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      Intravitreal gas injection for the treatment of diabetic macular edema

      case-report

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          Abstract

          Purpose

          This study investigates the efficacy of an intravitreal gas injection in inducing a posterior vitreous detachment (PVD) in patients with clinically significant diabetic macular edema refractory to laser therapy.

          Methods

          A local ethics committee-approved technique of an intravitreal injection of pure perfluoropropane gas (C 3F 8) was performed for all participants. After a period of prone positioning, the patients underwent regular and detailed clinical review.

          Main outcome measures

          The induction of a PVD, change in macular thickness, change in visual acuity.

          Results

          A PVD was induced in all five eyes with subsequent signs of reduction in macular thickness and resolution of exudates. Mean visual improvement was 11 ETDRS (Early Treatment Diabetic Retinopathy Study) letters (range 4–21). Apart from a transient vitreous hemorrhage in one eye, there were no significant treatment-related complications.

          Conclusion

          The induction of a PVD by pneumatic retinopexy appears to have a significant influence on diabetic macular edema in eyes which have not successfully responded to macular laser therapy. A randomized clinical trial is justified on the basis of the initial promising data.

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          Most cited references20

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          Grading diabetic retinopathy from stereoscopic color fundus photographs--an extension of the modified Airlie House classification. ETDRS report number 10. Early Treatment Diabetic Retinopathy Study Research Group.

          (1991)
          The modified Airlie House classification of diabetic retinopathy has been extended for use in the Early Treatment Diabetic Retinopathy Study (ETDRS). The revised classification provides additional steps in the grading scale for some characteristics, separates other characteristics previously combined, expands the section on macular edema, and adds several characteristics not previously graded. The classification is described and illustrated and its reproducibility between graders is assessed by calculating percentages of agreement and kappa statistics for duplicate gradings of baseline color nonsimultaneous stereoscopic fundus photographs. For retinal hemorrhages and/or microaneurysms, hard exudates, new vessels, fibrous proliferations, and macular edema, agreement was substantial (weighted kappa, 0.61 to 0.80). For soft exudates, intraretinal microvascular abnormalities, and venous beading, agreement was moderate (weighted kappa, 0.41 to 0.60). A double grading system, with adjudication of disagreements of two or more steps between duplicate gradings, led to some improvement in reproducibility for most characteristics.
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            Photocoagulation for diabetic macular edema. Early Treatment Diabetic Retinopathy Study report number 1. Early Treatment Diabetic Retinopathy Study research group.

            (1985)
            Data from the Early Treatment Diabetic Retinopathy Study (ETDRS) show that focal photocoagulation of "clinically significant" diabetic macular edema substantially reduces the risk of visual loss. Focal treatment also increases the chance of visual improvement, decreases the frequency of persistent macular edema, and causes only minor visual field losses. In this randomized clinical trial, which was supported by the National Eye Institute, 754 eyes that had macular edema and mild to moderate diabetic retinopathy were randomly assigned to focal argon laser photocoagulation, while 1,490 such eyes were randomly assigned to deferral of photocoagulation. The beneficial effects of treatment demonstrated in this trial suggest that all eyes with clinically significant diabetic macular edema should be considered for focal photocoagulation. Clinically significant macular edema is defined as retinal thickening that involves or threatens the center of the macula (even if visual acuity is not yet reduced) and is assessed by stereo contact lens biomicroscopy or stereo photography. Follow-up of all ETDRS patients continues without other modifications in the study protocol.
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              Primary intravitreal bevacizumab (Avastin) for diabetic macular edema: results from the Pan-American Collaborative Retina Study Group at 6-month follow-up.

              To report the 6-month anatomic and best-corrected visual acuity (BCVA) response after primary intravitreal bevacizumab (Avastin) in patients with diabetic macular edema (DME). Interventional retrospective multicenter study at 6 centers from 6 countries of patients with DME. We reviewed the clinical records of 88 consecutive patients (110 eyes) with DME. Seventy-eight eyes of 64 consecutive patients with a minimum follow-up of 6 months and mean age of 59.7+/-9.3 years were included in this analysis. Patients were treated with at least one intravitreal injection of 1.25 mg or 2.5 mg of bevacizumab and underwent Early Treatment Diabetic Retinopathy Study (ETDRS) BCVA testing, ophthalmoscopic examination, optical coherence tomography (OCT), and fluorescein angiography (FA) at baseline and follow-up visits. Repeated-measures analysis of variance was used to compare mean values. Changes in BCVA, OCT, and FA. Mean follow-up was 6.31+/-0.81 months (range, 6-9). Sixteen (20.5%) eyes needed a second injection at a mean of 13.8 weeks (range, 4-28), and 6 eyes needed a third injection (7.7%) at a mean of 11.5 weeks (range, 5-20). The mean baseline BCVA was 0.87 (logarithm of the minimum angle of resolution), and the final mean BCVA was 0.6, a difference that was statistically significant (P or =2 ETDRS lines of BCVA, and 3 (3.8%) decreased > or =2 ETDRS lines of BCVA. Mean central macular thickness at baseline by OCT was 387.0+/-182.8 mum and decreased to a mean of 275.7+/-108.3 at end of follow-up (P<0.0001). No ocular or systemic adverse events were observed. Primary intravitreal bevacizumab at doses of 1.25 to 2.5 mg seem to provide stability or improvement in VA, OCT, and FA in DME at 6 months. Follow-up is still short to make any specific treatment recommendations; however, the results appear promising. Evaluation in a multicenter randomized controlled clinical trial with longer follow-up is needed.
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                Author and article information

                Journal
                Clin Ophthalmol
                Clinical Ophthalmology
                Clinical Ophthalmology (Auckland, N.Z.)
                Dove Medical Press
                1177-5467
                1177-5483
                2011
                2011
                26 October 2011
                : 5
                : 1543-1548
                Affiliations
                King’s College Hospital, Denmark Hill, London, England, UK
                Author notes
                Correspondence: Bhaskar Gupta, King’s College Hospital, Denmark Hill, London SE5 9RS, England, UK, Tel +44 20 32994548, Fax +44 20 32993738, Email gupta_bhaskar@ 123456yahoo.com
                Article
                opth-5-1543
                10.2147/OPTH.S25348
                3218162
                22125399
                2b08d9e7-c01b-4dc1-8de2-d5f1005c0c44
                © 2011 McHugh et al, publisher and licensee Dove Medical Press Ltd

                This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited.

                History
                Categories
                Case Series

                Ophthalmology & Optometry
                optical coherence tomography,oct,posterior vitreous detachment,perfluoropropane

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