TREATMENT OF DIABETIC MACULAR EDEMA

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Primary treatment of diabetic macular edema

Primary treatment of diabetic macular edema

There are two ways to deliver steroids into the vitreous cavity. The fi rst is by direct injection into the vitreous cavity (intravitreal injection); triamcinolone is the most frequently used steroid for this purpose. In a recent prospective randomized study of more than 100 patients, intravitreal injection of triamcinolone improved visual acuity and decreased retinal thickness compared to baseline, and neither endpoint was signifi cantly different compared to macular laser treatment alone or laser combined with triamcinolone. 9 These fi ndings suggest that triamcinolone treats DME at least as well as laser alone over six months of follow-up, although some patients in the study had received previous laser treat- ment. 9 Intravitreal triamcinolone has also been successfully combined with macular laser treatment as the initial therapy for diabetic macular edema. 10,11 In addition, numerous studies have shown that intravitreal steroids reduce macular edema in cases that are refractory to laser treatment, although visual acuity does not consistently improve in these cases,
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Intravitreal gas injection for the treatment of diabetic macular edema

Intravitreal gas injection for the treatment of diabetic macular edema

Discussion The influence of the vitreoretinal relationship in diabetic macular edema has been long recognized, 12,13 and pars plana vitrectomy has been employed to induce a PVD and peel the inner limiting membrane, or any associated epiretinal mem- brane. The observed postoperative improvement in macular status has however been mitigated by such side effects as cataract formation, retinal breaks, and retinal detachment. 8,9 There are also logistical considerations with this technique in that it requires access to specialized facilities and must be performed by a vitreoretinal specialist. In many regions and countries, there are insufficient resources to allow the ready availability of this form of treatment.
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Dexamethasone intravitreal implant in the treatment of diabetic macular edema

Dexamethasone intravitreal implant in the treatment of diabetic macular edema

DeX implant + laser superior to laser alone at 1 month and 9 months (P0.007) BCVA change from B/L (AUC approach) CRT change from B/L Macular leakage change from B/L DeX implant + laser superior to laser alone over 12 months (P0.001) DeX implant + laser similar to laser alone at 12 months (P= NS) DeX implant + laser superior to laser alone at 3–12 months (P0.05) Phase III Randomized, double-masked, multicenter; pooled analysis (Boyer et al82; Danis et al ARvO83) 3 yearsBCvA 34–68 eTDRS letters; CRT 300µm; n=1,048DeX implant 0.7 mgDeX implant 0.35 mg Sham injection Percent patients with 15-letter improvement in BCvA CRT: mean AUC change from B/L DEX implant 0.7 mg (22.2%) and 0.35 mg (18.4%) superior to sham (12.0%) at 3 years (P0.018) DeX implant 0.7 mg (-111.6µm) and 0.35 mg (-107.9µm) superior to sham (-41.9µm) at 3 years (P0.001) Abbreviations: ARVO, Association for Research in Vision and Ophthalmology; AUC, area under curve; B/L, baseline; BCVA, best-corrected visual acuity; CRT, central retinal thickness; DEX implant, dexamethasone intravitreal implant; DME, diabetic macular edema; ETDRS, Early Treatment Diabetic Retinopathy Study; NS, nonsignificant.
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Fluocinolone acetonide intravitreal implant for the treatment of diabetic macular edema

Fluocinolone acetonide intravitreal implant for the treatment of diabetic macular edema

Abbreviations: DME, diabetic macular edema; FAc, fluocinolone acetonide; IOP, intraocular pressure; vA, visual acuity; vEGF, vascular endothelial growth factor. cation over nearly 3 years, which obviates the need for repeat procedures during the treatment window. This can be particularly valuable in previously vitrectomized eyes, where drug clearance is higher than in eyes with an intact vitreous. Each device has shown clinical efficacy in both functional and anatomic measures. Lastly, unlike anti- VEGF therapies, there are no reported cases of systemic complications from local therapy in fluocinolone-treated eyes.
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FDA approves Lucentis (ranibizumab injection) for treatment of diabetic macular edema

FDA approves Lucentis (ranibizumab injection) for treatment of diabetic macular edema

First major treatment advance in more than 25 years for sight-threatening condition Roche (SIX: RO, ROG; OTCQX: RHHBY) today announced that Lucentis (ranibizumab injection) was approved by the U.S. Food & Drug Administration (FDA) for treatment of diabetic macular edema (DME), an eye condition in people with diabetes that causes blurred vision, severe vision loss and sometimes blindness. Diabetes is now the leading cause of new cases of blindness in American adults, 1 and DME is estimated to affect more than 560,000 Americans with the disease. 2

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Ranibizumab in the treatment of patients with visual impairment due to diabetic macular edema

Ranibizumab in the treatment of patients with visual impairment due to diabetic macular edema

Abstract: Diabetic macular edema is the major cause of visual acuity impairment in diabetic patients. The exact etiopathogenesis is unknown and, currently, grid/focal retinal laser photocoagulation represents the recommended treatment. It has been demonstrated that vascular endothelial growth factor (VEGF) plays a key role in the pathogenesis of diabetic macular edema by mediating vascular permeability and accumulation of intracellular and extracellular fluid, and thereby represents an appealing candidate as a therapeutic target for the treatment of diabetic macular edema. The advent of intravitreal anti-VEGF drugs has opened up a new era for the management of diabetic macular edema. At present, three anti-VEGF substances are available for routine clinical use, ie, pegaptanib, ranibizumab, and bevacizumab. The aim of this review is to summarize the evidence supporting the use of ranibizumab in clinical practice. Most of the studies analyzed in this review are prospective, controlled clinical trials that have focused on documenting the therapeutic effect of ranibizumab and its safety, providing encouraging results.
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Preliminary Assessment of Celecoxib and Microdiode Pulse Laser Treatment of Diabetic Macular Edema

Preliminary Assessment of Celecoxib and Microdiode Pulse Laser Treatment of Diabetic Macular Edema

Methods—In this prospective, factorial, randomized, multicenter trial, we compared cyclo- oxygenase-2 inhibitor (celecoxib) with placebo and diode grid laser with standard Early Treatment Diabetic Retinopathy Study focal laser treatment in 86 participants with diabetic macular edema. The primary outcome is change in visual acuity of ≥15 letters from baseline, and the secondary outcomes include a 50% reduction in the retinal thickening of diabetic macular edema measured by optical coherence tomography and a 50% reduction in leakage severity on fluorescein angiography.
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Advocating for Improved Treatment and Outcomes for Diabetic Macular Edema

Advocating for Improved Treatment and Outcomes for Diabetic Macular Edema

The International Expert Summit on Advocating for Improved Treatment and Outcomes for Diabetic Macular Edema was convened in Paris, France on June 22, 2014. Dr. William Li, President, Medical Director, and Co-Founder of the Angiogenesis Foundation was the Chair of the event, along with regional Co-Chairs Dr. Francisco Rodriguez (representing Latin America), Dr. Ramin Tadayoni (Europe), and Dr. Tien Yin Wong (Asia-Pacific). This event was not a traditional scientific meeting, but rather an interactive, professionally moderated set of short presentations and roundtable discussions that aimed to establish a dialogue and agreement among the participants. The summit opened with three short presentations. The first presentation outlined the scope of the burden from DME-related vision and its global public health implications; the second offered an overview of the etiology, diagnosis, and treatment options for DME; and the third provided a state-of-the-art review of anti-VEGF therapies. Under the direction of the moderator, the assembled experts, who represented 13 different countries, then engaged in a discussion that defined and prioritized what DME
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Intravitreal pegaptanib for the treatment of ischemic diabetic macular edema

Intravitreal pegaptanib for the treatment of ischemic diabetic macular edema

Dovepress Treatment of ischemic diabetic macular edema with pegaptanib Research funding was provided by Pfizer Ltd. However, Pfizer Ltd was not acting as sponsor for this study. It had no involvement in the design of the study protocol and analysis of the data. The study drug was provided by Pfizer Ltd, free of charge, for use in this study. It was stored and used according to the manufacturer’s instructions. The treatment window was up to 3 weeks after the planned injection date. If an injection was given late, then the next injection was given no less than 4 weeks later. Participants were allowed to continue to receive treatment in the study if they missed one injection. After each pegaptanib injection the participant received a broad-spectrum antibiotic (ofloxacin 0.3%) 4 × /d for 3 days. The final assessment was 6 weeks after the fifth intravitreal pegaptanib injection.
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Diabetic macular edema: new concepts in patho-physiology and treatment

Diabetic macular edema: new concepts in patho-physiology and treatment

Abstract Diabetic macular edema (DME), a serious eye complication caused primarily by hyperglycemia, is one of the major causes of blindness. DME, which is characterized by cystic retinal thickening or lipid deposition, is prone to relapse after successful treatment. DME is a complex pathological process caused by multiple factors, including breakdown of the inner and outer blood-retinal barriers, oxidative stress, and elevated levels of vascular endothelial growth factor which have been demonstrated in both preclinical and clinical studies. Starling ’ s law theory explains many of the features of DME. Early detection and treatment of DME can prevent vision loss. Current effective interventions for DME include treatment of systemic risk factors, such as elevated blood glucose, blood pressure and dyslipidemia.
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Surgical Versus Medical Treatment for Diabetic Macular Edema: A Review

Surgical Versus Medical Treatment for Diabetic Macular Edema: A Review

ABSTRACT We aimed to compare the results of pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling, an alternative therapeutic strategy, with those of medical treatment for chronic macular edema. We conducted a review of the literature on the microscopic, anatomical, and functional reasons for performing PPV with ILM peeling in patients with diabetic macular edema (DME). We searched the PubMed database for articles published between 2000 and 2017. We used the medical subject heading “vitrectomy diabetic macular edema” and the keywords “diabetic macular edema”, “internal limiting membrane peeling”, “pars plana vitrectomy”, “diabetic retinopathy”, and “optical coherence tomography”. Analysis of the literature revealed that cytokines, vascular endothelial growth factor, reactive oxygen species (ROS), and advanced glycation end-products (AGEs) play a unique role in DME. The vitreous cavity serves as a physiological reservoir for all inflammatory molecules. AGE receptors are localized at the footplates of Müller cells and the external limiting membrane (ELM). The footplates of Müller cells are in contact with the ILM, which suggests that they might be responsible for the structural damage (i.e., thickening) observed in the ILM of patients with DME. Therefore, PPV could allow a reduction of cytokines and pro-inflammatory molecules from the vitreous cavity. ILM peeling could eliminate not only the physical traction of a thickened structure, but also the natural reservoir of AGEs, ROS, and inflammatory molecules. PPV with ILM peeling is a surgical option that should be considered when treating patients with chronic DME.
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Treatment patterns in diabetic macular edema in Taiwan: a retrospective chart review

Treatment patterns in diabetic macular edema in Taiwan: a retrospective chart review

Keywords: macular edema, diabetes, treatment patterns, treatment outcome, anti-vascular endothelial growth factor, corticosteroid Introduction The global prevalence of diabetes mellitus among people aged 20–79 years is expected to increase by 20% in 2030, compared with 2010. 1 This rapid growth poses a worldwide health and economic challenge, 2 in part because common microvas- cular complications of diabetes mellitus (diabetic retinopathy and diabetic macular edema [DME]), 2,3 are leading causes of visual impairment in developed countries. 2–5 Consistent with this assessment, an analysis of the Taiwan Longitudinal Health Insurance Database revealed that, among patients with type 2 diabetes, the number
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Fluocinolone acetonide and its potential in the treatment of chronic diabetic macular edema

Fluocinolone acetonide and its potential in the treatment of chronic diabetic macular edema

Abstract: Diabetic macular edema (DME) is a potentially sight-threatening disease that predominantly affects patients with type 2 diabetes. The pathogenesis is complex, with many contributing factors involved. In addition to overexpression of vascular endothelial growth factor in the diabetic eye, there is an inflammatory pathway that contributes to the breakdown of the blood-retina barrier and nonperfusion. In addition to vascular endothelial growth factor inhibitors, clinical and experimental investigations underline the great potential of steroids in the treatment of DME. Fluocinolone acetonide is currently the only corticosteroid approved for the treatment of DME in Europe. It is manufactured as an intravitreal insert, releasing fluocinolone acetonide at a rate of 0.2 µg per day. Phase III clinical studies have demonstrated that the beneficial effect of the fluocinolone acetonide insert lasts up to 3 years. Improvement in visual acuity was especially remarkable in patients with a prolonged duration of DME of at least 3 years at the initiation of therapy. Cataract formation occurs in nearly all phakic eyes treated, and needs to be considered when the indication for treatment is made. Given the efficacy versus potential complications of the insert, fluocinolone acetonide represents a promising second-line treatment option in patients with DME. Fluocinolone appears to be especially beneficial for patients whose options for visual recovery have seemed limited up until now.
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Intravitreal Fasudil Combined with Bevacizumab for Treatment of Refractory Diabetic Macular Edema; a Pilot Study

Intravitreal Fasudil Combined with Bevacizumab for Treatment of Refractory Diabetic Macular Edema; a Pilot Study

Please share how this access benefits you. Your story matters. Citation Nourinia, Ramin, Hamid Ahmadieh, Mohammad-Hassan Shahheidari, Souska Zandi, Shintaro Nakao, and Ali Hafezi- Moghadam. 2013. “Intravitreal Fasudil Combined with Bevacizumab for Treatment of Refractory Diabetic Macular Edema; a Pilot Study.” Journal of Ophthalmic & Vision Research 8 (4): 337-340.

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Critical appraisal of ranibizumab in the treatment of diabetic macular edema

Critical appraisal of ranibizumab in the treatment of diabetic macular edema

Adequate control of blood glucose, systemic arterial hypertension, hyperlipidemia, and other risk factors can decrease the development of diabetic retinopathy in type 1 patients by 76% and decrease progression of the disease by 54% over a nine-year period. 16 The Early Treatment of Diabetic Retinopathy Trial showed that laser photocoagula- tion for clinically significant macular edema reduces the risk of moderate vision loss by one half (23% versus 12%) over three years, but gains in vision occur slowly, and only 3% of patients experience a 15-letter improvement. 17 Unfortunately, the risks of laser photocoagulation include foveal damage due to inadvertent macular photocoagulation when laser is performed on microaneurysms close to the fovea and post- operative expansion of treatment scars, 18 both of which may result in a permanent decrease in visual acuity. Corticosteroid therapy with intraocular injections, inserts, and implants are effective, but all are accompanied by high rates of glaucoma and cataract formation. 19
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The effects and safety of intravitreal triamcinolone injections in the treatment of diabetic macular edema

The effects and safety of intravitreal triamcinolone injections in the treatment of diabetic macular edema

After a 6-month observation period, 6 patients were diagnosed with DME of a mostly tractional character. In these patients only a minimal effect was observed after IVTA, so pars plana (PP) vitrectomies were performed, combined with phacoemulsification. In 17 other patients, IVTA was repeated after 6 months due to recurrent DME; 5 of these developed cataracts and the IVTA was com- bined with phacoemulsification. In 6 patients IVTA was repeated 4 times, and in 1 patient 5 times. In patients with recurrent DME after repeated IVTA, fluorescein angiog- raphy was carried out and compared with pretreatment images. In 5 such patients avascular zones, which were not covered by laser spots, were found in the periphery of the retina. This observation supports some suggestions from other authors that macular edema is caused by vas- cular endothelial growth factor (VEGF) from ischemia in the peripheral retina. 17 The ETDRS guidelines do not rec-
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Intravitreal aflibercept versus intravitreal ranibizumab for the treatment of diabetic macular edema

Intravitreal aflibercept versus intravitreal ranibizumab for the treatment of diabetic macular edema

Wells et al 15 studied the effect of aflibercept, bevaci- zumab, and ranibizumab for DME. They concluded that the relative effect of these drugs depended on baseline visual acuity. When the initial visual acuity loss was mild, there were no apparent differences, on average, among the study groups. At worse levels of initial visual acuity, aflibercept was more effective at improving vision. In the present study, the baseline visual acuity was between 0.25 and 0.1, which is a common presenting visual acuity in parts of the world without a tight diabetic retinopathy screening program. In those eyes, other studies 15,23 showed that aflibercept was superior to bevacizumab and ranibizumab regrading visual gain. At the end of the follow-up period, this study failed to show significant difference in BCVA between afliber- cept and ranibizumab (P = 0.27) but showed less treatment burden with aflibercept. This could be explained by smaller sample size.
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Evaluation of markers of outcome in real-world treatment of diabetic macular edema

Evaluation of markers of outcome in real-world treatment of diabetic macular edema

The presence of an intact EZ and better BCVA at baseline, were important for attaining higher final BCVA scores. The 3 M re-rating of the EZ strongly correlated with being a functional responder. It is not clear whether the improvement of the EZ at 3 M was due to re-arrangement of the photoreceptors, true neuronal re- generation or just better definition of the OCT scan. Laser naivety was found to be a predictor of better func- tional outcome, using the multivariate linear regression model. This is an important issue since laser was widely used in most RCTs [6]. Laser rescue seems to decrease the number of injections and CRT at a cost of a lesser gain in the BCVA [15], making the role of laser rescue questionable [16]. However, when using the logistic re- gression model, laser naivety was not independent from the duration of diabetes. This association of a factor that indicates better prognosis (laser naivety, using the multi- variate regression model) with a factor that does not (duration of diabetes) may be attributed to the shift in DME treatment, from laser to anti-VEGFs, where laser naivety would be a real prognostic factor indeed or, on the other hand, may indicate that eyes with a history of laser photocoagulation had prior history of DME, there- fore worsening the prognosis [17]. Good metabolic con- trol was associated with being a functional responder, and it was confirmed to be an independent marker when using the linear multivariate regression model. These data enhance the importance of good metabolic control when using non-fixed regimens of treatment.
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Efficacy of intravitreal bevacizumab (AvastinTM) for short-term treatment of diabetic macular edema

Efficacy of intravitreal bevacizumab (AvastinTM) for short-term treatment of diabetic macular edema

INTRODUCTION Diabetic retinopathy (DR) is a major cause of visual loss in patients with diabetes mellitus. Dia- betic macular edema (DME), which can occur at any stage of DR, is characterised by increased vas- cular permeability and the deposition of hard exu- dates at the central retina. Diabetic macular edema is now the principal cause of vision loss in people

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Role of implants in the treatment of diabetic macular edema: focus on the dexamethasone intravitreal implant

Role of implants in the treatment of diabetic macular edema: focus on the dexamethasone intravitreal implant

All of the patients were treated with laser photocoagulation 1 month later, and retreatment with the DEX implant was done at 6 and 9 months as needed. The laser photocoagula- tion was repeated at 3 month intervals as required. At least a 10 letter statistically significant increase from the base- line was obtained in a higher percentage of the patients at week 1 and months 1 and 9 in the DEX implant plus laser group. Additionally, a significant difference in the BCVA was found in a higher percentage for the DEX implant with laser at week 1 and months 1, 4, and 9 in a subgroup of the DME patients with diffuse macular capillary bed leakage. As the primary efficacy variable, there was no significant difference found for $10 letters of improvement from the baseline at month 12 (27.8% vs 23.6%, DEX implant + laser vs laser, respectively). The maximum increase in the BCVA was obtained 1 month after the second retreatment with the implant or sham injection ( + 7.9 vs + 2.3 letters). Furthermore, a significant decrease in the central macular thickness was found in 4 of 8 visits, but no difference was obtained in either group at months 6 and 12 for the CRT. The change in the area of leakage measured with fluorescein angiography was sig- nificantly greater in the DEX implant group in all visits. One important finding of the study was discordance between the optical coherence tomography results and BCVA. The laser alone had an effect on reducing the edema at month 6, but the BCVA only improved in the DEX implant plus laser group at same time point. The authors concluded that the intervals for retreatment with the DEX implant were not enough because the CRT did not differ at months 6 and 12.
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