Ranibizumab for persistent diabetic macular edema after bevacizumab treatment.

PURPOSE: To evaluate the efficacy of switching from bevacizumab to ranibizumab in patients with diabetic macular edema (DME). METHODS: This was a retrospective study of patients with DME initially treated with bevacizumab and switched to ranibizumab. Visual acuity (VA) and central retinal thickness (CRT) were retrieved at fixed timepoints prior to and after the switch. RESULTS: Forty eyes of 32 patients were included in the study. The difference in VA between any of these fixed timepoints was not statistically significant. A significant gain in VA was found in eyes that lost more than 0.1 logMAR during treatment with the last 3 bevacizumab injections. The mean CRT was significantly lower after the first 3 ranibizumab injections and at the final follow-up (p<0.001), a 67 ± 14 µm and 78 ± 18 µm reduction in thickness, respectively. CONCLUSIONS: Switching to ranibizumab resulted in a significant decrease in the CRT of eyes with DME, and should be considered when there is a lack of response or deterioration while on bevacizumab injections. A significant gain in VA was observed in a subgroup of eyes that lost more than one line while receiving the last 3 bevacizumab injections prior to the switch.

[The revolution in the treatment of retinal diseases: anti-VEGF treatment at the Assuta Eye Institute].

The VEGF protein (Vascular Endothelial Growth Factor) was identified in the '80s as a factor which induces proliferation of blood vessels in the body in general and in the retina in particular. Proliferative processes in retinal blood vessels, vascular permeability and induced edema which follows, frequently cause blindness in the diseases of the macula: AMD (Age-related Macular Degeneration) diabetes and retinal vascular occlusions. Since 2006, through treatment using anti-VEGF drugs--Avastin (Bevacizumab) and Lucentis (Ranibizumab) and Eylea (Aflibercept)--blindness in many patients in Israel and elsewhere was prevented. This paper reviews the treatment with anti-VEGF intraocular injections in the above mentioned diseases with reference to the growing activity at the Assuta Eye Institute.

SWITCHING TREATMENT FOR NEOVASCULAR AGE-RELATED MACULAR DEGENERATION FROM BEVACIZUMAB TO RANIBIZUMAB: Who is Likely to Benefit From the Switch?

PURPOSE: To evaluate the safety and efficacy of switching from bevacizumab to ranibizumab in patients with neovascular age-related macular degeneration. METHODS: Retrospective study of patients with neovascular age-related macular degeneration initially treated with bevacizumab and switched to ranibizumab. Visual acuity and central retinal thickness (CRT) were retrieved at four time points: before the last three bevacizumab injections, at the switch, after the first three ranibizumab injections, and at the end of follow-up. RESULTS: One hundred and fourteen eyes of 110 patients were included. Switching from bevacizumab to ranibizumab did not achieve a significant change in visual acuity, and a significant reduction in CRT was achieved after the first three injections but was not maintained by the end of follow-up. Eyes that lost ≥0.1 logMAR before the switch were more likely to improve in visual acuity (P = 0.013), and eyes with ≥10% increase in CRT before the switch were more likely to improve anatomically (P = 0.0003). In 47.3% of the eyes, the CRT was reduced by ≥10% after the first 3 ranibizumab injections, and the reduction was maintained with additional injections. CONCLUSION: Switching to ranibizumab should be considered in patients with visual acuity decrease or CRT increase, despite monthly bevacizumab injections. The response should be evaluated after the first three injections to guide future treatment.

The rate of myocardial infarction events among patients with age-related macular degeneration: a population-based study.

PURPOSE: To examine the association between age-related macular degeneration (AMD) and the risk of myocardial infarctions (MIs) in a large health maintenance organization. DESIGN: A retrospective cohort study carried out at Maccabi Healthcare Services (MHS). PARTICIPANTS: A total of 6,546 patients aged ≥65 years who were diagnosed with AMD between April 18 1996 and June 6 2008, and 61,672 non-AMD patients frequency-matched for age and gender. METHODS: Participants were retrospectively followed to the day of leaving the MHS, to undergoing an MI, or to closure of the study on July 1 2008, whichever came earlier. The relative risk of MI associated with AMD was estimated using the Cox proportional hazard model. MAIN OUTCOME MEASURES: Incident myocardial infarction events. RESULTS: During the study period, there were 159 (5.1 per 1,000 person years [PY]) and 2,997 (4.2 per 1,000 PY) MIs respectively in the AMD and non-AMD patient groups. The age- and gender-adjusted hazard ratio (HR) of MI among AMD patients was 1.01 (95%CI: 0.85-1.20). Baseline medical characteristics associated with increased risk of mortality included diabetes mellitus, hypertension, older age, and male gender. The fully adjusted HR associated with AMD was 1.03 (95%CI: 0.87-1.22). CONCLUSION: Despite the shared risk factors associated with AMD and MIs, we found no increased risk of MI in AMD patients.

Mesopic foveal contrast sensitivity is impaired in diabetic patients without retinopathy.

BACKGROUND: Contrast sensitivity (CS) has been studied extensively to determine its effectiveness as a test for diagnosing early and advanced diabetic retinopathy. Various techniques have been adopted to measure CS, and most of them reported a significant difference between diabetic and normal eyes. Our purpose is to demonstrate differences in foveal CS between diabetic patients without retinopathy and healthy subjects under mesopic and photopic conditions, using a simple, rapid computerized test. METHODS: Seventeen eyes of nine patients with type 2 diabetes without diabetic retinopathy were included. Fourteen eyes of seven non-diabetic patients served as controls. All the patients underwent a careful ophthalmologic examination, including ETDRS chart visual acuity, color photographs, and optical coherence tomography (OCT). Patients with any ocular disease were excluded. All eyes had a visual acuity of 20/25 or better, a normal eye examination and optical coherence tomography (OCT). Photopic and mesopic contrast sensitivity was tested using a computerized psychophysical static method involving four forced-choice procedures. The targets were Gabor patches with spatial frequencies of 3-12 cycles per degree (cpd). The mesopic testing was conducted in a completely darkened room; the monitor was covered with a neutral density filter, allowing luminance of only 0.9 cd/m(2). RESULTS: The average age was similar: 59.1 ± 5.3 years in the diabetic group vs 61.4 ± 3.2 years in the control group. The average duration of diabetes was 16 years (range 6-26). The average visual acuity was 0.04 ± 0.01 logMAR and 0.01 ± 0.01 logMAR in the diabetic and control groups respectively. Photopic foveal CS was similar in both groups. Significantly lower CS was found in diabetic patients under mesopic conditions at a spatial frequency of 3 (p < 0.008). At higher spatial frequencies, the mesopic contrast sensitivity was very low in both groups and without a significant difference. CONCLUSIONS: Mesopic foveal CS is impaired in diabetic patients despite good visual acuity, a normal fundus examination and normal OCT. Early central visual function impairment may occur in diabetic patients before the appearance of retinopathy.

Retrospective analysis of vitrectomy with and without internal limiting membrane peeling for stage 3 and 4 macular hole.

BACKGROUND AND OBJECTIVE: To evaluate the efficacy and safety of pars plana vitrectomy with indocyanine green (ICG)-assisted internal limiting membrane (ILM) peeling versus pars plana vitrectomy without ILM peeling for stage 3 and 4 primary idiopathic macular hole. PATIENTS AND METHODS: Sixty-two eyes of 60 consecutive patients with idiopathic macular hole underwent vitrectomy with gas (C3F8) injection. The first 46 eyes underwent vitrectomy without ILM peeling; of these, 14 had epiretinal membrane peeling and were excluded, leaving 32 eyes (no ILM group). The remaining 16 eyes underwent vitrectomy with ICG-assisted ILM peeling (ICG-ILM group). Follow-up data at 6 to 48 months postoperatively were recorded and analyzed. RESULTS: Macular hole closure was achieved in 13 (81%) of 16 patients in the ICG-ILM group and 16 (50%) of 32 patients in the no ILM group (P = .036). Analysis of the data from eyes with closed holes indicates that the ICG-ILM group achieved a better mean final visual acuity compared with the no ILM group (20/60 vs 20/100, respectively) (P = .017). No complications were attributed to the use of ICG. CONCLUSIONS: ICG-assisted ILM peeling significantly increased the rate of hole closure in eyes with stage 3 or 4 idiopathic macular hole. The use of ICG did not adversely affect the visual acuity results, and it appears to be a safe adjunct to macular hole surgery.

Telemedicine in the service of peace.

Ophthalmology is well suited to telemedicine, since optical and imaging devices provide the basis for virtually all ophthalmic patient evaluations. We established the Middle East Ophthalmology Network among ophthalmologists working in 10 major ophthalmology centres in Israel, Jordan, Morocco, the Palestinian Authority and Tunisia. The project offered some 50 physicians around the Middle East the opportunity to benefit from sharing clinical consultation for diagnosis and management decisions beyond physical and political boundaries. In the first year, over 100 consultations took place. The system overcame some of the constraints imposed by the uneven distribution of medical resources and expertise in the region, reduced professional isolation, encouraged more collaboration between physicians and offered peace dividends from cooperation between physicians across the political divide.