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      Effect of Intravitreal Bevacizumab Based on Optical Coherence Tomography Patterns of Diabetic Macular Edema

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          Abstract

          Aim: To compare the effects of intravitreal bevacizumab on different morphologic patterns of diabetic macular edema (DME) classified using optical coherence tomography (OCT). Materials and Methods: Medical records for 65 eyes of 48 patients were retrospectively reviewed, and each subject was classified as one of three DME types according to the OCT features: diffuse retinal thickening (DRT), cystoid macular edema (CME), serous retinal detachment (SRD). Subjects were given three monthly intravitreal injections of bevacizumab (1.25 mg/0.05 ml). The clinical course of best-corrected visual acuity (BCVA) with a logarithm of the minimum angle of resolution chart and central foveal thickness (CFT) using OCT was monitored for 12 months after the injections. On follow-up, injections were repeated if DME remained or was aggravated. Results: Of the 65 eyes with DME, 29 eyes were of the DRT type, 21 of the CME type, and 15 of the SRD type. Before the injection, CFT and BCVA were, respectively, 377.1 ± 145.9 µm and 0.54 ± 0.36 in the DRT type, 427.7 ± 143.1 µm and 0.59 ± 0.42 in the CME type, and 485.1 ± 187.1 µm and 0.65 ± 0.27 in the SRD type; there was no significant difference in CFT and BCVA between DME types (p > 0.05). At 6 months, the changes in BCVA and CFT differed significantly between OCT types (p < 0.05). At 12 months, changes in CFT and BCVA from baseline were not significantly different between groups (p > 0.05). The DRT type was associated with a greater reduction in the CFT and greater BCVA improvement than the CME or SRD types. Conclusions: Three monthly injections of intravitreal bevacizumab seem to be effective treatment in the first 6 months, but the therapeutic effect is temporary and repeated injections of bevacizumab should be considered to maintain the therapeutic effect after 6 months. In addition, intravitreal injection of bevacizumab was more effective in the DRT type than in the CME or SRD types of DME.

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

          Michael Elman, Lloyd Paul Aiello, Roy Beck … (2010)
          Evaluate intravitreal 0.5 mg ranibizumab or 4 mg triamcinolone combined with focal/grid laser compared with focal/grid laser alone for treatment of diabetic macular edema (DME). Multicenter, randomized clinical trial. A total of 854 study eyes of 691 participants with visual acuity (approximate Snellen equivalent) of 20/32 to 20/320 and DME involving the fovea. Eyes were randomized to sham injection + prompt laser (n=293), 0.5 mg ranibizumab + prompt laser (n=187), 0.5 mg ranibizumab + deferred (> or =24 weeks) laser (n=188), or 4 mg triamcinolone + prompt laser (n=186). Retreatment followed an algorithm facilitated by a web-based, real-time data-entry system. Best-corrected visual acuity and safety at 1 year. The 1-year mean change (+/-standard deviation) in the visual acuity letter score from baseline was significantly greater in the ranibizumab + prompt laser group (+9+/-11, P<0.001) and ranibizumab + deferred laser group (+9+/-12, P<0.001) but not in the triamcinolone + prompt laser group (+4+/-13, P=0.31) compared with the sham + prompt laser group (+3+/-13). Reduction in mean central subfield thickness in the triamcinolone + prompt laser group was similar to both ranibizumab groups and greater than in the sham + prompt laser group. In the subset of pseudophakic eyes at baseline (n=273), visual acuity improvement in the triamcinolone + prompt laser group appeared comparable to that in the ranibizumab groups. No systemic events attributable to study treatment were apparent. Three eyes (0.8%) had injection-related endophthalmitis in the ranibizumab groups, whereas elevated intraocular pressure and cataract surgery were more frequent in the triamcinolone + prompt laser group. Two-year visual acuity outcomes were similar to 1-year outcomes. Intravitreal ranibizumab with prompt or deferred laser is more effective through at least 1 year compared with prompt laser alone for the treatment of DME involving the central macula. Ranibizumab as applied in this study, although uncommonly associated with endophthalmitis, should be considered for patients with DME and characteristics similar to those in this clinical trial. In pseudophakic eyes, intravitreal triamcinolone + prompt laser seems more effective than laser alone but frequently increases the risk of intraocular pressure elevation. Copyright 2010 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.
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            Intravitreal bevacizumab (Avastin) therapy for persistent diffuse diabetic macular edema.

            Christos Haritoglou, Daniel Kook, Aljoscha Neubauer … (2015)
            To evaluate the efficacy of bevacizumab (Avastin; Genentech, Inc., South San Francisco, CA) for the treatment of diabetic macular edema. This prospective, consecutive, noncomparative case series included 51 consecutive patients (26 females and 25 males; mean age, 64 years) with diffuse diabetic macular edema. Inclusion criteria were determined independently of the size of edema, retinal thickness, visual acuity, age, metabolic control, type of diabetes, or previous treatments beyond a 6-month period. At each visit, patients underwent complete eye examination, including determination of best-corrected visual acuity, slit-lamp examination, intraocular pressure measurement, stereoscopic biomicroscopy of the macula, retinal thickness measurement by optical coherence tomography, fluorescein angiography, and fundus photography. After written informed consent was obtained, all patients were treated with a 0.05-mL injection containing 1.25 mg of bevacizumab. All patients completed 6 weeks of follow-up; 23 (45%) completed 12 weeks of follow-up. Sixteen patients (70%) had received at least two intravitreal injections. All patients had undergone previous treatments, such as focal laser therapy (35%), full-scatter panretinal laser therapy (37%), vitrectomy (12%), and intravitreal injection of triamcinolone (33%). The mean diameter of the foveal avascular zone was 503 micro m, with 49% with values of >500 micro m. At baseline, mean visual acuity +/- SD was 25.88 +/- 14.43 ETDRS letters (0.86 +/- 0.38 logMAR of Snellen letters). Mean central retinal thickness by optical coherence tomography +/- SD was 501 +/- 163 micro m (range, 252-1,031 micro m). Mean visual acuity +/- SD increased to 0.75 +/- 0.37 logMAR of Snellen letters at 6 weeks after injection (P = 0.001), with some regression to 0.84 +/- 0.41 logMAR of Snellen letters after 12 weeks. Changes in ETDRS letters were not significant throughout follow-up. Mean retinal thickness +/- SD decreased to 425 +/- 180 micro m at 2 weeks (P = 0.002), 416 +/- 180 micro m at 6 weeks (P = 0.001), and 377 +/- 117 micro m at 12 weeks (P = 0.001). Changes of retinal thickness and visual acuity correlated weakly (r = -0.480 and P = 0.03 at 6 weeks; r = -0.462 and P = 0.07 at 12 weeks). The increase of visual acuity after 6 weeks as measured by ETDRS charts could be predicted best by baseline visual acuity. No other factors investigated, such as age, thickness by optical coherence tomography, or previous treatments, were predictive for the increase in visual acuity. Even in cases of diffuse diabetic macular edema not responding to previous treatments such as photocoagulation, intravitreal injection of triamcinolone, or vitrectomy, improvement of visual acuity and decrease of retinal thickness could be observed after intravitreal injection of bevacizumab. Although our follow-up period was too short to provide specific treatment recommendations, the short-term results encourage further prospective studies with different treatment groups and longer follow-up.
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              Intravitreal triamcinolone acetonide for diabetic diffuse macular edema: preliminary results of a prospective controlled trial.

              Alain Gaudric, Rym Benosman, Ali Erginay … (2004)
              To evaluate prospectively the efficacy and safety of 1 intravitreal injection of 4 mg of triamcinolone acetonide for refractory diffuse diabetic macular edema. Interventional case series. Fifteen patients with bilateral diabetic macular edema unresponsive to laser photocoagulation. In all patients, one eye received the injection, and the other served as a control. Intravitreal injection of 4 mg of triamcinolone acetonide under subconjunctival anesthesia. The main outcome measure was central macular thickness (CMT) at 1, 3, and 6 months, measured by optical coherence tomography. Secondary outcomes were Early Treatment Diabetic Retinopathy Study (ETDRS) scores, intraocular pressure, and cataract progression. In this preliminary report, we give the results for 12 patients who had a follow-up of at least 3 months. Seven of them were followed up for 6 months. Before injection, CMT was 509.6+/-143.5 microm (mean +/- standard deviation [SD]) in injected eyes, versus 474.4+/-82.6 microm in control eyes. Four weeks after injection, it was 207.3+/-44.2 microm in injected eyes and 506.7+/-122.4 microm in control eyes (P<0.001, bilateral Wilcoxon test for paired samples), and after 12 weeks, 207+/-96.7 microm and 469.3+/-117.6 microm, respectively (P = 0.005). The difference between the CMTs of injected and control eyes was no longer significant at 24 weeks because of the recurrence of macular edema in 5 of 12 injected eyes. Before triamcinolone injection, the ETDRS score was 47.8+/-13 (mean +/- SD; range, 28-66) in injected eyes, versus 51.9+/-14.6 (range, 31-71) in control eyes. Twelve weeks thereafter, the corresponding values were 52.7+/-10.8 (range, 34-70) and 50.8+/-14.3 (range, 29-69), respectively, and at 24 weeks, 54.7+/-7.6 (range, 47-68) and 50.6+/-18.4 (range, 28-71). At no time was the difference between the ETDRS scores for injected and control eyes significant. In 6 of the 12 injected eyes, intraocular pressure exceeded 25 mmHg, and was controlled by topical medication. Intravitreal injection of triamcinolone effectively reduces macular thickening due to diffuse diabetic macular edema, at least in the short term. Further studies are required to demonstrate that it provides visual benefit.
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                Author and article information

                Journal
                Journal ID (publisher-id): OPH
                Journal ID (nlm-ta): Ophthalmologica
                Journal ID (doi): 10.1159/issn.0030-3755
                Title: Ophthalmologica
                Publisher: S. Karger AG
                ISSN (Print): 0030-3755
                ISSN (Electronic): 1423-0267
                Publication date Subscription-year: 2011
                Publication date (Print): September 2011
                Publication date (Electronic): 03 August 2011
                Volume: 226
                Issue: 3
                Pages: 138-144
                Affiliations
                aDepartment of Ophthalmology, Inje University Seoul Paik Hospital, bDepartment of Ophthalmology, Kyung Hee University Hospital, Kyung Hee University, and cDepartment of Ophthalmology, Eulji University Hospital, Seoul, Korea
                Author notes
                *Seung-Young Yu, Department of Ophthalmology, Kyung Hee University Hospital, 1 Hoegi-dong, Dongdaemun-gu, Seoul 130-702 (Republic of Korea), Tel. +82 2 958 8455, E-Mail syyu@khu.ac.kr
                Article
                Publisher ID: 330045 Other ID: Ophthalmologica 2011;226:138–144
                DOI: 10.1159/000330045
                PubMed ID: 21822008
                SO-VID: 088ebd9f-c49b-46aa-a199-8bfbccdd4d44
                Copyright © © 2011 S. Karger AG, Basel
                License:

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                History
                Date received : 28 March 2011
                Date accepted : 08 June 2011
                Page count
                Figures: 3, Tables: 3, Pages: 7
                Categories
                Subject: EURETINA – Original Paper

                ScienceOpen disciplines: Vision sciences,Ophthalmology & Optometry,Pathology
                Keywords: Bevacizumab,Optical coherence tomography,Diabetic macular edema
                Data availability:
                ScienceOpen disciplines: Vision sciences, Ophthalmology & Optometry, Pathology
                Keywords: Bevacizumab, Optical coherence tomography, Diabetic macular edema

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