Caracterización clínica y epidemiológica de la maculopatía diabética en adultos de 50 años y más en Cuba / Clinical and epidemiological characterization of diabetic maculopathy in adults aged 50 years and over in Cuba

RESUMEN Objetivo: Determinar las características clínicas y epidemiológicas de la maculopatía diabética en adultos de 50 años y más en Cuba. Métodos: Se realizó una investigación epidemiológica, descriptiva transversal, que tomó la Encuesta Rápida de Ceguera Evitable realizada en Cuba en el año 2016, la cual incluyó la retinopatía diabética validada por la Organización Mundial de la Salud. Resultados: La prevalencia de cualquier grado de maculopatía fue de 8,5 por ciento (6,1 a 10,8) y la maculopatía observable y remitible fue de 4,2 por ciento (2,2 a 6,0). El riesgo de desarrollar maculopatía resultó mayor en el sexo femenino, con el 9,3 por ciento (6,6-12,9), y en los diabéticos que tenían entre 60 y 69 años de edad, de 9,2 por ciento (5,7-14,0). Este riesgo se incrementaba si existía descontrol de la glicemia y si la enfermedad tenía 15 años y más de evolución. La asociación con la retinopatía observable fue de 2,5 por ciento. La discapacidad visual moderada por maculopatía fue de 1,4 % y la grave junto con la ceguera de 0,8 por ciento. La cobertura de tratamiento fue baja (28,6 por ciento por personas). Conclusiones: El diabético de 50 años y más en Cuba tiene baja prevalencia de maculopatía diabética, la cual se comporta de manera similar para la forma observable y para la remitible. La retinopatía no proliferativa moderada tiene mayor riesgo de afectación macular. La discapacidad visual por afectación macular en el diabético es baja, aunque la estrategia de atención oftalmológica en el diabético no alcanza los estándares necesarios de efectividad, relacionados con la cobertura del tratamiento con láser(AU)

ABSTRACT Objective: Determine the clinical and epidemiological characteristics of diabetic maculopathy in adults aged 50 years and over in Cuba. Methods: A descriptive cross-sectional epidemiological study was conducted based on the Rapid Assessment of Avoidable Blindness survey developed in Cuba in the year 2016, which included diabetic retinopathy with validation by the World Health Organization. Results: Prevalence of any maculopathy grade was 8.5 percent (6.1 to 10.8), whereas observable, referable maculopathy was 4.2 percent (2.2 to 6.0). Risk for maculopathy was higher in the female sex with 9.3 percent (6.6-12.9) and among diabetics from the 60-69 years age group with 9.2 percent (5.7-14.0). Risk increased in uncontrolled glycemia and when the evolution of the disease was 15 years and over. Association with observable retinopathy was 2.5 percent. Moderate visual disability due to maculopathy was 1.4 percent, while severe disability and blindness were 0.8 percent. Treatment coverage was low (28.6 percent per persons). Conclusion: Prevalence of maculopathy is low among diabetics aged 50 years and over in Cuba, with similar behavior in the observable and the referable variants. Moderate non-proliferative retinopathy shows a higher risk for macular damage. Visual disability due to macular damage is low among diabetics, though the ophthalmological care strategy for diabetics does not achieve the required effectiveness standards in terms of laser therapy coverage(AU)

Modelo de manejo en red y por telemedicina de la retinopatía diabética en dos comunas del Servicio de Salud Metropolitano Oriente / Management of diabetic retinopathy using telemedicine and network integration

Background: If we are able to increase the resolution of complex medical problems at primary health care levels, we would improve the efficiency of the health care systems and would reduce the burden of specialists. Aim: To describe the result of a telemedicine and network management of diabetic retinopathy supervised by an ophthalmological service. Material and Methods: Diabetic patients attended in primary health care centers of the East Metropolitan Health Service in Santiago, Chile, derived for 45° digital retinographies were evaluated using telemedicine by the ophthalmologists of the base hospital. These professionals screened for diabetic retinopathy and classified it. Those patients with diabetic retinopathy were derived to the base hospital for specialized management. Results: Of 2,566 patients evaluated, 22% had signs of diabetic retinopathy, 75% did not have the condition and 2% could not be evaluated with retinography. Seventy percent of patients with retinopathy, equivalent to only fifteen percent of total diabetics, were referred to the specialists for treatment. Conclusions: This model allowed a reduction of referrals to ophthalmologists, reducing the burden of secondary and tertiary health care systems.

Efecto del uso preoperatorio de bevacizumab intravítreo en pacientes con retinopatía diabética proliferativa sometidos a vitrectomía- Primera actualización / Preoperative intravitreal bevacizumab for proliferative diabetic retinopathy patients undergoing vitrectomy - First update

ACTUALIZACIÓN: Este resumen Epistemonikos (Living FRISBEE: Living FRIendly Summary of the Body of Evidence using Epistemonikos) es una actualización del resumen publicado en diciembre de 2014. INTRODUCCIÓN: La retinopatía diabética proliferativa conlleva un alto riesgo de ceguera si no es tratada de manera oportuna. El tratamiento muchas veces incluye la vitrectomía. El uso preoperatorio de bevacizumab, un anti-factor de crecimiento endotelial vascular, podría mejorar variables intraoperatorias que facilitan la cirugía y mejorarían el curso postoperatorio. MÉTODOS: Realizamos una búsqueda en Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante el cribado de múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, analizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos cinco revisiones sistemáticas que en conjunto incluyeron 16 estudios primarios, de los cuales 14 corresponden a ensayos aleatorizados. Concluimos que el uso preoperatorio de bevacizumab disminuye la incidencia de hemorragia vítrea en el postoperatorio temprano y probablemente también en el postoperatorio tardío, pero no está claro su efecto sobre la agudeza visual. Además, probablemente disminuye el tiempo quirúrgico, podría disminuir la incidencia de roturas retinianas iatrogénicas, y si bien no está claro que disminuya la ocurrencia de sangrado intraoperatorio, podría disminuir la necesidad de uso de endodiatermia.

UPDATE: This Living FRISBEE (Living FRIendly Summary of the Body of Evidence using Epistemonikos) is an update of the summary published in December 2014. INTRODUCTION: Proliferative diabetic retinopathy can cause severe vision loss and even blindness if left untreated. Vitrectomy is often required in the treatment of more severe cases. Preoperative administration of bevacizumab, a humanized anti-vascular endothelial growth factor would improve intraoperative variables that facilitate surgery and improve postoperative course. METHODS: We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified five systematic reviews including 16 studies overall, of which 14 were randomized trials. We concluded the preoperative use of intravitreal bevacizumab reduces the rate of vitreous hemorrhage in the early postoperative period, and probably also in the late postoperative period, but its effect on visual acuity is not clear. Furthermore, it probably decreases the surgical time and may decrease the incidence of iatrogenic retinal breaks. Although we are uncertain whether preoperative bevacizumab decreases intraoperative bleeding, it may reduce the need for endodiathermy.

Estrategias en el tratamiento de la retinopatía diabética / Treatment strategies for diabetic retinopathy

Con este trabajo nos proponemos revisar las evidencias científicas relacionadas con el tratamiento de la retinopatía diabética. Para la investigación documental se examinaron los artículos de la temática indexados en las bases de datos Pubmed, Pubmed Central y Scielo, que correspondieron a los descriptores DeCs-MeSH: retinopatía diabética y tratamiento actual. La evaluación de los datos se realizó mediante el análisis de contenido de tipo directo. El progreso de la retinopatía diabética va desde los estados más benignos hasta los más severos cuando no se aplica una intervención médica apropiada. Es importante reconocer cada estado de la retinopatía diabética para que el tratamiento sea más efectivo. Varias décadas de estudios clínicos han proporcionado excelentes datos sobre el curso natural de la enfermedad y la estrategia de tratamiento que son efectivas en alrededor de un 90 por ciento para prevenir la pérdida visual severa(AU)

The purpose of the study was to present scientific evidence associated with the treatment of diabetic retinopathy. Document analysis was conducted based on examination of papers about the topic indexed in the databases PubMed, PubMed Central and SciELO, using the DeCs-MeSH terms 'diabetic retinopathy' and 'current treatment'. Data were evaluated with the method of direct content analysis. Diabetic retinopathy evolves from its most benign stages to the severest when appropriate medical action is not taken. It is important to identify each stage of diabetic retinopathy and apply the most effective treatment. Several decades of clinical studies have provided excellent data about the natural course of the disease, as well as about treatment strategies which are effective in around 90 percent of the cases to prevent severe visual loss(AU)

Atualizações no manejo de retinopatia diabética: revisão de literatura / Updates in the management of diabetic retinopathy: literature review

Introdução: O desenvolvimento da retinopatia diabética e consequente edema macular diabético é a complicação mais frequente do diabetes mellitus, que é uma das doenças mais prevalentes na atualidade. Nos últimos anos, houve uma grande revolução no manejo dessas complicações. É fundamental, portanto, que a identificação e o manejo precoces e corretos dessas condições sejam discutidos entre os profissionais da saúde. Metodologia: Com o objetivo de avaliar as atualizações no tratamento da retinopatia diabética, foi realizada uma ampla revisão de literatura em relação a esse tema utilizando as bases de dados MEDLINE e LILACS durante os meses de abril e maio de 2018. A estratégia de busca utilizou os seguintes termos: "retinopatia diabética", "edema macular" e "manejo". Os critérios de elegibilidade foram: guidelines, ensaios clínicos, revisões sistemáticas e metanálises que possuíam texto completo publicado em português ou em inglês publicados nos últimos cinco anos. Resultados: Quinze artigos foram selecionados para inclusão nesta revisão. A partir de um total de 738 artigos encontrados, sendo 724 no PUBMED e 14 no LILACS, 15 foram selecionados para inclusão nesta revisão. Discussão: O diagnóstico e o manejo precoces da retinopatia e da maculopatia diabéticas é fundamental para a manutenção da visão. O padrão ouro para diagnóstico de retinopatia diabética é a fundoscopia. Já para o do edema macular, a tomografia de coerência óptica e angiografia fluoresceínica também são utilizados. A fotocoagulação permite a ablação de áreas de não perfusão capilar, diminuindo a produção de vascular endothelial growth factor e a neovascularização. Os anti-vascular endothelial growth factor surgiram como alternativa para suprimir a atividade do fator de crescimento neovascular e melhorar a resposta à fotocoagulação, diminuindo os nevosos e a permeabilidade capilar, responsável pelo edema macular.

Introduction: The development of diabetic retinopathy and consequent diabetic macular edema is the most frequent complication of diabetes mellitus, which is one of the most prevalent diseases nowadays. In recent years, there has been a major revolution in managing these complications. It is essential, therefore, that the early and correct identification and management of these conditions be discussed among health professionals. Methodology: In order to evaluate the updates in the treatment of diabetic retinopathy, a broad literature review was carried out in relation to this topic using MEDLINE and LILACS databases during the months of April and May of 2018. The search strategy used the following terms: "diabetic retinopathy", "macular edema" and "management". The eligibility criteria were: guidelines, clinical trials, systematic reviews and meta-analyzes that had a full text published in Portuguese or English published in the last five years. Results: Fifteen articles were selected for inclusion in this review. From a total of 738 articles found, being 724 in PUBMED and 14 in LILACS, 15 were selected for inclusion in this review. Discussion: Early diagnosis and management of diabetic retinopathy and maculopathy is critical to maintaining vision. The gold standard for diagnosis of diabetic retinopathy is fundoscopy. As for macular edema, optic coherence tomography and fluorescein angiography are also used. Photocoagulation allows the ablation of areas of capillary non perfusion, decreasing the production of vascular endothelial growth factor and neovascularization. Anti-vascular endothelial growth factor appeared as an alternative to suppress the activity of the neovascular growth factor and improve the response to photocoagulation, reducing the snowy and capillary permeability, responsible for macular edema.

Guía de Práctica Clínica: retinopatía diabética / Clinical Practice Guideline: diabetic retinopathy

Objetivo General: Generar recomendaciones basadas en la mejor evidencia disponible acerca del manejo de personas con Retinopatía Diabética. Tipo de pacientes y escenario clínico: Personas con retinopatía diabética que reciben atención en el nivel primario y secundario de salud en el sector público y privado de salud. Usuarios de la Guía: Todos los profesionales de salud con responsabilidades en personas con retinopatía diabética: médicos oftalmólogos, médicos generales, diabetólogos, internistas, otros médicos especialistas y enfermeras.

The effect of laser pan-retinal photocoagulation with or without intravitreal bevacizumab injections on the OCT-measured macular choroidal thickness of eyes with proliferative diabetic retinopathy

OBJECTIVES: To investigate the effect of laser pan-retinal photocoagulation with or without intravitreal bevacizumab injections on macular choroidal thickness parameters in eyes with high-risk proliferative diabetic retinopathy. METHODS: High-risk proliferative diabetic retinopathy patients undergoing laser treatment were prospectively enrolled in this study. One eye was randomly selected for laser treatment combined with bevacizumab injections, study group, whereas the corresponding eye was subjected to laser treatment alone, control group. Spectral-domain optical coherence tomography with enhanced depth imaging was used to measure the macular choroidal thickness prior to and 1 month after treatment. Measurements in both groups were compared. Clinicaltrials.gov: NCT01389505. RESULTS: Nineteen patients (38 eyes) with a mean±standard deviation age of 53.4±9.3 years were evaluated, and choroidal thickness measurements for 15 patients were used for comparison. The greatest measurement before treatment was the subfoveal choroidal thickness (341.68±67.66 μm and 345.79±83.66 μm for the study and control groups, respectively). No significant difference between groups was found in terms of macular choroidal thickness measurements at baseline or after treatment. However, within-group comparisons revealed a significant increase in choroidal thickness parameters in 10 measurements in the study group and in only 5 temporal measurements in the control group when 1-month follow-up measurements were compared to baseline values. CONCLUSIONS: The macular choroidal thickness does not appear to be significantly influenced by laser treatment alone but increases significantly when associated with bevacizumab injections in patients with proliferative diabetic retinopathy and macular edema. Because bevacizumab injections reduce short-term laser pan-retinal photocoagulation-induced macular edema, our findings suggest that the choroid participates in its pathogenesis.

What do Cochrane systematic reviews say about diabetic retinopathy? / O que as revisões sistemáticas da Cochrane dizem sobre retinopatia diabética?

ABSTRACT CONTEXT AND OBJECTIVE: Diabetic retinopathy is a disease caused by increased permeability of retinal vessels. Its incidence and prevalence have been increasing due to urbanization, greater life expectancy and the habits of modern life. Its onset is insidious and it may lead to blindness in 75% of individuals who have been diabetic for more than 20 years. The aim here was to evaluate the evidence from Cochrane systematic reviews on interventions relating to diabetic retinopathy. DESIGN AND SETTING: Review of systematic reviews, conducted at Cochrane Brazil. METHODS: We included Cochrane systematic reviews on interventions relating to diabetic retinopathy. Two researchers evaluated the inclusion criteria, summarized the reviews and presented the results narratively. RESULTS: Ten reviews met the inclusion criteria. They showed some evidence of benefits from: (a) photocoagulation for diabetic retinopathy; (b) strict glucose and pressure control for postponing the onset of retinopathy; (c) antiangiogenic drugs for macular edema (high-quality evidence); (d) anti-vascular endothelial growth factor agents for proliferative diabetic retinopathy (very low to low-quality evidence); and (e) intravitreal injection or surgical implantation for treating persistent or refractory macular edema. However, blood pressure control seems to have no benefit after the onset of retinopathy. CONCLUSION: Only a few options are likely to be effective for treating diabetic retinopathy. These include photocoagulation and anti-vascular endothelial growth factor agents. Strict glucose and pressure control seem to postpone the onset of retinopathy. For macular edema, antiangiogenic drugs, intravitreal injection and surgical implantation seem to have some benefit.

RESUMO CONTEXTO: A retinopatia diabética é uma doença causada pelo aumento da permeabilidade dos vasos da retina. Sua incidência e prevalência vêm aumentando devido à urbanização, maior expectativa de vida e hábitos de vida modernos. Seu início é insidioso e pode levar à cegueira em 75% dos pacientes diabéticos com mais de 20 anos de doença. O objetivo foi avaliar a evidência das revisões sistemáticas Cochrane sobre intervenções para retinopatia diabética. TIPO DE ESTUDO E LOCAL: Revisão de revisões sistemáticas conduzida no Centro Cochrane do Brasil. MÉTODOS: Nós incluímos revisões sistemáticas Cochrane sobre intervenções para retinopatia diabética. Dois pesquisadores avaliaram os critérios de inclusão, resumiram as revisões e apresentaram os resultados narrativamente. RESULTADOS: Dez revisões preencheram os critérios de inclusão e mostraram benefícios com: (a) fotocoagulação para retinopatia diabética; (b) controle rigoroso da glicose e da pressão para adiar o início da retinopatia; (c) fármacos antiangiogênicos para edema macular (evidência de alta qualidade); (d) agentes antifator de crescimento do endotélio vascular para retinopatia diabética proliferativa (evidência de qualidade muito baixa a baixa); (e) injeção intravítrea ou implante cirúrgico para o tratamento do edema macular persistente ou refratário. No entanto, o controle da pressão arterial parece não ter benefício após o início da retinopatia. CONCLUSÃO: Existem poucas opções provavelmente efetivas para o tratamento da retinopatia diabética. Estas incluem fotocoagulação e agentes antifator de crescimento do endotélio vascular. O controle rigoroso da glicose e da pressão parecem adiar o início da retinopatia. Para o edema macular, fármacos antiangiogênicos, injeção intravítrea e implante cirúrgico parecem ter algum benefício.

Glaucoma neovascular, complicación de la isquemia retiniana / Neovascular glaucoma, a retinal ischemia complication

Introducción: el glaucoma neovascular es un tipo de glaucoma secundario frecuente en los pacientes diabéticos, se produce por la formación de una membrana fibrovascular a nivel del ángulo camerular, como consecuencia de un estímulo angiogénico producido por enfermedades que generan isquemia ocular. Los pacientes con retinopatía diabética proliferativa pueden sufrir esta enfermedad de difícil tratamiento para el oftalmólogo, y que constituye una amenaza para la visión del paciente. Objetivo: revisar aspectos clínicos, patogenia, métodos para el diagnóstico y tratamiento terapéutico del glaucoma neovascular con vistas a prevenir o reducir la pérdida visual. Desarrollo: el glaucoma neovascular es una complicación de la diabetes mellitus y de otras enfermedades generales, que provoca una disminución importante de la visión, y en muchas ocasiones, ceguera. Las enfermedades oculares que con más frecuencia lo producen son la oclusión de la vena central de la retina, la retinopatía diabética proliferativa y el síndrome isquémico ocular, generando isquemia retiniana y coroidea con la consecuente formación de neovasos. Conclusiones: la educación al paciente diabético y el adecuado tratamiento terapéutico de la retinopatía diabética es importante para prevenir la aparición del glaucoma neovascular(AU)

Introduction: neovascular glaucoma is the type of secondary glaucoma common in diabetic patients; it is caused by the formation of fibrovascular membrane at the camerular angle as a result of angiogenic stimulus due to ocular ischemia-generating diseases. The proliferative diabetic retinopathy patients may suffer this difficult-to-treat disease that represents a threat to the vision of a patient. Objective: to review clinical aspects, pathogenenesis, diagnosis methods and treatment of the neovascular glaucoma with a view to preventing or reducing the vision loss. Development: neovascular glaucoma is a complication of diabetes mellitus and of other general diseases, which brings about significant reduction of vision and often blindness. The most frequent eye diseases responsible for this are central retinal vein occlusion, proliferative diabetic retinopathy and ocular ischemic syndrome, leading to retinal and choroid ischemia with resulting formation of neovessels. Conclusions: education aimed at diabetic patient and the adequate therapeutic treatment of the diabetic retinopathy is important to prevent the occurrence of neovascular glaucoma(AU)

Estrategia nacional para la prevención de ceguera por retinopatía diabética / National strategy for the prevention of blindness due to diabetic retinopathy

Los pacientes con diabetes se incrementan; pero aún contamos con tiempo para actuar en el diagnostico precoz y en el tratamiento oportuno de la retinopatía diabética para prevenir la pérdida visual en estos pacientes. Establecemos una guía para la prevención de la ceguera por retinopatía diabética, donde se involucran los tres niveles de atención médica. Se realiza un análisis de la situación epidemiológica a nivel mundial y en Cuba; además, se tienen en cuenta las instalaciones con equipamiento y personal médico especializado para el diagnóstico y tratamiento de la retinopatía diabética. Se trazan estrategias para el desarrollo del programa en el cual ponemos todo nuestro esfuerzo y empeño para mejorar la calidad visual de los pacientes diabéticos(AU)

The number of patients with diabetes is on the increase, but we still have time to work in the early diagnosis and due treatment of diabetic retinopathy to prevent the visual loss in these patients. A guideline for the prevention of blindness due diabetic retinopathy involving the three levels of care was set. An analysis of the present epidemiological situation in Cuba and worldwide was made, taking into account the duly equipped facilities with specialized medical staff for the diagnoses and treatment of the diabetic retinopathy. Strategies are being drawn up for the development of the program, in a joint effort to improve the visual quality of the diabetic patients(AU)

Estudo comparativo de fotocoagulação panretiniana com e sem ranibizumabe intravítreo no tratamento da retinopatia diabética proliferativa / A comparative study of panretinal photocoagulation with and without intravitreal ranibizumab in treatment of proliferative diabetic retinopathy

Objetivo: Comparar o efeito da terapia da fotocoagulação panretiniana (PFC) associada à injeção intravítrea de Ranibizumabe (RBZ) versus terapia isolada com PFC em pacientes com retinopatia diabética proliferativa (RDP) precoce, virgens de tratamento, com ou sem edema macular diabético (DME) durante 6 meses de acompanhamento. Projeto: Estudo prospectivo intervencionista, randomizado e controlado. Métodos: Sessenta olhos de 30 pacientes com RDP bilateral precoce foram randomizados para o grupo de estudo (GE) que foram tratados com PFC associado a duas injeções de RBZ intravítreo (0.5mg/0.05ml) ou para o grupo controle (GC) tratados apenas com PFC. Mudanças na acuidade visual (AV) corrigida, na sensibilidade ao contraste (SC) e na espessura foveal (EF) foram comparados no início, e nos 1, 3 e 6 meses após o tratamento. Resultados: No GE, a diferença na média da AV do baseline para o mês 6 teve um aumento significativo de + 3,4 letras (p = 0,006) e uma diminuição significativa na EF de - 47.6um (p < 0,001). No GC, a diferença na média da AV teve uma diminuição de - 3,4 letras (p = 0,04) e uma mudança na EF de -3.8 um (p = 0,96). Com relação ao teste de SC dentre os 28 olhos do GE, houve uma melhora no mês 6 em relação ao baseline nos ciclos: 1,5 (p < 0.001) e 3,0 ciclo (p=0.023). Dentre os 30 olhos do GC, não houve uma diferença estatística nos momentos estudados. Conclusão: A injeção intravítrea de RBZ associado com PFC pode ser um tratamento eficaz em olhos de pacientes com RDP precoce e EMD.

Purpose: To compare the efficacy of therapy with panretinal photocoagulation (PRP) and intravitreal ranibizumab (RBZ) injection versus PRP alone in patients with treatment-naive bilateral non-high risk proliferative diabetic retinopathy (PDR) with and without diabetic macular edema (DME) with a 6-month follow-up. Design: Prospective, interventional, randomized controlled trial. Methods: Sixty eyes of 30 patients with bilateral non-high risk PDR were randomized either to the study group (SG) receiving PRP plus two intravitreal ranibizumab injections (0.5mg/0.05ml), the first one week before and the second four weeks after the PRP or to the control group (CG) receiving PRP alone. Mean change in best-corrected visual acuity (BCVA), contrast sensitivity (CS) and central macular thickness (CMT) were compared at baseline and 1, 3 and 6 months after treatment. Results: Changes from baseline to 6 months showed in the SG an increased in the BCVA by + 3.4 letters (p= 0.006) with a decrease in CMT by - 47.6um (p < 0.001). In the CG, a decrease by - 3.4 letters (p = 0.04) and an decrease by -3.8um (p= 0.96). Regarding the CS in the SG, there was an improvement compared to baseline for the sixth month in the 1.5 (p < 0.001) and 3.0 cycles (p = 0.023). The CG did not show significant results from baseline to month 6. Conclusion: Intravitreal RBZ associated with PRP can be an effective treatment in eyes with non-high risk PDR and DME.

Aspectos bioéticos en el tratamiento de la retinopatía diabética / Bioethical aspects of the treatment of diabetic retinopathy

La medicina es una práctica tan antigua como la humanidad, que se ha ido modificando y enriqueciendo con la revolución científico-técnica, pero siempre sigue los mismo principios y normas éticas que establecen una relación médico- paciente basada en el respeto, la confianza y el precepto hipocrático de no hacer daño. En el quehacer del ejercicio de la medicina, la mayoría de los procedimientos diagnósticos, terapéuticos y profilácticos involucran riesgos, esto se aplica especialmente a la investigación biomédica y a todos aquellos novedosos medios diagnósticos y tratamientos que pueden ocasionar cierto perjuicio al aplicarlo. La retinopatía diabética constituye una de las principales causas de ceguera en pacientes en edad laboral. La búsqueda de alternativas de tratamiento para esta enfermedad debe evaluar siempre los riesgos y beneficios.

Medicine is such an old practice as the mankind. It has been modified and enriched with the scientific and technical revolution advances, but it always follows the same principles and ethical standards that set the physician-patient relationship based on respect, confidence and the Hippocratic precept of doing no harm. In the medical practice, most of the diagnostic, therapeutic and prophylactic procedures involve risks. This is especially true for the biomedical research and mainly for all those novel diagnostic and therapeutic methods which can cause some damage when applied. Diabetic retinopathy is one of the main causes of blindness in working-age patients. Searching alternative treatments for this illness should always evaluate the risks and the advantages.

Fotocoagulación panretinal y bevacizumab intravítreo en el tratamiento de la retinopatía diabética proliferativa activa / Panretinal photocoagulation and intravitreal bevacizumab in the treatment of active proliferative diabetic retinopathy

OBJETIVO: evaluar el efecto de la fotocoagulación panretinal e inyección intravítrea de bevacizumab sobre las áreas de neovascularización en pacientes con retinopatía diabética proliferativa activa. MÉTODOs: estudio experimental en 80 ojos de 62 pacientes con retinopatía diabética proliferativa con características de alto riesgo, a quienes se les asignó aleatoriamente fotocoagulación panretinal (Grupo L) o fotocoagulación panretinal con bevacizumab intravítreo (Grupo L + B). Variables: edad, sexo, color de la piel, tipo de diabetes mellitus, tiempo de evolución, tipo de tratamiento, área de difusión de fluoresceína y regresión de neovascularización retinal y/o del disco óptico. Se realizó un seguimiento de 9 meses. RESULTADOS: en la evaluación inicial el área media de difusión fue de 8,95 mm2 en el grupo L y de 10,08 mm2 en el grupo L + B (p = 0,347), que se modificó a 6,40 mm2 y 3,91 mm2 (p = 0,012) al mes; 3,15 mm2 y 1,02 mm2(p = 0,002) a los tres meses; 2,45 mm2 y 0,58 mm2 (p = 0,001) a los seis meses; 2,18 mm2 y 0,46 mm2 (p = 0,001) a los nueve meses, respectivamente. El análisis de las diferencias absolutas de los promedios mostró una reducción significativa de las áreas de difusión a favor del tratamiento combinado en comparación con el momento inicial. CONCLUSIONES: en pacientes con retinopatía diabética proliferativa activa el bevacizumab intravítreo combinado con fotocoagulación panretinal produjo regresión dramática de la neovascularización, permaneciendo estable desde el tercer mes al noveno.

OBJECTIVE: to evaluate the effect of panretinal photocoagulation and intravitreal injection of bevacizumab on neovascularization areas of patients with active proliferative diabetic retinopathy. METHODS: experimental study conducted in 80 eyes from 62 patients with proliferative diabetic retinopathy with high risk characteristics. These patients were randomly assigned to panretinal photocoagulation group (group L) or to the panretinal photocoagulation plus intravitreal bevacizumab group (group L + B). The studied variables were age, sex, race, type of diabetes mellitus, illness duration, type of treatment, fluorescein distribution area and retinal/optical disc neovascularization regression area. They were followed-up for 9 months. RESULTS: in the initial evaluation, the average diffusion area was 8,95 mm2 in group L and 10,08 mm2 in group L + B (p = 0,347), which changed to 6,40 mm2 and 3,91 mm2 (p = 0,012) respectively, after one month; 3,15 mm2 and 1,02 mm2 (p = 0,002) three months later, 2,45 mm2 and 0,58 mm2 (p = 0,001) after six months and 2,18 mm2 and 0,46 mm2 (p = 0,001) after nine months, respectively. The analysis of absolute differences of averages showed a significant reduction in the distribution areas of fluorescein that favored the combined therapy. CONCLUSIONS: in patients with active proliferative diabetic retinopathy, intravitreal bevacizumab combined with panretinal photocoagulation bring about dramatic regression of neovascularization, which remained stable from the third to the ninth month.

Resultados visuales y anatómicos post-operatorios obtenidos mediante el empleo de vitrectomía pars plana en el pelaje de membranas epirretinianas idiopáticas / Anatomical and visual post-operative results using pars plana vitrectomy in idiopathic epiretinal membranes peeling procedure

Objetivo: examinar resultados anatómicos y visuales de los pacientes con membranas epirretinianas idiopáticas (MER) tratados mediante pelaje de membranas y su correlación funcional post-operatoria. Métodos: Estudio de serie de casos donde se revisaron las historias clínicas de 27 pacientes elegidos de manera aleatoria y a quienes se realizó pelaje de membranas epirretinianas idiopáticas con seguimiento clínico por 6 meses del post-operatorio. Al 90% (n=24) de los pacientes se les realizó cirugía combinada de facovitrectomía. Se tomaron como variables a analizar la agudeza visual pre y post-operatoria a la semana, al mes y a los 6 meses, tomografía de coherencia óptica pre y post-operatoria al mes y a los 6 meses de la cirugía. Se comparó la agudeza visual y el grosor retiniano en el milímetro central entre la medida pre y postoperatoria utilizando la prueba de t de student. Resultados: la media de agudeza visual pre-operatoria fué de 20/60 y post-operatoria (6 meses) de 20/30. La media del grosor retiniano en el milímetro central pre-operatoria resultó 409.7 micras con un valor post-operatoria (6 meses) de 341 micras. En el 82% de los pacientes se observó una mejoría en la agudeza visual post-operatoria a los 6 meses. Los pacientes con mejores agudezas visuales fueron aquellos cuya agudeza visual pre-operatoria estuvo alrededor del 20/50. Conclusiones: la agudeza visual y el grosor retiniano pre-operatorio son los mejores factores pronósticos para estimar la agudeza visual post-operatoria en pacientes operados con diagnóstico de MER. La agudeza visual post-operatoria definitiva se alcanza posterior a los 6 meses de la cirugía. Se recomienda establecer como punto de corte para la decisión quirúrgica aquellos pacientes con agudezas visuales de 20/50 o peor.

Objective: to examine anatomic and visual outcomes in patients undergoing epiretinal membrane surgery. Methods: a case series study. Twentyseven eyes from 27 patients who underwent epiretinal membrane surgery were reviewed. Correlations between preoperative and first week, one and six months post-operative bestcorrected visual acuity and Optical Coherence Tomography (OCT) findings were obtained and analyzed using t student test. Results: mean pre-operative best corrected visual acuity (BCVA) was 20/60 and six months post-op was 20/30. Mean pre-op retinal central thickness was 409.7 microns and six months post-op was 341 microns. BCVA significantly improved in 82% of the patients after six months of surgery. Patients whom achieved higher BCVA levels post-op were those with pre-op BCVA around 20/50. Conclusions: pre-operative BCVA and central retinal thickness are the most importante factors to estimate post-operative BCVA. Highest BCVA levels were achieved after six months of surgery. It is recommended to use pre-op BCVA of 20/50 as cut-off level to consider surgical treatment.

Panretinal photocoagulation versus intravitreal injection retreatment pain in high-risk proliferative diabetic retinopathy / Dor em panfotocogulação retiniana versus injeção intravítrea em pacientes com retinopatia diabética proliferativa de alto risco

PURPOSE: To compare pain related to intravitreal injection and panretinal photocoagulation in the management of patients with high-risk proliferative diabetic retinopathy. METHODS: Prospective study including patients with high-risk proliferative diabetic retinopathy and no prior laser treatment randomly assigned to receive panretinal photocoagulation (PRP group) or panretinal photocoagulation plus intravitreal ranibizumab (PRPplus group). In all patients, panretinal photocoagulation was administered in two sessions (weeks 0 and 2), and intravitreal ranibizumab was administered at the end of the first laser session in the PRPplus group. Retreatment was performed at weeks 16 and 32 if active new vessels were detected at fluorescein angiography. Patients in the PRPplus group received intravitreal ranibizumab and patients in the PRP group received 500-µm additional spots per quadrant of active new vessels. After the end of retreatment, a 100-degree Visual Analog Scale was used for pain score estimation. The patient was asked about the intensity of pain during the whole procedure (retinal photocoagulation session or intravitreal ranibizumab injection). Statistics for pain score comparison were performed using a non-parametric test (Wilcoxon rank sums). RESULTS: Seventeen patients from PRPplus and 14 from PRP group were evaluated for pain scores. There were no significant differences between both groups regarding gender, glycosylated hemoglobin and disease duration. Mean intravitreal injection pain (±SEM) was 4.7 ± 2.1 and was significantly lower (p<0.0001) than mean panretinal photocoagulation pain (60.8 ± 7.8). Twelve out of 17 patients from the PRPplus group referred intensity pain score of zero, while the minimal score found in PRP group was found in one patient with 10.5. CONCLUSION: In patients with high-risk proliferative diabetic retinopathy who needed retreatment for persistent new vessels, there was more comfort for the patient when retreatment was performed with an intravitreal injection in comparison with retinal photocoagulation. Further larger studies are necessary to confirm our preliminary findings.

OBJETIVO: Comparar a dor relacionada à injeção intravítrea e panfotocoagulação no tratamento de pacientes com retinopatia diabética proliferativa de alto risco. MÉTODOS: Estudo prospectivo incluindo pacientes com retinopatia diabética proliferativa de alto risco e nenhum tratamento a laser prévio aleatoriamente designados para receber panfotocoagulação retiniana (grupo PRP) ou panfotocoagulação e ranibizumabe intravítreo (grupo PRPplus). Em todos os pacientes, a panfotocoagulação foi administrada em duas sessões (semanas 0 e 2), e ranibizumabe intravítreo foi administrado no final da primeira sessão de laser no grupo PRPplus. Retratamento foi realizado nas semanas 16 e 32 se neovasos ativos fossem detectados na angiofluoresceinografia, utilizando ranibizumabe intravítreo no grupo PRPplus e laser adicional grupo PRP. Após o fim do retratamento, uma Escala Analógica Visual de 100-unidades foi utilizada para a estimativa da pontuação da dor. O paciente foi questionado sobre a intensidade da dor durante todo o procedimento (sessão de fotocoagulação de retina ou injeção intravítrea de ranibizumabe). A comparação dos índices de dor foi realizada utilizando um teste não-paramétrico (Wilcoxon rank sums). RESULTADOS: Dezessete pacientes do grupo PRPplus e 14 do grupo PRP foram avaliados para os índices de dor. Não houve diferenças significativas entre os dois grupos quanto ao sexo, hemoglobina glicosilada e duração da doença. A média de dor da injeção intravítrea (±SEM) foi 4,7 ± 2,1, significativamente menor (p<0,0001) do que a dor média da panfotocoagulação (60,8 ± 7,8). Doze dos 17 pacientes do grupo PRPplus referiram pontuação de intensidade da dor zero, enquanto que o índice mínimo no grupo PRP foi encontrado em um paciente com 10,5. CONCLUSÃO: Em pacientes com retinopatia diabética proliferativa de alto risco que necessitaram de retratamento por neovasos persistentes, houve mais conforto para o paciente quando o retratamento foi realizado com uma injeção intravítrea em comparação com fotocoagulação da retina. Estudos posteriores são necessários para confirmar nossos achados preliminares.

Combined therapy for diabetic macular edema

Diabetic macular edema [DME] is the main cause of visual impairment in diabetic patients. Macular edema within 1 disk diameter of the fovea is present in 9% of the diabetic population. The management of DME is complex and often multiple treatment approaches are needed. This review demonstrates the benefits of intravitreal triamcinolone, bevacizumab and ranibizumab as adjunctive therapy to macular laser treatment in DME. The published results indicate that intravitreal injections of these agents may have a beneficial effect on macular thickness and visual acuity, independent of the type of macular edema that is present. Therefore, pharmacotherapy could complement focal/grid laser photocoagulation in the management of DME. For this review, we performed a literature search and summarized recent findings regarding combined therapy for DME

Best practice eye care models.

Since the launching of Global Initiative, VISION 2020 “the Right to Sight” many innovative, practical and unique comprehensive eye care services provision models have evolved targeting the underserved populations in different parts of the World. At places the rapid assessment of the burden of eye diseases in confined areas or utilizing the key informants for identification of eye diseases in the communities are promoted for better planning and evidence based advocacy for getting / allocation of resources for eye care. Similarly for detection and management of diabetes related blindness, retinopathy of prematurity and avoidable blindness at primary level, the major obstacles are confronted in reaching to them in a cost effective manner and then management of the identified patients accordingly. In this regard, the concept of tele-ophthalmology model sounds to be the best solution. Whereas other models on comprehensive eye care services provision have been emphasizing on surgical output through innovative scales of economy that generate income for the program and ensure its sustainability, while guaranteeing treatment of the poorest of the poor.