Ranibizumab intravítreo para el tratamiento de oclusiones vasculares retinianas: análisis mediante tomografía de coherencia óptica / Intravitreal Ranibizumab for the Treatment of Retinal Vascular Occlusions: Analysis Using Optical Coherence Tomography

Introducción: El uso del medicamento ranibizumab intravítreo favorece la reducción del edema macular generador de las oclusiones vasculares retinianas causantes de la pérdida visual. Objetivo: Evaluar la eficacia y seguridad de la administración intravítreo de ranibizumab en el cambio de espesor macular central en las oclusiones vasculares retinianas analizado mediante tomografía de coherencia óptica. Material y métodos: Se desarrolló un estudio de tipo retrospectivo, analítico, correlacional y observacional de campo con diseño no experimental en 125 pacientes mayores de 30 años con oclusión vascular retiniana diagnosticados en la consulta de oftalmología del Hospital "Teodoro Maldonado Carbó" durante enero de 2017 a junio de 2018. La técnica ANOVA compara las medias para determinar mediante el proceso de contraste de hipótesis si existen diferencias estadísticamente significativas entre estas. Resultados: El análisis de la agudeza visual con escala logMAR demostró diferencias estadísticamente significativas entre los promedios obtenidos 3 meses antes y después de la aplicación del tratamiento (p=0,0001). Se encontró 28,8 por ciento de efectos adversos. Con frecuencia en aumento de presión intraocular (4 por ciento), sequedad ocular (16 por ciento) y hemorragia conjuntival (11,2 por ciento). Conclusiones: El ranibizumab en oclusiones vasculares retinianas proporciona una mejor agudeza visual corregida en relación con el grosor macular, favorece el desarrollo de nuevos vasos sanguíneos a partir de vasos preexistentes desde migración de células endoteliales(AU)

Introduction: The use of the intravitreal ranibizumab favors the reduction of the macular edema that generates retinal vascular occlusions that cause visual loss. Objective: To evaluate the efficacy and safety of the intravitreal administration of ranibizumab in the change in central macular thickness in retinal vascular occlusions analyzed by optical coherence tomography. Material and methods: A retrospective, analytical, correlational and observational field study with a non-experimental design was carried out on 125 patients over 30 years of age diagnosed with retinal vascular occlusion in the Ophthalmology Service of "Teodoro Maldonado Carbó" Hospital during the period between January 2017 and June 2018. The ANOVA technique was used to compare means in order to determine, through the hypothesis contrast process, if there are statistically significant differences between them. Results: Visual acuity analysis using the logMAR scale showed statistically significant differences between the averages obtained 3 months before and after the application of the treatment (p =0.0001). In addition, 28,8 percent of adverse effects were found. The most frequent ones included increased intraocular pressure (4 percent), dry eyes (16 percent), and conjunctival hemorrhage (11,2 percent). Conclusions: In retinal vascular occlusions, Ranibizumab provides a better corrected visual acuity in relation to macular thickness, favors the development of new blood vessels from pre-existing vessels from endothelial cell migration(AU)

Generalidades del tratamiento del edema macular diabético y la indicación de las estatinas / Generalities of the Treatment of Diabetic Macular Edema and the Use of Statins

RESUMEN Introducción: Cualquiera de las formas de retinopatía diabética se puede acompañar de la presencia de edema macular diabético. El uso de las estatinas en personas con diabetes mellitus y edema macular diabético se ha sugerido como una medida terapéutica. Objetivo: Describir de manera general el tratamiento del edema macular diabético y en particular algunos resultados obtenidos con el uso de las estatinas. Métodos: Se realizó una búsqueda de literatura relevante sobre el tema en el primer semestre de 2019. Fueron evaluados artículos de revisión y de investigación provenientes de diferentes bases de datos: PubMed, Cochrane, SciELO y páginas web que, en general, tenían menos de 10 años de publicados, en idioma español, portugués o inglés. Se utilizó como buscador de información científica a Pubmed, Google y Google Académico. Se emplearon como palabras clave: diabetes mellitus, tratamiento, estatinas y edema macular diabético. Fueron excluidos los artículos que no cumplían con los objetivos del presente trabajo. Fueron estudiados 87 artículos, de los cuales 57 fueron referenciados. Conclusiones: Un estricto control glucémico y combatir los factores de riesgo modificables, en los pacientes con diabetes mellitus, representa la medida más importante para evitar y disminuir la aparición y progresión del edema macular diabético. Cuando se encuentra establecido, se debe hacer uso del tratamiento apropiado o específico. El uso de las estatinas pudiera ser un complemento importante en la prevención y tratamiento del edema macular diabético(AU)

ABSTRACT Introduction: Any form of diabetic retinopathy can be accompanied by the presence of diabetic macular edema. The use of statins in patients with diabetes mellitus and diabetic macular edema has been suggested as a therapeutic measure. Objectives: To describe, in a general way, the treatment of diabetic macular edema and, particularly, some outcomes obtained with the use of statins. Methods: A relevant literature search on the subject was carried out in the first half of 2019. Review and research articles published in the last ten years were assessed, taken from different databases, such as PubMed, Cochrane, SciELO, as well as from web pages, written in Spanish, Portuguese or English. Pubmed, Google and Google Scholar were used as engines for searching scientific information. The following keywords were used: diabetes mellitus, tratamiento [treatment], estatinas [statins], and edema macular diabetic [diabetic macular edema]. Articles that did not meet the objectives of the present work were excluded, which allowed the study of 87 articles, of which 57 were referenced. Conclusions: Strict glycemic control and confronting modifiable risk factors in patients with diabetes mellitus represents the most important measure to avoid and reduce the appearance and progression of diabetic macular edema. When established, appropriate or specific treatment should be used. The use of statins could be an important complement for the prevention and treatment of diabetic macular edema(AU)

Diabetic macular edema: a literature review

Diabetic Macular Edema is a major cause of visual impairment in economically active population, being responsible for a significant impact in quality of life in the affected population, as well as high costs to the health care system. Over decades, some studies have compared treatments using Laser, Anti-VEGF and intravitreous corticosteroids, establishing protocols to reach effectives therapies. Thus, it is essential an entire understanding of available therapies to reach the goal of disease control, in an individual basis and in a collective health care system, as efficient as possible.

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.

combination of phacoemulsification surgery and intravitreal triamcinolone injection in patients with cataract and diabetic macular edema

Purpose: To assess the safety and efficiency of combined phacoemulsification [PHACO] surgery and intravitreal triamcinolone [IVTA] injection with or without macular grid laser photocoagulation in patients with cataract and diabetic macular edema

Material and methods: This prospective study included 41 eyes of 36 diabetic patients with cataract and coexisting clinically significant macular edema [CSME]. After PHACO and IVTA injection eyes were divided into two groups: the laser and IVTA group [Group 1] and only IVTA group [Group 2]. Preoperative and postoperative best corrected visual acuity [BCVA], central macular thickness [CMT], and intraocular pressure [IOP] were recorded. Paired sample t-test was used to compare data in the groups and C square test for qualitative variables

Results: Postoperative BCVA was significantly higher than the initial BCVA during the follow-up period in both groups [p < 0.01]. The BCVA 6 months after surgery was significantly higher in group 1 than in group 2 [p < 0.01]. There was no statistically significant difference in IOP between two groups preoperatively and postoperatively during the follow-up period [p > 0.05]. There was no statistically significant difference between both groups in mean CMT preoperatively and 2nd week, 2nd month and 3rd month after surgery [p > 0.05]. The mean CMT 6 months after surgery was statistically significantly lower in group 1 than in group 2 [p < 0.01]

Conclusions: PHACO surgery combined with IVTA injection improves BCVA and provides a decrease in CMT in diabetic patients with CSME. Additional macular grid laser photocoagulation after surgery helps to preserve this improvement in BCVA and decrease in CMT

Inyección intravítrea de bevacizumab vs. acetato de triamcinolona en el edema macular secundario a oclusión de rama venosa retiniana / Intravitreal bevacizumab vs. triamcinolone acetonide injection to treat macular edema secondary to branch retinal vein occlusion

Objetivo: comparar los resultados del tratamiento intravítreo de bevacizumab y de acetato de triamcinolona en el edema macular secundario ante la oclusión de rama venosa retiniana. Métodos: estudio prospectivo, intervencional, aleatorio y comparativo realizado en 34 pacientes. El grupo 1 (16 pacientes) con inyección intravítrea de acetato de triamcinolona y el grupo 2 (18 pacientes) con inyección de bevacizumab hasta completar 3 dosis en cada grupo, seguida la tercera dosis de grid macular. La dosis inicial fue a los 3 meses de la afección, y la evaluación final a los 12 meses. Se evaluó la agudeza visual mejor corregida (Snellen), grosor macular y complicaciones. Resultados: en el grupo 1 la mejor agudeza visual con corrección evolucionó de 0,29 (0,05-0,5) a 0,64 (0,05-1,0); en el grupo 2 de 0,24 (0,05-0,5) a 0,66 (0,11,0). El grosor macular en el grupo 1, de 551,3 (346-967) micras, mejoró a 204,06 (112-449) micras; en el grupo 2, de 546,2 (283-1020) micras, hasta un grosor retinal foveal de 181,05 (112-312) micras. Como complicaciones, en el grupo 1 hubo un incremento de la tensión ocular en el 25,0 por ciento de los pacientes y una progresión de catarata en el 12,5 por ciento. Conclusiones: el tratamiento de inyección intravítrea de bevacizumab en el edema macular secundario a oclusiones venosas de rama retiniana muestra mejor resultado que el de acetato de triamcinolona. También son menores las complicaciones asociadas al bevacizumab(AU)

Objective: to compare the results of the intravitreal treatment with bevacizumab and with triamcinolone acetonide in the macular edema secondary to branch retinal vein occlusion. Methods: a prospective, interventional, random and comparative study was carried out in 34 patients. The first group (16 patients) received intravitreal triamcinolone acetonide injection whereas the second group (18 patients) had bevacizumab injection up to completing three doses in each group, followed by a third dose of macular grid. The initial dose was applied three months after the occurrence of edema and the final evaluation was made 12 months afterwards. Best corrected visual acuity (Snellen's chart), the macular thickness and complications were assessed. Results: in the first group, the best corrected visual acuity increased from 0,29 (0,05-05) to 0,64 (0,05-1,0) whereas in the second group it went from 0,24 (0,05-05) to 0,66 (0,1-1,0).The macular thickness of 551,3 (346-967) microns of the first group improved when reaching 204,06 (112-449) microns and that of the second group went from 546,2 (283-1020) microns to 181,05 (112-312) microns. As to the complications, 25 percent of patients of the first group experienced eye hypertension, and 12,5 percent of patients in the same group had cataract progression. Conclusions: intravitreal bevacizumab injection treatment of the macular edema secondary to branch retinal vein occlusion was better than that based on triamcinolone acetonide injection. The complications associated to bevacizumab treatment were fewer(AU)

Efectividad y seguridad de ranibizumab, comparado con implante intravítreo de dexametasona, fotocoagulación, triamcinolona, bevacizumab y aflibercept, en pacientes con edema macular secundario a oclusión de la vena central de la retina / Effectiveness and safety of ranibizumab compared to intravitreal implantation of dexamethasone, photocoagulation, triamcinolone, bevacizumab and aflibercept in patients with macular edema secondary to central retinal vein occlusion

Introducción: La oclusión de la vena central de la retina (OVCR) reduce las funciones individuales y la calidad de vida de aquellos individuos que la presentan; típicamente afecta a personas mayores y se considera que alrededor de un 90 % de los pacientes son mayores de 50 años al momento de inicio del cuadro. Es considerada la segunda causa más común de trastorno vascular de la retina después de la retinopatía diabética. Esta enfermedad puede conducir a pérdida visual severa a causa del edema o isquemia macular, hemorragia vítrea o glaucoma neovascular. Objetivo: examinar los beneficios y riesgos del uso de ranibizumab como uno de los criterios para informar la toma de decisiones relacionada con la posible inclusión de tecnologías en el Plan Obligatorio de Salud, en el marco de su actualización integral para el año 2015. Metodología la evaluación fue realizada de acuerdo con un protocolo definido a priori por el grupo desarrollador. Se realizó una búsqueda sistemática en MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, LILACS y Google, sin restricciones de idioma, fecha de publicación y tipo de estudio. Las búsquedas electrónicas fueron hechas en noviembre de 2014 y se complementaron mediante búsqueda manual en bola de nieve y consulta con expertos temáticos. La tamización de referencias se realizó por dos revisores de forma independiente y los desacuerdos fueron resueltos por consenso. La selección de estudios fue realizada mediante la revisión en texto completo de las referencias preseleccionadas, verificando los criterios de elegibilidad predefinidos. Las características y hallazgos de los estudios fueron extraídos a partir de las publicaciones originales. Resultados: efectividad triamcinolona, ranibizumab, bevacizumab, aflibercept, tienen alta probabilidad de presentar cambios en la mejor agudeza visual corregida comparado con placebo y con implante intravítreo de dexametasona. Los pacientes tratados con triamcinolona 4mg DEM 9,42 (IC 95 % 3,46-15,38), ranibizumab 0,5 mg DEM 14,06 (IC 95 % 10,46-17,65), bevacizumab 1,25 mg DEM 15,69 (IC 95 % 5,86-25,47), aflibercept 2 mg DEM 17,46 (IC 95% 14,37-20,57), tienen alta probabilidad de presentar cambio en la mejor agudeza visual corregida cuando se comparan con placebo. Cambios en la tomografía de coherencia óptica (grosor de la retina) Al mes de seguimiento : se presentó disminución significativa a favor de los inhibidores de VEGF cuando se comparan con placebo DEM - 264,67 (IC 95 % -377,00 ; -152,35), con una heterogeneidad extremadamente alta I2 94 %. A los seis meses se presentó disminución significativa a favor de los inhibidores de VEGF cuando se comparan con placebo DEM -224,52 (IC 95 % -377,77; -111,27), con una heterogeneidad extremadamente alta I2 93 %. A los doce meses: No se encontraron diferencias estadísticamente significativas. Conclusiones: efectividad triamcinolona, ranibizumab, bevacizumab, aflibercept, tienen alta probabilidad de presentar cambios en la mejor agudeza visual corregida comparado con placebo y con implante intravítreo de dexametasona. Además tienen alta probabilidad de ganar tres o más líneas comparado con placebo, así como, disminuir el grosor central de la retina. En relación con la seguridad del tratamiento para el edema macular secundario a oclusión de la vena central de la retina, se evidenció que el uso de corticoides como: la triamcinolona y la dexametasona incrementa la presión intraocular y la presencia de cataratas cuando se comparan con placebo; mientras que para los inhibidores de VEGF como: aflibercept, ranibizumab y bevacizumab no se reportaron de manera significativa eventos adversos oculares o sistémicos cuando se comparan con placebo. En esta revisión no se identificó evidencia que cumpliera con los criterios de inclusión para los desenlaces de grado de isquemia retiniana y mantenimiento de la ganancia en la agudeza visual, ni la comparación con láser.(AU)

Intravítrea de bevacizumab en el edema macular secundario a oclusión venosa de rama retiniana / Intravitreal bevacizumab injection treatment for the macular edema secondary to the retinal vein branch occlusion

OBJECTIVE: to evaluate the results of the treatment of bevacizumab in the macular edema secondary to occlusion of a branch retinal vein. METHODS: prospective, interventional, not comparative study, in 18 patients with macular edema secondary to occlusion of branch retinal vein. The treatment was of intravitreal injection of Bevacizumab (up to 3 dose) followed by grid macular if was necessary. The initial evaluation went to the 3 months of the occlusion and they were followed the patients by 12 months. It was evaluated the corrected better visual acuity, macular thickness and the occurrence of complications. RESULTS: the patients were 7 men (38,89%) and 11 women (61,11 %) 63,1 (44-80) years of age average. Of the treatment, 7 required 1 dose (38,89 %), 6 with 2 dose (33,33 %) and 5 with 3 dose (27,77 %) more grid macular. To the beginning the average of the best visual acuity with correction was of 0,24 (0,05-0,5) and of the macular thickness of 546,2 (283-1 020) µ. To the 12 months the best visual acuity with correction average improved at 0,65 (0,1-1,0) and the macular thickness at 181,05 (112-312) µ. there were not complications associated with proceeding. CONCLUSION: the injection of bevacizumab constitutes an effective treatment in the edema secondary macular to occlusion of branch veined retiniana.

OBJETIVO: evaluar los resultados del tratamiento de intravítrea de bevacizumab en el edema macular secundario a oclusión de rama venosa retiniana. MÉTODOS: estudio prospectivo, intervencional, no comparativo, en 18 pacientes con edema macular secundario a oclusión de rama venosa retiniana. El tratamiento fue de inyección intravítrea de bevacizumab (hasta 3 dosis) seguido de grid macular si era necesario. La evaluación inicial fue a los 3 meses de la oclusión y se siguieron a los pacientes por 12 meses. Se evaluó la agudeza visual mejor corregida, el grosor macular y la ocurrencia de complicaciones. RESULTADOS: los pacientes fueron 7 hombres (38,89 %) y 11 mujeres (61,11 %). El promedio de edad fue de 63,1 (44-80). Durante el tratamiento, hubo 7 pacientes con 1 dosis (38,89 %), 6 con 2 dosis (33,33 %) y 5 con 3 dosis (27,77 %) más grid macular. Al inicio, el promedio de la mejor agudeza visual con corrección fue de 0,24 (0,05-0,5) y del grosor macular de 546,2 (283-1 020) µ. A los 12 meses la mejor agudeza visual con corrección promedio mejoró a 0,65 (0,1-1,0) y el grosor macular a 181,05 (112-312) µ. No hubo complicaciones asociadas con el proceder. CONCLUSIÓN: la inyección intravítrea de bevacizumab constituye un tratamiento eficaz en el edema macular secundario a oclusión de rama venosa retiniana.

efficacy of ranibizumab in the treatment of macular edema secondary to central retinal vein occlusion [CRVO]

Purpose: To evaluate the effect of 3 consecutive intravitreal injections of ranibizumab [Lucentis] on visual acuity [VA] and central macular thickness [CMT] for central retinal vein occlusion [CRVO] induced macular edema. Study design: Our study was a prospective interventional case series

Patients and Methods: Twenty eyes of 19 consecutive patients diagnosed as CRVO-related macular edema [eight perfused, twelve ischemic CRVO] treated with 3 monthly intravitreal injections of ranibizumab at presentation as a monotherapy. Follow up visits were scheduled on the first, third and sixth months post-injections. Main outcome measures included mean changes in BCVA and CMI as measured by OCT

Results: The mean time from diagnosis until injection was 20 days. The mean BCVA of 0.03 +/- 0.03 [2/60] at baseline improved to a mean BCVA of 0.07 +/- 0.02 [5/60] six months after the last injection [final outcome], which was statistically significant [p<0.05] .Eleven eyes showed improved visual acuity [ 55%], 8 eyes [40%] had a stable visual acuity and 1 eye [5%] had worse visual acuity compared with baseline. A mean CMT of 679 um +/- 198 at baseline was improved to a mean CMT of 411 um +/- 158 six months after the last injection [final outcome], which was statistically significant [p<0.001]. The improvement in BCVA was superior in perfused CRVO compared to ischemic CRVO No ocular or systemic side-effects were noted

Conclusion: Intravitreal injection of ranibizurnab has shown promising results in VA improvement and decrease in CMT in patients with macular edema associated with CRVO especially the perfused form. However, long term results need to be further investigated

Resultados de la implantación de la cámara no midriática sobre la población diabética / Results of non-mydriatic fundus camera screening in a diabetic population

Objetivo: Determinar el impacto de la implantación de sistemas de cribado de retinopatía diabética (RD) mediante cámara no midriática (CNM) en una población con diabetes mellitus (DBT). Métodos: Estudio prospectivo de 6 años de duración, sobre el cribado oportunístico de una población de 12 801 pacientes con DBT. Resultados: Se revisaron 10 047 pacientes con DBT, un 78.48% de los individuos con DBT censados. En 86 (0.86%) pacientes no se pudo interpretar la imagen y debieron ser referidos a las consultas de oftalmología. Un total de 1 908 pacientes (19%) requirió dilatación pupilar. A los 6 años se detectó RD en 1 410 pacientes, con una incidencia anual del 6.15%; la forma leve fue la más frecuente, con un 77.94% de casos. La incidencia de edema macular diabético fue del 4.84% anual. Se verificó la presencia de otras enfermedades en 995 pacientes (9.91%). Conclusiones: Podemos extraer que el cribado mediante CNM es altamente útil para poder acceder a una gran parte de la población diabética, en especial aquella que acude con escasa frecuencia al oftalmólogo, lo que nos permite diagnosticar un número importante de individuos susceptibles de tratamiento láser para evitar que presenten ceguera.

Ranibizumab as an adjunct to laser for macular edema secondary to branch retinal vein occlusion.

To compare the safety, efficacy, and dosing regimen of intravitreal ranibizumab as an adjunct to laser therapy for the treatment of macular edema secondary to branch retinal vein occlusion (BRVO). Materials and Methods: Thirty eyes of 30 patients of BRVO of at least 6 weeks duration were randomized into three groups: Group 1 received grid laser treatment alone, Group 2 received a single dose of intravitreal injection of ranibizumab (0.5 mg / 0.05 ml) followed by grid laser treatment on 7th day following injection, while Group 3 received three loading doses of intravitreal ranibizumab at monthly interval (i.e. 0, 1, & 2 months) + standard laser treatment 7 days after the 1st injection. Outcome measure noted at 6 months follow-up were the improvement in best-corrected visual acuity (BCVA) and central macular thickness (CMT). Results: At 6 months follow-up, there was an average gain of 12 letters (P=0.05), 17.5 letters (P=0.05) and 19 letters (P=0.05) in groups 1, 2, and 3, respectively, with the decrease in CMT being 208.7 μm (P=0.05), 312.9 μm (P= 0.05) and 326.8 μm (P=0.05), respectively, in these groups. Gain in BCVA of more than 3 lines was noted in 1/10 patients in Group 1(10%) as compared to 3/10 (30%) and 4/10 (40%) patients in groups 2 and 3, respectively. Conclusion: The gain in BCVA and reduction in CMT were better with combination therapy (single- and triple- dose regimen) compared to grid laser alone. Single dose of intravitreal ranibizumab with grid laser seems to be an effective therapy.

Análogos de la somatostatina en el tratamiento de la retinopatía diabética / Somatostatin analogues in the treatment of diabetic retinopathy

La retinopatía diabética constituye un importante problema de salud por la discapacidad visual que provoca. El tratamiento de elección continúa siendo la fotocoagulación láser, pero en ocasiones hay formas avanzadas en que la respuesta es pobre y la evolución tórpida. Se continúan buscando otras alternativas de tratamiento que puedan mejorar la evolución, como son los esteroides y antiangiogénicos. Con el objetivo de reagrupar información actual sobre este grupo de medicamentos (análogos de la somatostatina), los cuales tienen efectos antiangiogénicos y han sido usados en el tratamiento de la retinopatía diabética proliferativa y el edema macular diabético, se realizó esta revisión. Los análogos de la somatostatina han mostrado ser eficaces, fundamentalmente, en el control de los fenómenos hemorrágicos y proliferativos en la retinopatía diabética proliferativa, y al mejorar también la integridad de la barrera hematoretiniana, ofrecen una alternativa de tratamiento para el edema macular diabético, fundamentalmente, cuando la respuesta al láser no resulta favorable(AU)

The diabetic retinopathy is an important health problem due to visual disability provoked. The choice treatment still remains the laser photocoagulation, but sometimes there is advanced ways in which the response is poor and the course is torpid. Other alternatives of treatment are look for to improve the course including the steroids and anti-angiogenic. The aim of present review was to regroup the current information on this group of drugs (somatostatin analogues), which has a anti-angiogenic effect and used in the treatment of proliferative diabetic retinopathy and the diabetic macular edema. The somatostatin analogues have shown to be effective, mainly in the control of hemorrhagic and proliferative phenomena and to also improve the integrity of the hematoretinal barrier, offer an alternative of treatment for diabetic macular edema, mainly when the response to laser is not favorable(AU)

A Three-year Follow-up of Intravitreal Triamcinolone Acetonide Injection and Macular Laser Photocoagulation for Diffuse Diabetic Macular Edema

PURPOSE: To report the three-year outcomes of macular laser photocoagulation following intravitreal injection of triamcinolone acetonide (IVTA) for diffuse diabetic macular edema (DME). METHODS: A prospective, randomized controlled study was completed. Eighty-six eyes of 74 patients with diffuse DME were randomized into two groups. Eyes assigned to the combination group (n = 48) were subjected to macular laser photocoagulation three weeks after IVTA. Eyes in the IVTA group (n = 38) underwent IVTA alone. Central macular thickness was measured by optical coherence tomography, and the number of additional treatments and mean time to recurrence were assessed. RESULTS: Thirty-seven eyes in the combination group and 26 eyes in the IVTA group completed the three-year follow-up. Recurrence of DME after initial treatment was not observed for nine of the 37 (24.3%) eyes in the combination group or for one of the 26 (3.9$) eyes in the IVTA group (p = 0.028). DME was absent for 19.9 months after treatment in the combination group compared to 10.3 months in the IVTA group (p = 0.027). The mean number of additional treatments was 0.92 in the combination group and 1.88 in the IVTA group (p = 0.001). CONCLUSIONS: Results in the subset of subjects who completed the three-year follow-up demonstrated that laser photocoagulation following IVTA is more effective than IVTA monotherapy for diffuse DME. Combination therapy required fewer additional treatments and resulted in a lower recurrence rate than IVTA monotherapy.

Treatment of diffuse diabetic maculopathy with intravitreal triamcinolone and laser photocoagulation: randomized clinical trial with morphological and functional evaluation / Tratamento da maculopatia diabética difusa com triancinolona intravítrea e fotocoagulação a laser: ensaio clínico randomizado com avaliação morfofuncional

PURPOSE: Treatment of diffuse macular edema in diabetes mellitus is currently unsatisfactory. The purpose of this double blind randomized clinical trial was to compare the treatment of diffuse diabetic macular edema with intravitreal triamcinolone or laser in type 2 diabetes mellitus patients using a morphofunctional assessment. METHODS: Fourteen patients (21 eyes) with clinically significant diffuse macular-edema, previously untreated and with a macular thickness >250 µm at optical coherence tomography were randomized for treatment with laser or intravitreal injection of triamcinolone acetate. Optical coherence tomography, biomicroscopy, fundoscopy, fluorescein angiography, tonometry, scotometry, visual and contrast acuities were performed at 0, 1, 3 and 6 months. RESULTS: At pre-treatment stage, Laser (n=9) and Triamcinolone (n=12) groups did not differ regarding retinal thickness, visual and contrast acuities. In Triamcinolone group macular thickness decreased after 1 month (424.1 ± 19.9 µm to 358.4 ± 18.2 µm; p=0.04) and started to return to the initial values in the 3rd month (p=0.02). No changes occurred in macular scotometry and visual and contrast acuities. No side effects were observed with both treatments. CONCLUSION: During the study macular thickness diminished in the triamcinolone group, especially in the first month of treatment. At 3 and 6 months there was no difference. Macular thickness did not change during the study in the laser group. In the study sample it was not possible to demonstrate differences relates to visual acuity and scotometry between the two groups. CLINICALTRIALS.GOV IDENTIFIER: NCT00668239.

OBJETIVO: O tratamento do edema macular difuso diabético atualmente é insatisfatório. O objetivo deste ensaio clínico randomizado duplo cego foi comparar, através de avaliação morfofuncional, o tratamento do edema macular difuso diabético com triancinolona intravítrea ou laser em grade em pacientes com DM tipo 2. MÉTODOS: Quatorze pacientes (21 olhos) com edema macular difuso clinicamente significativo, sem tratamento prévio e com espessura macular >250 µm à tomografia de coerência óptica (OCT) foram randomizados para tratamento com laser ou injeção intravítrea de acetato de triancinolona. Nos tempos 0, 1, 3 e 6 meses foram realizados OCT, biomicroscopia, fundoscopia, angiografia fluoresceínica, tonometria, escotometria, acuidade visual e de contraste. RESULTADOS: Na fase pré-tratamento, os grupos Laser (n=9) e Triancinolona (n=12) não diferiram na espessura retiniana, escotometria, acuidade visual e de contraste. No grupo Triancinolona houve redução da espessura macular após 1 mês (424,1 ± 19,9 µm vs. 358,4 ± 18,2 µm; P=0,04) com retorno aos valores iniciais a partir do mês 3 (P=0,02). Não houve modificação significativa na escotometria macular, acuidade visual e de contraste. Não ocorreram efeitos colaterais nos tratamentos. CONCLUSÃO: Durante o estudo observou-se diminuição da espessura macular no grupo tratado com triancinolona, principalmente no primeiro mês de tratamento. Aos 3 e 6 meses de tratamento não houve diferença. A espessura macular não modificou durante o estudo no grupo tratado com laser. Nesta amostra estudada não foi possível demonstrar diferenças relacionadas à escotometria e acuidade visual entre os dois grupos.

Diabetic retinopathy: an update

Management of diabetes should involve both systemic and ocular aspects. Control of hyperglycemia, hypertension and dyslipidemia are of major role in the management of diabetic retinopathy. In the ocular part; laser treatment remains the cornerstone of treatment of diabetic macular edema [focal/grid], severe non-proliferative and proliferative diabetic retinopathy [panretinal photocoagulation]. There is a strong support to combination therapy. Using one or two intravitreal injections such as anti-VEGF and or steroid to reduce central macular thickness followed by focal or grid laser to give a sustained response may offer an alternative to treatment in diabetic macular edema. Anti-VEGF were found to be effective as an adjunct therapy in proliferative diabetic retinopathy patient who is going to have vitrectomy for vitreous hemorrhage with neovascularization, panretinal photocoagulation, and other ocular surgery such as cases with neovascular glaucoma and cataract with refractory macular edema

Advances in the treatment of diabetic retinopathy

Diabetic retinopathy, the most common long-term complication of diabetes mellitus, remains one of the leading causes of blindness worldwide. Strict metabolic control, tight blood pressure control, laser photocoagulation, and vitrectomy remain the standard care for diabetic retinopathy. Focal/grid photocoagulation is a better treatment than intravitreal triamcinolone acetonide in eyes with diabetic macular edema and should be considered as the first-line therapeutic option. The current evidence suggests that intravitreal triamcinolone acetonide or anti-vascular endothelial growth factor agents result in a temporary improvement of visual acuity and a short-term reduction in central macular thickness in patients with refractory diabetic macular edema and are an effective adjunctive treatments to laser photocoagulation or vitrectomy. However, triamcinolone is associated with risks of elevated intraocular pressure and cataract. Vitrectomy with the removal of the posterior hyaloid without internal limiting membrane peeling seems to be effective in eyes with persistent diffuse diabetic macular edema, particularly in eyes with associated vitreomacular traction. Emerging therapies include islet cell transplantation, fenofibrate, ruboxistaurin, pharmacologic vitreolysis, rennin-angiotensin system blockers, and peroxisome proliferator-activated receptor gamma agonists

Correlation between fluorescein angiography, optical coherence topography and visual acuity in diffuse diabetic macular edema pre and post intravitreal injection of triamcinolone acetonide

To study the correlation between macular thickness by OCT, macular edema by FA and visual acuity finding in eyes with diffuse diabetic macular edema pre and after intravitreal injection of triamcinolone acetonide. This study included 40 eyes of 28 diabetic patients diagnosed as they had diabetic macular edema. Group I: included 20 eyes with primary diabetic macular edema. Group II: included 20 eyes with refractory diabetic macular edema. All patients received 4mg of intravitreal triamcinolone acetonide [IV TA]. Full ophthalmological examination. Fluorescein angiography and measurement of macular thickness [MT] by OCT were done to all cases preoperatively and 1.3 and 6 months postoperatively. Pre IVTA in group I: there was strong negative correlation between FA and VA[r/=-0.519] and weak correlation MT and VA[r=-0.421] while the correlation was positive between MT and VA[r=0.924]. In group II; there was negative correlation between FA,MT and VA[r=-0.594 and r=-0.672] but the correlation between MT and VA was positive, after IVTA allover the follow up period there was positive correlation between FA and MT in both groups. While the Correlation between BCVA and FA in Group I was negative correlation at 3rd and 6th month, the correlation in Group II was statistically non significant The correlation between MT and VA in group I was statistically significant 3 months after injection in both groups, however its effect decreases and recurrence of macular edema occurred 6 months after injection. In group II the correlation between MT and VA was statistically non significant. There is strong correlation between VA, OCT and fluorescein leakage. Visual acuity depends mainly on the macular perfusion not the amount of edema. OCT can differentiate between diffuse macular edema and cystoid macular edema diagnosed by fluorescein angiography

Aphakic and pseudophakic cystoid macular edema

To evaluate the effectiveness of medical treatment in patients with aphakic and pseudophakic cystoid macular edema [CME]. A two years prospective study of 25 cases with CME following cataract surgery. Every case underwent full ophthalmological examination and fluorescein fundus angiography. All cases treated by topical non-steroidal anti-inflammatory [Diclofenac 01%] ophthalmic solution 1-2 drops 4 times a day, 10 cases received 0 - [B - hydroxyaethyl] -rutosidea [Venoruton - 300] capsules 1200 mg in two divided oral dose daily for 2 weeks together with the topical diclofenac. Follow-up ranged 6 - 30 months [mean 19 months]. The 25 eyes of 25 patients all unilateral. 21[84.0%] pseudophakic and 4[16.0%] aphakic. Mean duration of CME [10.50 months]. Mean BCVA 0.2. Two groups were identified according to medical treatment, Group A - 15 cases received diclofenac 0.1% alone with 13 [86.7%] improved in a mean period of 8.5 weeks, 2 [13.4%] not improved and 3 [23.1%] with on/off phenomenon. Group B - 10 cases received topical diclofenac 0.1% together with Venoruton 300 capsules 9 [90.0%] improved in a mean 5 weeks, 1 [10.0%] not improved and 1 [11.2%] with on/off phenomenon. Topical non - steroidal anti-inflammatory drugs [Diclofenic 0.1%] ophthalmic solution proved to be beneficial in the prevention and treatment of chronic aphakic and pseudopahkic cystoid macular edema. Oral O - [B - hydroxyaethyl] - rutosidea [Venoruton 300] capsules was beneficial in the present study in augmenting the action of topical diclofenac by shortening the duration of recovery and lowering the rate of recurrence [on/off] phenomenon, but needs further studies

Retinopatía diabética en la población piurana: prevalencia y asociación con otras complicaciones de la diabetes mellitus / Diabetic retinopathy in the population piurana: prevalence and asociation with complications of the diabetes mellitus

Se evaluaron 849 pacientes del Programa de Diabetes Mellitus del IPSS - Piura estudiándose la presencia de Retinopatía Diabética (RD) y Edema Macular (EM), así como su asociación con otras complicaciones de la enfermedad. La prevalencia de RD fue 30 por ciento, de ellos el 81 por ciento tuvo RD no proliferativa, 19 por ciento RD Proliferativa; y 35 por ciento EM. El tiempo de enfermedad, hipertensión arterial y tipo de tratamiento fueron factores relacionados con su aparición. La realización del fondo de ojo durante las sesiones educativas del Programa de Diabetes Mellitus incrementó marcadamente la precosidad del diagnóstico, participación y cumplimiento del tratamiento.