.05 mL at baseline, 4 weeks, and 8 weeks, and as needed from 12 weeks onward) or PRP (completed in initial fractionated sessions and then on an as-needed basis when reviewed every 8 weeks). Main outcomes were per-retinal quadrant frequencies of NV at baseline and frequencies of patterns of regression, recurrence, and new occurrence at 12-week and 52-week unmasked follow-up. The study included 120 treatment-naive patients (75 men; mean [SD] age, 54.8 [14.6] years) with proliferative diabetic retinopathy (there was a 1:1 ratio of eyes to patients). At baseline, NVD with or without NVE was observed in 42 eyes (35.0%), and NVE only was found in 78 eyes (65.0%); NVE had a predilection for the nasal quadrant (64 [53.3%]). Rates of regression with treatment were higher among eyes with NVE (89 of 102 [87.3%]) compared with eyes with NVD (23 of 43 [53.5%]) by 52 weeks, with NVD being more resistant to either treatment with higher rates of persistence than NVE (20 of 39 [51.3%] vs 29 of 100 [29.0%]). Considering NVE, the regression rate in the temporal quadrant was lowest (32 of 42 [76.2%]). Eyes treated with aflibercept showed higher rates of regression of NVE compared with those treated with PRP (50 of 52 [96.2%] vs 39 of 50 [78.0%]; difference, 18.2% [95% CI, 5.5%-30.8%]; P = .01), but no difference was found for NVD (11 of 17 [64.7%] vs 12 of 26 [46.2%]; difference, 18.6% [95% CI, -11.2% to 48.3%]; P = .23). This post hoc analysis found that NVD is less frequent but is associated with more resistance to currently available treatments than NVE. Aflibercept was superior to PRP for treating NVE, but neither treatment was particularly effective against NVD by 52 weeks. Future treatments are needed to better target NVD, which has poorer visual prognosis. isrctn.org Identifier: ISRCTN32207582.

Macular hole formation following panretinal photocoagulation in proliferative diabetic retinopathy

A 61-year-old woman with diabetes mellitus and hypertension presented with both eyes (OU) floaters. The best corrected visual acuity (BCVA) was 20/30 OU. Anterior segment OU showed grade 2 nuclear...

Impact and Characterization of Delayed Pan-Retinal Photocoagulation in Proliferative Diabetic Retinopathy

The American Academy of Ophthalmology recommends that patients diagnosed with proliferative diabetic retinopathy (PDR) be considered for pan-retinal photocoagulation (PRP) treatment within 1month of diagnosis. This study aimed to investigate the effect delayed treatment had on visual outcomes and to characterize the medical and socioeconomic factors that contributed to delayed treatment of PDR. Retrospective clinical study. This study examined 259 patients diagnosed with PDR and treated with PRP from 2015 to the present. Visual acuity (VA) outcomes through 24months were compared among patients treated the day of diagnosis, and at 1-14days, 14-31days, and >31days post-treatment. The relationships between time to treatment (days between PDR diagnosis and PRP) and medical comorbidities (coronary artery disease and/or myocardial infarction, heart failure, chronic kidney disease, dialysis, stroke, inpatient admission), laboratory values (hemoglobin A1c, blood urea nitrogen, serum creatinine), and socioeconomic factors (health insurance, median household income of ZIP code, and distance from ZIP code to treatment site) were examined. Mean time to treatment for all patients was 27.8 ± 41.4days. VA was significantly decreased in patients who received PRP after 31days compared with those treated on the day of diagnosis at 12 (P < .001) and 24 (P= .03) months post-treatment. Inpatient admission between diagnosis and treatment was significantly associated with an increase in time to treatment (86.5 ± 50.2days; P < .001). In patients with diagnosed PDR, a delay in PRP treatment beyond 31days was associated with worse visual outcomes than those treated earlier. Hospital admissions significantly delayed PRP delivery.

Electroretinogram Changes Following Sequential Panretinal Photocoagulation for Proliferative Diabetic Retinopathy.

PurposeTo evaluate changes in electroretinogram (ERG) response over the course of multiple sessions of panretinal photocoagulation (PRP) in patients with proliferative diabetic retinopathy (PRP).MethodsA prospective cohort study of 11 patients with PDR who required PRP was conducted. PRP was completed over three sessions. Each patient had five ERGs done: baseline, 1 week after each PRP session, and 6 weeks after the last session of PRP. Dark-adapted 0.01 ERG, Dark-adapted 3 ERG, Dark-adapted 10 ERG, Light- adapted 3 ERG, and Light-adapted 30 Hz flicker ERG were done. The mean change in a- and b-wave amplitudes as well as implicit times compared to baseline was analyzed.ResultsA significant reduction in peak amplitudes of both a- and b-waves and delay in latencies were observed in all responses (p<0.05). The absolute amplitude reduction and delay in latency were higher for scotopic b-waves (p<0.05). The root mean square (RMS) of Dark-adapted 10.0 ERG (p<0.05) and total mean amplitude changes of a- and b-waves (p<0.001) were reduced after each laser session; however, the magnitude of change was not different between the first, second, or third sessions of PRP, and each session showed a similar deterioration rate of ERG parameters comparing to each other (p=0.4 for RMS and p=0.2 for total mean amplitude changes). In addition, the results indicated recovery of the amplitude and latency of ERG waves after 6 weeks from the final treatment (p<0.001) although not to baseline levels.ConclusionERG findings following PRP show reduced retinal function after each session which partially recovers by 6 weeks after the completion of therapy. Clinicians should be mindful of these changes when planning the treatment course for patients with PDR.

Incidence and Risk for Developing Proliferative Diabetic Retinopathy after Photocoagulation for Diabetic Maculopathy

ABSTRACT Purpose Diabetic maculopathy (DM) treated with photocoagulation may subsequently progress to proliferative diabetic retinopathy (PDR). However, there is insufficient knowledge about the incidence and risk factors for the development of PDR in patients previously treated for DM. Materials and methods Survival data was used to analyze prospectively collected epidemiological and clinical data to describe the incidence and risk factors for the occurrence of PDR in all 1,235 patients photocoagulation treated for DM in a defined population from the Aarhus area, Denmark, from January 1. 1993 until December 31. 2016. Results Among 1,204 (97.5%) of the patients in whom the subsequent clinical history was known, 536 (44.5%) had died and 131 (10.9%) had received panretinal photocoagulation for PDR. The cumulative incidence of developing PDR after photocoagulation for diabetic maculopathy increased with time to reach a plateau around 13% after approximately 15 years. Earlier age at diagnosis of diabetes and higher HbA1c at the time of macular treatment were significant risk factors for the development of PDR, whereas gender, diabetes type, body mass index, known diabetes duration at the time of macular photocoagulation and blood pressure were not significant risk factors. Conclusions In patients treated with retinal photocoagulation for DM, a tight metabolic control is accompanied with a reduced risk for subsequent progression to PDR. In the treated patients who do not develop PDR, the control interval can be gradually increased with time.

Panretinal Photocoagulation along the Long Ciliary Nerve in Diabetic Retinopathy

Abstract Patients with a history of pan retinal photocoagulation for proliferative diabetic retinopathy underwent ultra-widefield imaging with identification of the long ciliary nerve. This study found high prevalence of photocoagulation along the nerve despite current guidance. Proliferative diabetic retinopathy is a prevalent disease associated with significant morbidity, reduced quality of life, high costs, and significant visual loss. 1 Panretinal photocoagulation (PRP) is a widely-used technique to decrease neovascularization and bleeding and reduce severe vision loss in proliferative diabetic retinopathy (PDR). 2 , 3 Despite its uses, multiple cases have linked peripheral laser photocoagulation near the long ciliary nerve (LCN) to corneal ulceration, transient accommodative paresis and pupillary disturbances 4 , 5 , 6 . Current guidelines from the Basic and Clinical Science Course recommend that “the long ciliary nerves in the 3 o’clock and 9 o’clock meridians should be avoided” during PRP. 7 The development of ultra-widefield (UWF) fundus imaging offers a unique opportunity to visualize the long ciliary nerve. The aim of this study is to establish the frequency of inadvertent panretinal photocoagulation along the long ciliary nerve through confirmation of laser marks on widefield fundus imaging.

Improved Macular Capillary Flow on Optical Coherence Tomography Angiography After Panretinal Photocoagulation for Proliferative Diabetic Retinopathy

This study evaluated the macular microvascular changes in eyes with proliferative diabetic retinopathy (PDR) following panretinal photocoagulation (PRP). Using optical coherence tomographic angiography (OCTA), we prospectively studied 10 eyes of 10 subjects with high-risk PDR immediately before, at 1month, and at 3-6months following PRP, using a 3-× 3-mm OCTA scan at each visit. The following parameters were calculated for the superficial (SCP), middle (MCP), and deep capillary plexuses (DCP): parafoveal vessel density (VD), adjusted flow index (AFI), and percent area of nonperfusion (PAN). Parafoveal SCP vessel-length density (VLD) was also evaluated. We performed univariate and multivariable statistics, adjusting for age and signal strength. To model the hemodynamic effect of PRP, we also present a mathematical model based on electrical circuits. We found no significant difference for the vascular density parameters following PRP, except for decreased density at the MCP at the latest timepoint in the adjusted multivariable model. PAN, a metric of nonperfusion adjusted for noise, and AFI, a surrogate metric of blood flow, showed significant increases at all capillary levels in the adjusted model. Our mathematical model explained how PRP would increase macular blood flow. Using OCTA, we found an overall increase in the flow metrics of all capillary layers in the macula following PRP, unrelated to macular edema or thickening, in line with the mathematical model. Our results suggest an overall redistribution of blood flow to the posterior pole following PRP, adding a new dimension to our understanding of the complex biologic effects of PRP in PDR. NOTE: Publication of this article is sponsored bythe American Ophthalmological Society.

Anti-VEGF Therapy for Persistent Neovascularization after Complete Panretinal Photocoagulation in Proliferative Diabetic Retinopathy

To report the rate of new vessel (NV) regression after monthly injections of bevacizumab in laser-treated proliferative diabetic retinopathy (PDR) eyes with persistent neovascularization. Prospective cohort study. Eyes with PDR with incomplete response to prior complete panretinal photocoagulation (PRP). Ninety eyes of 80 patients with persistent PDR (pPDR) despite adequate PRP were prospectively followed on a monthly basis with anti-vascular endothelial growth factor (VEGF) injections when needed and stereo fundus images looking at the regression of NVs. Regression of NVs. A total of 70 of 90 eyes (77.8%) had regression of the NV. Mean number of injections to reach quiescence was 9±3 for pPDR in the high-risk characteristics (HRC) group (80 eyes) and 3±1 for PDR in the group without HRC (10 eyes) (P < 0.001). All patients with PDR without HRC responded to the adjuvant therapy, whereas 75.0% of the eyes with PDR with HRC responded. Eyes with initial retinal neovascularization all responded to the adjuvant treatment. Eyes without a vitreous hemorrhage at study entry were more likely to respond (odds ratio, 5.43; 95% confidence interval, 1.37-21.44; P < 0.01). Therapy was judged unsuccessful because of the continuous growth of the NV despite treatment (3 eyes), the development of traction (5 eyes), and the development of a dense vitreous hemorrhage (6 eyes). Anti-VEGF rescue therapy has a potential role in select cases of laser-treated PDR with persistent NVs and no evidence of traction to achieve regression of neovessels.

The effect of panretinal photocoagulation on confocal laser scanning ophthalmoscopy and stereo photographic parameters of optic disk topography in patients with diabetic retinopathy.

To determine the effect of panretinal photocoagulation on optic disk topographic parameters in non-glaucomatous patients with proliferative diabetic retinopathy. This was a prospective, single-center, observational study. Thirty-eight eyes of 26 patients with diabetes underwent panretinal photocoagulation for proliferative diabetic retinopathy. Stereoscopic disk photographs and optic nerve head parameters were evaluated using the Zeiss fundus camera and the confocal scanning laser ophthalmoscope (Heidelberg Retinal Tomograph), respectively, at baseline and 12 months after the completion of panretinal photocoagulation. Thirty-eight eyes of 26 patients (15 female) with a mean age of 53.7 (range 26-74) years were recruited. No significant difference was found between the stereo photography determined mean horizontal and vertical cup-to-disk ratio before and after panretinal photocoagulation treatment (p=0.461 and 0.839, respectively). The global values of the optic nerve head parameters analyzed with the HRT3 showed no significant change from baseline to 12 months, including the disk area, cup area, rim area, cup volume, rim volume, cup-to-disk area ratio, linear cup-to-disk ratio, mean cup depth, maximum cup depth, cup shape measure, height variation contour, mean retinal nerve fiber layer thickness, and cross-sectional area. Our results suggest that panretinal photocoagulation does not cause morphological optic disk changes in patients with diabetic proliferative retinopathy after 1 year of follow-up.

Intravitreal aflibercept compared with panretinal photocoagulation for proliferative diabetic retinopathy: the CLARITY non-inferiority RCT

Background Panretinal photocoagulation (PRP) has been the standard of care for patients with proliferative diabetic retinopathy (PDR) for the last 40 years. It prevents severe visual loss in PDR but is also associated with adverse effects on visual functions. Objectives The clinical efficacy and mechanistic evaluation of aflibercept for proliferative diabetic retinopathy (CLARITY) trial evaluated the clinical efficacy, mechanisms and cost-effectiveness of intravitreal aflibercept (Eylea®, Regeneron, Tarrytown, NY, USA/Bayer Pharma AG, Berlin, Germany therapy for PDR. Design A multicentre, prospective, individually randomised, single-masked, active-controlled trial with concurrent economic evaluation that tested the non-inferiority of intravitreal aflibercept versus standard care PRP at 52 weeks. A subset of the participants enrolled in a mechanistic evaluation substudy. Setting 22 UK NHS clinical sites. Participants Patients aged at least 18 years having either treatment-naive PDR or active retinal neovascularisation (NV) despite prior PRP requiring treatment and best corrected visual acuity (BCVA) of 54 Early Treatment Diabetic Retinopathy Study (ETDRS) letters or better in the study eye were included. Eyes with evidence of macular oedema at baseline confirmed by central subfield thickness &gt; 320 µm on spectral-domain optical coherence tomography were excluded. Intervention In the intervention arm, intravitreal aflibercept injections were given at baseline, 4 and 8 weeks and patients were subsequently reviewed every month and injected pro re nata based on the treatment response defined by degree of regression of retinal NV. In the comparator arm, PRP was completed in 2-weekly sessions and then supplemented if necessary at 8-weekly intervals. Main outcome measures The primary outcome was the mean change in BCVA at 52 weeks utilising a linear mixed-effects model incorporating data from both week 12 and week 52. Results A total of 232 participants (116 per arm) were recruited between August 2014 and November 2015. A total of 221 and 210 participants contributed to the intention-to-treat (ITT) model and per-protocol (PP) analysis, respectively. Economic evaluation was undertaken on 202 participants (101 per arm) with complete cost and outcome data. Aflibercept was non-inferior and superior to PRP in both the ITT population [mean BCVA difference 3.9 letters, 95% confidence interval (CI) 2.3 to 5.6 letters; p &lt; 0.0001] and the PP population (difference 4.0 letters, 95% CI 2.4 to 5.7 letters; p &lt; 0.0001). From a public sector multiagency perspective that covers health and social care services, treatment with aflibercept costs more in terms of total resource use (mean adjusted total additional cost per patient = £5475, bootstrapped 95% CI £5211 to £5750) than PRP over a 12-month follow-up period. There were a small number of important safety events in each arm. Patients were more satisfied with aflibercept than PRP. Limitations This study is limited to 1 year of follow-up. Conclusions At an additional cost, the study shows that intravitreal aflibercept is an effective alternative treatment option for PDR in the first year. Future work Future research is needed to evaluate the long-term benefits of aflibercept in comparison with PRP and other anti-vascular endothelial growth factor agents for this condition. Trial registration Current Controlled Trials ISRCTN32207582. Funding This project was funded by the National Institute for Health Research (NIHR) Efficacy and Mechanistic Evaluation programme, a Medical Research Council and NIHR partnership. Aflibercept was supplied by Bayer Plc (Reading, UK). The study was sponsored by NIHR Moorfields Biomedical Research Centre and supported by the UK Clinical Research Network. The research was supported by the NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and University College London Institute of Ophthalmology, the NIHR Moorfields Clinical Research Facility and the UK Clinical Reasearch Collaboration-registered King’s Clinical Trials Unit at King’s Health Partners, which is partly funded by the NIHR Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust and King’s College London.

Serous retinal detachment after panretinal photocoagulation for proliferative diabetic retinopathy: a case report

BackgroundProliferative diabetic retinopathy is a major cause of visual impairment in working-age adults worldwide. Panretinal photocoagulation is a cornerstone in its management; however, it may include a range of side effects and complications, one of these being serous retinal detachment. To the best of our knowledge, this is the first report of the use of intravitreal injection of bevacizumab for serous retinal detachment after panretinal photocoagulation.Case presentationA 24-year-old Saudi man with poorly controlled type 1 diabetes presented with bilateral progressive proliferative retinopathy in spite of several sessions of panretinal photocoagulation. After one additional such session, he developed bilateral serous retinal detachment and vision loss, which was managed with a single bilateral intravitreal bevacizumab injection. The serous retinal detachment subsided with partial recovery of vision.ConclusionsSerous retinal detachment after panretinal photocoagulation for proliferative diabetic retinopathy is a rare complication nowadays. In this case, it seems that excessive photocoagulation exceeded the energy-absorbing capacity of the retinal pigment epithelium, leading to a disruption of the blood–retinal barrier. A single injection of bilateral intravitreal bevacizumab was sufficient to control the serous retinal detachment. This effect may have been due to a reduction of vascular leakage resulting from the mechanism of action of this drug. No complications were noted from the injection. Caution should be exerted when attempting bilateral panretinal photocoagulation.

Patient Comfort with Yellow (577 nm) vs. Green (532 nm) Laser Panretinal Photocoagulation for Proliferative Diabetic Retinopathy

Pain associated with panretinal photocoagulation (PRP) can adversely affect the number and quality of retinal burns delivered and subsequently increase the number of treatment sessions required to achieve regression of proliferative diabetic retinopathy (PDR). We assessed comfort in patients undergoing treatment with yellow (577 nm) vs. green (532 nm) PRP for PDR. Prospective, single-center, randomized crossover clinical trial. Patients with PDR with high-risk characteristics. Subjects were equally randomized to first receive PRP with a laser indirect ophthalmoscope with either green (IQ 532; IRIDEX, Mountain View, CA) or yellow (IQ 577; IRIDEX) laser, followed by additional treatment with the opposite laser using standardized settings in the superior hemisphere of a single treatment eye per patient. Topical anesthetic was used in all study eyes before each treatment and power was titrated until moderate grey-white retinal burns were achieved. The primary outcome measure was patient's perceived pain as measured with a standardized 10-point pain scale. Secondary outcome measures included laser power, treatment time, number of treatment shots with each laser, and physician ease-of-use score with each laser on a 10-point scale. Forty patients (40 eyes) with a mean age of 54.0 years were enrolled. Mean pain scores were similar when comparing treatment with yellow and green laser (3.1 ± 2.3 vs. 2.8 ± 2.6; P= 0.40). No significant difference was seen in visual acuity (P= 0.44) or central macular thickness (P= 0.39) 1 month after PRP. Additionally, there were no significant differences when comparing minimum power required (243.2 ± 74.2 vs. 234.0 ± 59.6 mW; P= 0.55), treatment time (5.1 ± 3.6 vs. 5.6 ± 3.9 minutes; P= 0.384), and number of treatment shots (257.6 ± 12.6 vs. 258.0 ± 2.3; P= 0.68). Six of 7 co-investigators (85%) preferred using yellow laser over green and reported ease-of-use scores of 9.0 ± 1.2 and 7.6 ± 1.4, respectively (P= 0.07). No severe adverse events occurred. Patient comfort during PRP for PDR utilizing laser indirect ophthalmoscopy is similar for green and yellow wavelengths.