A 12-month prospective study to evaluate the efficacy of using the treat-and-extend regimen with intravitreal aflibercept as a Second-Line Treatment for Diabetic Macular Oedema (the TADI Study).

PURPOSE: To evaluate the efficacy of intravitreal aflibercept as a second-line therapy in eyes with persistent diabetic macular oedema (DMO) despite receiving initial bevacizumab treatment. METHODS: A prospective multicentre study was conducted in nine academic clinics in Israel. Starting from the first follow-up visit, a treat-and-extend regimen was applied in which the treatment intervals were extended by 2 weeks based on macular thickness using SD-OCT. The primary outcome was central subfield thickness (CST) at week 52. RESULTS: Forty-four patients (n = 48 eyes) were recruited to the study, and 43 eyes completed 52 weeks of follow-up. Patients received a mean (±SD) of 7.9 ± 3.5 bevacizumab injections before enrolment. The mean (±SD) CST under aflibercept therapy decreased from 468 ± 131 µm at baseline to 303 ± 67 µm at 52 weeks (p = 0.002), and best corrected visual acuity improved from 64 ± 15 ETDRS letters at baseline to 75 ± 8 letters at week 52 (p = 0.001). Twenty (46%) eyes met the treat-and-extend criteria and received a mean (±SD) of 10.9 ± 2 aflibercept injections. CONCLUSIONS: Eyes with persistent DMO following initial bevacizumab therapy had a marked reduction in macular thickness and improved visual acuity following 1 year of treatment with intravitreal aflibercept. Less than half of the patients met eligibility criteria for extension of the treatment interval; for these patients, the treat-and-extend regimen resulted in a maximum treatment interval of 10 weeks during the first year.

[PHACOEMULSIFICATION IN EYES WITH NEOVASCULAR AGE-RELATED MACULAR DEGENERATION (AMD)].

INTRODUCTION: Age-related macular degeneration (AMD) is the leading cause of blindness in the western world. The debate continues over the safety of cataract surgery in the setting of neovascular (wet) AMD. This retrospective review aims to describe our experience in treating patients with wet AMD, who underwent cataract surgery by phacoemulsification. METHODS: We prepared a retrospective chart review of patients treated in our clinic between the years 2006 - 2013. RESULTS: Forty-two eyes of 38 patients were included. Visual acuity (VA) improved significantly 1 month after cataract removal, without a significant change in retinal thickness. Twenty-six patients (62%) needed anti-VEGF injections during follow-up after surgery within an average period of 6 months. In eyes that were dry preoperatively, the re-injection rate was lower than those that were still wet (56 % vs. 80%) and the time from surgery to the first injection was longer in dry eyes (7 months and 3 months, respectively). Eyes that were injected with anti-VEGF up to one week before surgery had greater improvement in VA immediately after surgery but the proportion of those receiving injections (78%) was greater and the time to first injection post-surgery was earlier (3 months) compared to eyes that received the last injection 6 months or more prior to surgery ( 53 % and - 7 months). CONCLUSIONS: Cataract removal improves vision in wet AMD patients. It is of great importance to treat these patients and try to reach dry retina prior to surgery and a close followup is needed after surgery. In eyes that were more stable within 6 months before surgery and their retina was dry, the re-injection rate post surgery was lower and the time to first injection was longer.

Early OCT changes of neuroretinal foveal thickness after first versus repeated PDT in AMD.

PURPOSE: To compare early optical coherence tomography (OCT) changes in neuroretinal foveal thickness (NFT) after first versus repeated photodynamic treatment (PDT) in eyes with choroidal neovascularization (CNV) due to age-related macular degeneration (AMD). METHODS: This is a prospective comparative case series study. Consecutive AMD patients, treated with PDT due to subfoveal CNV, were enrolled. The eyes were divided into two groups: group A included eyes that had received the first initial treatment, and group B included eyes that had received repeated treatment. All eyes underwent serial examinations with OCT: prior to PDT, 1 h, and 3 months after the PDT. The primary outcome measure was early OCT change in NFT after PDT. RESULTS: Thirty-three eyes of 33 patients were included in this study; 16 in group A and 17 in group B. Optical coherence tomography showed a significant increase in NFT 1 h after PDT, as compared to pre-treatment status, in group A eyes (P = 0.008) but not in group B eyes (P = 0.731). Subretinal fluid was increased in both groups (93.8% and 88.2%, respectively), whereas intraretinal fluid was remarkably more increased in group A eyes (88%) than in group B eyes (59%). CONCLUSION: Early change in NFT, demonstrated on OCT, indicates that PDT causes different retinal response in primary versus repeated treatment of PDT for CNV due to AMD.

[Intravitreal triamcinolone acetonide for diffuse diabetic macular edema--one year follow-up].

BACKGROUND: Macular edema is the main cause of visual impairment in diabetic patients. Its treatment is mainly based on laser photocoagulation. Intravitreal triamcinolone acetonide (TA) has recently been proposed as a new treatment for eyes with diabetic macular edema resistant to conventional laser photocoagulation. AIM: To evaluate the one year efficacy and safety of a single TA injection administered for diffuse diabetic macular edema unresponsive to prior laser treatment. DESIGN: Interventional case series. METHODS: Setup: University medical center out-patient clinic. PARTICIPANTS: Twenty-one patients with bilateral diffuse diabetic macular edema. INTERVENTION: A single intravitreal injection of triamcinolone acetonide. MAIN OUTCOME MEASURES: Visual acuity measured by ETDRS score, retinal area evaluation clinically and retinal thickness evaluation by Retinal Thickness Analysis (RTA) at 3 and 12 months following injection. Secondary outcomes were intraocular pressure control and cataract progression. RESULTS: Three months following injection, the mean improvement in visual acuity was 4.7 +/- 11.7 letters in the study group as compared to 0.2 +/- 11.4 in the control group (p = 0.18). No difference was noticed one year following injection. Clinical assessment of the retinal area of edema revealed a substantial difference between patients and controls at 3 months (p = 0.0006) and at one year (p = 0.05). RTA evaluation revealed improvement in retinal thickness solely at the 3 months exam. Four eyes developed high intraocular pressure and required treatment (p = 0.054). No difference in cataract progression was noted between the two groups (p = 0.69). CONCLUSIONS: Injection of TA may improve visual acuity for a limited time. Increased intraocular pressure is a frequent side effect. During a one year follow-up, no evidence of ocular toxicity was noted in eyes with diffuse diabetic macular edema.

[Diabetic retinopathy following cataract surgery].

BACKGROUND: Approximately 20% of patients undergoing cataract surgery have diabetes mellitus. AIM: To evaluate the course of diabetic retinopathy after cataract surgery. METHODS: Diabetic patients with no or mild to moderate preoperative diabetic retinopathy were included and classified into 4 groups (A-D): A--The course of retinopathy, B--macular edema, C--the effect of voltaren ophtha eye drops and D--systemic glycemic control. Group E included eyes with previous laser treatment for proliferative retinopathy. Clinical and angiographic retinal findings were scored before and after surgery. Progression was defined as an increase in the retinal score. In groups A, C, D and E the non-operated eye served as a control. In group B, the eyes of nondiabetic patients who had undergone cataract surgery served as a control. RESULTS: Retinopathy was stable in 66% and progressed in 34% (p < 0.005). Progression occurred during the first 6 postoperative months in 84%. Preoperative retinopathy was a risk factor for progression. Good visual acuity was achieved in 67% and was correlated with: preoperative retinopathy and postoperative deterioration. Macular edema was found in 50% of eyes compared to 8% of the controls (p < 0.005). Its development was correlated with preoperative retinal status. Twenty six eyes were treated with voltaren eye drops and 24 with placebo. Progression of macular edema was seen less often in eyes treated with voltaren (p < 0.001). Deterioration of retinopathy was less common in cases when HbA1C was equal to or lower than 7.5 mg%. CONCLUSIONS: Close retinal follow-up after cataract surgery is recommended, especially in patients with preoperative diabetic retinopathy. Systemic control of diabetes and antiinflammatory eye drops may improve surgical results.

Results of combined surgery by phacoemulsification and vitrectomy.

BACKGROUND: Eyes scheduled for posterior segment surgery may have cataract, which obscures the visualization of the retina. Surgery may be carried out either by a two-step procedure: i.e., removal of the cataract followed later by posterior segment surgery; or it may be done in a single session: i.e., combined surgery of both the anterior and posterior segments. OBJECTIVE: To evaluate the outcomes of combined surgery by phacoemulsification and vitrectomy. METHODS: We retrospectively reviewed the records of 42 patients with coexisting cataract and vitreoretinal disease who underwent combined surgery by phacoemulsification and pars plana vitrectomy at one session. RESULTS: Indications for surgery were vitreous hemorrhage in 71.4%, retinal detachment in 11.9%, macular hole in 11.9%, and epiretinal membrane in 4.8%. There were no significant intraoperative complications. The main early postsurgical complications were fibrinous formation in 11.9%, elevated intraocular pressure in 23.8%, and recurrent vitreous hemorrhage in 9.5%. There were a few late complications related to phacoemulsification: posterior synechia in 9.5%, posterior capsular opacification in 7.1%, and dislocating intraocular lens in 4.8%. Recurrent retinal detachment occurred in five eyes and rubeoisis iridis in one. Visual acuity was improved in 85.8%, stable in 7.1% and worse in 7.1%. CONCLUSIONS: Phacoemulsification performed at the time of posterior segment surgery enables good visualization during the vitrectomy, facilitates surgery, and is associated with only minor complications. In cases with cataract and vitreoretinal diseases, combined surgery by phacoemulsification and vitrectomy in one session may be considered.