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.

Case Report: A Case of Perifoveal Exudative Vascular Anomalous Complex With a Good Prognosis

Significance: Perifoveal exudative vascular anomalous complex (PEVAC) is a unique clinical lesion. It manifests as isolated lesions and is easily misdiagnosed. Thus far, few PEVAC case reports have been published. PEVAC is typically inconsistent with other reported macular lesions.Purpose: To report our 24-month follow-up experience on the treatment of PEVAC with a micropulse laser (MPL).Case Report: A 56-year-old Chinese woman with no history of other diseases complained of decreased vision in her left eye that had persisted for more than 1 year. Comprehensive ophthalmic examinations were performed, including a vision test, slit lamp fundus exam, optical coherence tomography (OCT), optical coherence tomography angiography (OCT-A), fluorescein fundus angiography (FFA) and indocyanine green angiography (ICGA). Intravitreal injection of ranibizumab was ineffective, and bleeding, exudation and visual acuity were not improved. After two rounds of micropulse laser (MPL) treatment, the patient was followed up, and the prognosis was good.Conclusion: PEVAC is very rare, and early diagnosis is important, as the lesions readily cause irreversible damage. Our results indicate that an MPL can be used as an alternative treatment for PEVAC patients.

Navigated micropulse laser for central serous chorioretinopathy: Efficacy, safety, and predictive factors of treatment response

Purpose There is no widely accepted treatment for persistent/chronic central serous chorioretinopathy. The present study aimed to evaluate the efficacy, safety, and factors associated to treatment response to navigated micropulse laser in chorioretinopathy. Methods Retrospective observational case series including consecutive patients presenting with symptomatic persistent and chronic chorioretinopathy. All patients were treated with 5% navigated micropulse laser with the Navilas system (Navilas®, OD-OS GmBH, Teltwo, Germany), by overlying fluorescein angiography, indocyanine green angiography and/or spectral domain-optical coherence tomography images of visible leaking points and/or choroidal hyperpermeability/subretinal fluid to plan the laser treatment. Results Thirty-nine eyes of 36 consecutive patients (29 men and 7 women, with a mean age of 51.87 years) were included. Logarithm of the minimum angle of resolution (LogMar) best-corrected visual acuity increased from 0.39 ± 0.24 at baseline to 0.24 ± 0.22 at 3 months ( p < 0.0001) and to 0.20 ± 0.07 at 6 months ( p < 0.0001). Subretinal fluid decreased from 166.82 ± 111.11 micron at baseline to 52.33 ± 78.97 micron ( p < 0.0001) at 3 months and 34.12 ± 67.56 micron at 6 months ( p < 0.0001). The presence of a hot spot on fluorescein angiography and a focal choroidal hyperpermeability on indocyanine green angiography, but not the duration of symptoms correlated significantly with the resolution of subretinal fluid at month 3 ( p = 0.023 and p = 0.001). Conclusion Navigated micropulse laser laser treatment was found to be effective and safe for the treatment of chorioretinopathy, with significant improvement in visual and anatomical outcomes, unaccompanied by any adverse event at 3 and 6 months follow-up. Factors associated to subretinal fluid resolution may allow a better selection of likely responders to navigated micropulse laser treatment.

Efıcacy of Mıcropulse Laser In The Treatment of Dıabetıc Macular Edema

Purpose: In this study, we aimed to evaluate and compare the visual acuity, macular volume, central macular thickness, change in number of intravitreal ranibizumab injections with micropulse laser applications after loading dose of antiVEGF to DME patients.Study Design: Retrospective study Methods: This study was carried out on 97 patients (45 ranibizumab and 52 micropuls grid laser + ranibizumab) with diabetic macular edema patients who were followed in the Retina Unit. At the control visit after three loading ranibizumab injections administered once a month, micropuls grid laser was applied to one group and ranibizumab injection was continued PRN to both groups for an average of 9.27 ± 2.42 months and central macular thickness, macular volume and visual acuity were recorded. Results: There was no significant difference between the groups in terms of gender, smoking and systemic diseases, initial central macular thickness, macular volume and visual acuity measurements (p> 0.05). Central macular thickness, macular volume and visual acuity values measured at the last follow-up of the patients were not significantly different between the groups (p> 0.05). The mean post-treatment injection requirement was 4.19 ± 1.01 for the ranibizumab with micropuls laser group and 5.53 ± 1.14 for the ranibizumab group. In the group treated with micropuls laser, statistically less number of intravitreal ranibizumab injections were needed (p <0.001). Conclusion: Micropulse laser treatment after initial loading doses reduces the need for antiVEGF injections. Studies with the participation of more patients may help in the selection of treatment methods by comparing micropulse laser combined with different injection protocols.

One-year outcome of cystoid macular degeneration in central serous chorioretinopathy

Purpose: To study structural and functional outcomes of cystoid macular degeneration (CMD) in chronic central serous chorioretinopathy (CSCR). Methods: This retrospective study included 26 eyes having chronic CSCR with CMD who underwent either observation, photodynamic therapy (PDT), micropulse laser, or eplerenone therapy. Various optical coherence tomography parameters were analyzed at baseline and 1 year. Results: Number of eyes that maintained or gained vision after treatment was 63.1%, compared to a loss of 2.1 ± 1.1 lines in observation group. Sub-foveal large choroidal vessel responded to PDT ( p = 0.03); while CMT ( p = 0.035) and intra-retinal cystoid spaces (0.037) responded to eplerenone. Longer duration of the symptoms and round cystoid spaces were associated with a decrease in CMT ( p = 0.03) and decrease in cystoid spaces size ( p = 0.02) respectively on follow up. Conclusion: Treatment of eyes with CMD prevents further deterioration of vision. Round configuration of intra-retinal cystoid space has a better anatomical outcome.

Subthreshold micropulse yellow (577nm) laser versus intravitreal Ranibizumab in treatment of center involving diabetic macular oedema

Purpose To evaluate the effectiveness of subthreshold micropulse laser as compared to intravitreal injection of ranibizumab in treatment of center involving diabetic macular oedema. Methods A total of 76 eyes of 62 patients with center involving diabetic macular oedema were divided into two groups. Group A received intravitreal injection of ranibizumab while group B received subthreshold micropulse laser with rescue intravitreal injection of ranibizumab. The change from baseline in best correscted visual acuity and central subfield thickness were compared at 3, 6, 9 and 12 months follow-up. Any adverse effects were recorded. Results Group A (n = 34 eyes) experienced a statistically significant improvement in best corrected visual acuity (from 0.32±0.16 Log MAR at baseline to 0.21±0.14 Log MAR at 12 months) (P value =0.006), with a statistically significant reduction in central subfield ghickness (from 352.06±34.34µm to 289.47±58.88 µm) (P value=0.001). Group B (n = 42 eyes), also experienced a statistically significant improvement in best corrected visual acuity (from 0.34±0.22 Log MAR at baseline to 0.13±0.31 Log MAR at 12 months) (P value=0.001), with a statistically significant reduction in central subfield thickness (from 300±47.34µm to 253.12±39.60 µm at 12 months) (P value= 0.009). The mean difference in best corrected visual acuity between the group B and group A was -0.08 Log MAR with a 95% CI ranging from -0.197 to 0.037, which supports the claim of non-inferiority between the two treatment regimens. No adverse effects from subthreshold micropulse laser were recorded in both groups. Conclusion subthreshold micropulse laser with rescue intravitreal injection of ranibizumab was non inferior to intravitreal injection of ranibizumab in treatment of center involving diabetic macular oedema as regards the mean change in best corrected visual acuity.

Changes in entropy on polarized-sensitive optical coherence tomography images after therapeutic subthreshold micropulse laser for diabetic macular edema: A pilot study

Purpose To investigate the dynamics of the healing process after therapeutic subthreshold micropulse laser (SMPL) for diabetic macular edema (DME) using polarization-sensitive optical coherence tomography (PS-OCT). Methods Patients with treatment-native or previously-treated DME were prospectively imaged using PS-OCT at baseline, 1, 2, 3, and 6 months. The following outcomes were evaluated: changes in the entropy value per unit area (pixel2) in the retinal pigment epithelium (RPE) on the B-scan image; changes in the entropy value in each stratified layer (retina, RPE, choroid) based on the ETDRS grid circle overlaid with en face entropy mapping, not only the whole ETDRS grid area but also a sector irradiated by the SMPL; and the relationship between edema reduction and entropy changes. Results A total of 11 eyes of 11 consecutive DME patients were enrolled. No visible signs of SMPL treatment were detected on PS-OCT images. The entropy value per unit area (pixel2) in the RPE tended to decrease at 3 and 6 months from baseline (35.8 ± 17.0 vs 26.1 ± 9.8, P = 0.14; vs 28.2 ± 18.3, P = 0.14). Based on the en face entropy mapping, the overall entropy value did not change in each layer in the whole ETDRS grid; however, decrease of entropy in the RPE was observed at 2, 3, and 6 months post-treatment within the SMPL-irradiated sectors (P < 0.01, each). There was a positive correlation between the change rate of retinal thickness and that of entropy in the RPE within the SMPL-irradiated sector at 6 months (r2 = 0.19, P = 0.039). Conclusion Entropy measured using PS-OCT may be a new parameter that facilitates objective monitoring of SMPL-induced functional changes in the RPE that could not previously be assessed directly. This may contribute to a more promising therapeutic evaluation of DME. Clinical trial This clinical study was registered in UMIN-CTR (ID: UMIN000042420).

Micropulse Laser Trabeculoplasty On Glaucoma Patients: Average 35 Months Follow-Up Results

Background: Glaucoma is a group of eye diseases that can damage the optic nerve and cause vision loss. A novel technology micropulse laser trabecular plasty (MLT) can use duty-circle subvisible laser pulses to treat glaucoma. The aim of this study is to evaluate the efficacy of 360° MLT to alleviate intraocular pressure (IOP) in patients with glaucoma.Methods: This was a single-center prospective study on patients treated with 360° MLT using a Diode True-Yellow 577-nm Laser with MicroPulse technology. All the patients were recruited from the Department of Ophthalmology. Follow-up visits were carried out at 1 day, 1 week, 1 month, 3 months, 6 months, 18 months, and 36 months after the procedure. Best-corrected visual acuity (BCVA), Intraocular pressure (IOP), and vertical cup-to-disc ratio (C/D ratio) were measured during the follow-up. Repeated-measures analysis of variance (ANOVA) and Kaplan–Meier analysis were performed to evaluate the outcomes.Results: A total of 39 eyes from 26 patients were included in this study (10 men/15 women). The average age of patients was 41.47±14.39 years old, and the baseline IOP was 21.13 ± 7.75 mmHg. MLT significantly reduced the IOP at 1 day (range 15.61–19.01, P=0.0218), 3 months (range 16.47–19.22, P=0.0390), and 6 months (range 15.38–18.56, P=0.0332) compared with the baseline. However, by the end of the study, only 21.88% of patients demonstrated a ≥ 20% IOP reduction, while seven eyes needed further laser or surgical treatment. Conclusions: Micropulse laser trabeculoplasty could reduce IOP in patients with glaucoma or ocular hypertension for a short period, but its lowering efficiency was limited up to 6 months of the follow-up period.