Diabetic macular edema and proliferative diabetic retinopathy treated with anti-vascular endothelial growth factor under the reimbursement policy in Taiwan

The purpose of this retrospective interventional case series is to compare the functional and anatomical outcomes in eyes with diabetic macular edema (DME) and proliferative diabetic retinopathy (PDR) treated intravitreally with aflibercept or ranibizumab under the Taiwan National Insurance Bureau reimbursement policy. 84 eyes were collected and all eyes were imaged with spectral-domain optical coherence tomography (SD-OCT), color fundus photographs (CFPs), and fluorescein angiography (FA). At 24 months after therapy initiation, the logMAR BCVA improved from 0.58 ± 0.33 to 0.47 ± 0.38 (p < 0.01), the CRT decreased from 423.92 ± 135.84 to 316.36 ± 90.02 (p < 0.01), and the number of microaneurysms decreased from 142.14 ± 57.23 to 75.32 ± 43.86 (p < 0.01). The mean injection count was 11.74 ± 5.44. There was no intergroup difference in logMAR BCVA (p = 0.96), CRT (p = 0.69), or injection count (p = 0.81). However, the mean number of microaneurysms was marginally reduced (p = 0.06) in eyes treated with aflibercept at the end of the follow-up, and the incidence rates of supplementary panretinal photocoagulation (PRP) (p = 0.04) and subthreshold micropulse laser (SMPL) therapy sessions (p = 0.01) were also reduced. Multivariate analysis revealed that only initial logMAR BCVA influenced the final VA improvements (odds ratio (OR) 0.49, 95% confidence interval (CI) 0.21 ~ 0.93, p < 0.01); in contrast, age (OR − 0.38, 95% CI − 6.97 ~ − 1.85, p < 0.01) and initial CRT (OR 0.56, 95% CI 0.34 ~ 0.84, p < 0.01) both influenced the final CRT reduction at 24 months. To sum up, both aflibercept and ranibizumab are effective in managing DME with PDR in terms of VA, CRT and MA count. Eyes receiving aflibercept required less supplementary PRP and SMPL treatment than those receiving ranibizumab. The initial VA influenced the final VA improvements at 24 months, while age and initial CRT were prognostic predictors of 24-month CRT reduction.

Aflibercept as Adjunctive Treatment for Filtration Surgery in Neovascular Glaucoma

Objective: To investigate intravitreal aflibercept (IVA) injection as an adjunctive treatment to trabeculectomy with mitomycin C (TMC) and panretinal photocoagulation (PRP) for neovascular glaucoma (NVG).Materials and Methods: PRP and IVA (2 mg/0.05 ml) injection were given, and TMC was performed within 2weeks after IVA. Additional PRP, laser suture lysis, subconjunctival 5-fluorouracil injection, and bleb needlingwere performed after TMC if indicated. Best corrected visual acuity (BCVA), intraocular pressure (IOP), surgicalcomplications, and number of anti-glaucoma medications were collected.Results: Five eyes from 5 consecutive patients were included. Two eyes had proliferative diabetic retinopathy (PDR), 2 central retinal vein occlusion, and 1 ocular ischemic syndrome (OIS) (mean initial IOP: 46.8±6.8 mmHg). NVI regression occurred in one eye after PRP alone, and in one eye after PRP and IVA resulting in a good IOP control with topical medical therapy. The other 3 underwent TMC. The preoperative IOP was 34 (OIS), 54 (PDR), and 50 (PDR) mmHg. The 3-month postoperative IOP decreased to 8, 8, and 4 mmHg, respectively, and to 21, 10, and 6 mmHg, respectively, at the last visit. Only the one OIS eye required postoperative topical IOP-lowering medications. Final BCVA was improved, unchanged, and decreased in 2, 2, and 1 eye, respectively. No intraoperative/postoperative complications or NVI recurrence were observed (mean follow-up: 10.7 months).Conclusion: Intravitreal aflibercept was shown to be a potentially effective additional treatment to PRP and TMC in patients with NVG.

The Effectiveness of Laser Treatment for Diabetic Retinopathy in Patients with Chronic Kidney Disease

Background: Panretinal photocoagulation (PRP) remains one of the effective methods of treatment in pre- and proliferative forms of retinopathy with high efficiency. The aim of this study was to investigate the efficacy of PRP depending on the somatic status, laboratory parameters, and the severity of chronic kidney disease (CKD) in patients with type 2 diabetes (T2D) and a history of diabetic retinopathy (DR). Methods and Results: The study included 76 patients (50 women and 26 men) with T2D who underwent PRP for DR (152 eyes) using a VISULAS® 532s solid-state laser (ZEISS). The patients were divided into two groups depending on the severity of CKD. Group 1 (n=32, 64 eyes) included patients with CKD Stage 1, Group 2 (n=44, 88 eyes) included patients with CKD Stage 2. All patients underwent standard ophthalmological examination: visometry, tonometry, perimetry, biomicroscopy of the anterior segment of the eye and vitreous body, and fundus ophthalmoscopy. Thickness map of the retina was obtained using the RTVue-100 OCT (Optovue, Fremont, CA) EMM5 scan protocol and the Stratus OCT (Carl Zeiss Meditec, USA) radial scan protocol. Laboratory methods included a general blood test, PPG, FG, HbA1c, general urine analysis, and the assessment of blood levels of creatinine, ALT, and AST. PRP was carried out according to the standard method, gradually, in three stages; the interval between the stages of laser treatment was 1 month. After laser treatment, all patients, regardless of the treatment stage, were prescribed topical Broxinac® (Bromfenac ophthalmic solution 0.09%). The dynamics of corrected visual acuity (CVA) parameters and the retinal thickness of the macular region were assessed before PRP and 3 months after the complex treatment. Multivariate analysis revealed a linear and nonlinear effect of lipid spectrum indicators (TC and LDL) on the formation of CL (crystalline lens) pathology. After treatment, a significant increase in CVA was noted in both study groups. The effectiveness of PRP coagulation depended on the severity of the CKD stage in T2D patients with DR. Normalization of morphometric parameters of the macular region of the retina was noted in 93.8% of cases in Group 1 and in 86.4% of cases in Group 2. The decrease in the effectiveness of treatment was associated with the presence of macroangiopathy (CAD), concomitant diseases (CHF, AH and dyslipidemia), and CKD stage. Conclusion: Prolonged administration of the non-steroidal, anti-inflammatory drug Bromfenacum® for a month after each stage of PRP is effective.

Unveiling the Nanotechnology-Based Drug Delivery Systems and Patent Literature for Diabetic Retinopathy

Diabetes mellitus is a principal reason for globally developing chronic microvascular disorders defined as diabetic retinopathy (DR). Proliferative retinopathy and non-proliferative retinopathy are the two types of DR. Long-term diabetes, and poor blood sugar and arterial blood pressure regulation are the key risk factors for the onset and advancement of DR. A variety of biochemical pathways are involved in the pathogenesis of DR, which includes increased polyol pathway fluxes, advanced glycation end product growth, protein kinase C isoform activation, and increased hexosamine pathway flux. The varieties of cells are involved in diabetic retinopathy, including glial cells, retinal ganglion cells, endothelial cells, and pericytes. Surgical treatment of DR includes laser treatment, panretinal photocoagulation, focal laser photocoagulation, and vitrectomy surgery. The systemic treatment of DR includes glycemic management and control of blood pressure and hyperlipidemia. Nanotechnology-based formulations like nanoparticles, polymeric nanomicelles, and nanocarrier composite, and various patented formulations have been investigated for the treatment of DR.

OCTA in macular intraretinal microvascular abnormalities: Retinal vascular density remodeling after panretinal photocoagulation

Purpose To describe a case of macular intraretinal microvascular abnormality (IRMA) detected with Optical Coherence Tomography Angiography (OCTA) and to show its remodeling and vascular density changes after panretinal photocoagulation (PRP) during an 18-month follow-up. Methods Case report. Results A 22-year-old female patient with proliferative diabetic retinopathy was found to have a small hyperreflective formation with posterior shadow cone and signal flow, located at the temporal margin of the fovea avascular zone (FAZ), identified as macular IRMA with OCTA. Her best-corrected-visual acuity was 20/20. Four months later the macular IRMA was larger and, in its context, there was also an increase in the flow area in B-scan. The patient underwent PRP and after 18 months we observed a regression of macular IRMA and an increase in the superficial capillary plexus vessel density in all sectors in comparison to baseline. Conclusion OCTA is a non-invasive tool that recognize macular IRMA in diabetic retinopathy patient and it could be helpful to follow their qualitative and quantitative vascular evolution over time.