Ranibizumab and diabetic macular oedema: after laser therapy

Diabetic retinopathy is sometimes accompanied by macular oedema, leading to a marked decline in visual acuity. The standard treatment, in addition to glycaemic and blood pressure control, is laser photocoagulation, despite its modest efficacy. Ranibizumab (Lucentis, Novartis), a VEGF (vascular endothelial growth factor) inhibitor, was initially authorised for age-related macular degeneration (AMD) in the European Union. It is now also approved for the treatment of visual loss due to macular oedema in diabetic patients. In this setting, clinical evaluation of ranibizumab is mainly based on two double-blind randomised trials comparing ranibizumab + laser photocoagulation versus placebo + laser photo-coagulation in a total of about 1000 patients. Compared with placebo, addition of ranibizumab to laser therapy led to a marked improvement in visual acuity in approximately 15% of patients after 12 months of treatment. The improvement appeared to persist after 24 months of treatment. In a trial that included a group treated with ranibizumab alone, efficacy did not differ from that of the ranibizumab + laser combination. Uncertainties remain concerning the long-term efficacy of ranibizumab and its benefits in patients with poorly controlled diabetes or proliferative retinopathy. The adverse effect profile of ranibizumab in patients with diabetic macular oedema is similar to that reported in patients with AMD, and mainly includes ocular adverse effects such as pain, bleeding and increased intraocular pressure. A risk of systemic adverse effects, particularly cardiovascular disorders, should be kept in mind in case of long-term treatment. Ranibizumab can cause birth defects, even after intravitreal injection during pregnancy. Monthly treatment with ranibizumab is inconvenient, difficult and expensive. In practice, laser therapy remains the standard treatment for diabetic patients with significantly reduced visual acuity due to macular oedema. Ranibizumab, which requires intravitreal injections, should be restricted to second-line use.     

Ranibizumab: in diabetic macular oedema

Ranibizumab, an intravitreally administered inhibitor of vascular endothelial growth factor (VEGF), is approved for the treatment of visual impairment associated with diabetic macular oedema (DME) in the EU. In four well designed, phase II or III trials (RESOLVE, RESTORE, RIDE and RISE), 1-2 years' treatment with ranibizumab was more effective than sham or focal/grid laser therapy in improving best corrected visual acuity (BCVA) and reducing central retinal thickness (CRT) in patients with visual impairment associated with DME. Additionally, in two well designed phase III trials (RESTORE and DRCR.net-1), 1 year of treatment with ranibizumab as an adjunct to laser therapy was more effective than laser monotherapy in improving BCVA and CRT in patients with visual impairment associated with DME. Improvements in BCVA with ranibizumab alone or as an adjunct to laser therapy were observed at the first follow-up visits in these studies (i.e. 1-4 weeks after the start of treatment), and were associated with gains in vision-related quality of life, as assessed using the National Eye Institute Visual Functioning Questionnaire-25. The ocular and non-ocular adverse event profile of ranibizumab in patients with DME is similar to that observed in patients with neovascular (wet) age-related macular degeneration or retinal vein occlusion. Based on tolerability data from clinical trials, there is no indication that ranibizumab alone or combined with laser is associated with an increased risk of cardiovascular or cerebrovascular events potentially related to systemic VEGF inhibition.     

Ranibizumab

Ranibizumab is the antigen-binding fragment of a recombinant, humanised monoclonal antibody, which binds with high affinity to, and inhibits the activity of, all active forms of vascular endothelial growth factor A, an important mediator in the development of choroidal neovascularisation. Well designed, phase III trials in patients with neovascular (wet) age-related macular degeneration (AMD) indicated that monthly intravitreal injections of ranibizumab 0.3 or 0.5 mg for up to 2 years maintained or improved visual acuity to a greater extent than sham injection, verteporfin photodynamic therapy or sham photodynamic therapy. In patients with predominantly classic wet AMD who received ranibizumab in combination with verteporfin therapy, preliminary results indicate that combination therapy is superior to that of verteporfin therapy alone. Most serious ocular adverse events, which were uncommon, were associated with either the injection procedure or ranibizumab.     

康柏西普与雷珠单抗治疗视网膜中央静脉阻塞继发黄斑水肿的疗效及安全性分析

目的 比较康柏西普与雷珠单抗治疗视网膜中央静脉阻塞（central retinal vein occlusion,CRVO）继发黄斑水肿的效果和安全性。方法 将陕西省杨凌示范区医院自2015年6月-2017年1月纳入的CRVO继发黄斑水肿患者102例作为研究对象,随机分为两组,即使用康柏西普治疗的A组50例（50眼）,使用雷珠单抗治疗的B组52例（52眼）,观察治疗后1、3、6个月时患者视力恢复情况和黄斑部视网膜厚度变化情况,评价不同药物的治疗效果和安全性。结果 治疗6个月后A组患者视力提高率（52.00%）高于B组（30.77%）,差异具有统计学意义（P<0.05）;两组患者的黄斑部视网膜厚度的改善A组优于B组,且各个复诊时间点比较,差异均具有统计学意义（P<0.05）。两组不良反应发生率分别为8.00%和11.54%,差异无统计学意义。结论 康柏西普治疗CRVO继发黄斑水肿的临床效果优于雷珠单抗,但二者的安全性差异不显著,有待于进一步长期大样本研究证实。     

Ranibizumab: new drug. Macular degeneration: second-line use due to risks

(1) Due to a lack of any better alternatives, photodynamic therapy is the standard treatment for subfoveal lesions due to neovascular age-related macular degeneration (AMD). It consists of intravenous injection of a photosensitizer, verteporfin, followed by local red laser activation. This treatment, sometimes repeated every 3 months, stabilises the loss of visual acuity for 2 years in about 50% of patients. Adverse effects are generally acceptable. (2) Ranibizumab is an antibody fragment targeting vascular endothelial growth factor (VEGF). VEGF is implicated in the neovascularisation involved in age-related macular degeneration. Ranibizumab is injected into the vitreous in the same way as pegaptanib, the first VEGF antagonist to be approved for an ocular indication. (3) Clinical evaluation of ranibizumab includes 2 placebo-controlled trials (900 patients in total), a trial versus verteporfin (423 patients), and a trial testing ranibizumab in combination with verteporfin (162 patients). More than 90% of patients treated with ranibizumab in these two trials had no tangible loss of vision for one to two years, compared to about 68% of patients treated with verteporfin (statistically significant difference). These trials did not attempt to determine the optimal interval between intravitreal injections. (4) No trials have directly compared ranibizumab with pegaptanib; indirect comparisons suggest that ranibizumab is better than pegaptanib. (5) Intravitreal injection of ranibizumab can have local adverse effects, similar to pegaptanib. These include inflammatory reactions, infections, and elevated intraocular pressure. Arterial thromboses at distant sites, in particular strokes, have been reported with ranibizumab, at a higher frequency with 0.5 mg per infection (about 1%) than with 0.3 mg per injection. (6) When visual acuity continues to deteriorate in patients with age-related macular degeneration despite treatment with verteporfin, ranibizumab provides an effective alternative for patients with no particular risk factors for stroke.     

Comparison between “early” or “late” intravitreal injection of dexamethasone implant in branch (BRVO) or central (CRVO) retinal vein occlusion: six-months follow-up

Aim: The aim of this study was to compare early and late injections of intravitreal dexamethasone implant in patients affected by central retinal vein occlusion (CRVO) or branch retinal vein occlusion (BRVO) with a six-months follow-up. We assessed whether an earlier treatment start (within seven days from diagnosis) could be more beneficial than a delayed (or late) treatment start (after seven days).

Materials and methods: The study included 81 patients (81 eyes) affected by retinal vein occlusion. Best corrected visual acuity was assessed through Early Treatment Diabetic Retinopathy Study (ETDRS) while central macular thickness (CMT) was measured by spectral-domain optical coherence tomography.

Results: Both types of patients had a positive therapeutic response to dexamethasone, with an increase in visual acuity (ETDRS) and CMT reduction. CRVO patients were characterized by lower ETDRS values at baseline and at the end of the follow-up as compared to BRVO. CRVO patients showed higher CMT values at baseline, after three and six months from injection. No significant differences in therapeutic response to dexamethasone were observed between patients treated early or late, regardless of RVO type.

Conclusions: This study demonstrates that the therapeutic properties of dexamethasone implant are not significantly influenced by an early or late treatment start in patients affected by BRVO and CRVO, although its therapeutic efficacy seems greater in the former type.     

玻璃体腔注射雷珠单抗联合曲安奈德治疗视网膜静脉阻塞继发黄斑水肿的meta分析

目的 评价玻璃体腔注射雷珠单抗联合曲安奈德（IVR+IVT）与单用雷珠单抗（IVR）治疗视网膜静脉阻塞继发黄斑水肿的疗效和安全性差异。方法 检索数据库资源，包括PubMed、Embase、Cochrane图书馆、中国知网（CNKI）、维普中文科技期刊数据库（VIP）和万方数据，收集建库至2019年1月治疗方案为IVR+IVT与IVR治疗视网膜静脉阻塞继发黄斑水肿的随机对照临床研究文献，纳入符合标准的文献，评价其质量，提取相关数据，采用RevMan 5.3统计软件进行Meta分析。结果 本研究共纳入4项RCTs文献，病例数215例，217眼。Meta分析结果提示，IVR+IVT组患者随访3个月时黄斑中心凹视网膜厚度（CMT）优于IVR组，差异有统计学意义，随访1，2，4，5，6个月2组间CMT差异无统计学意义；4项研究最佳矫正视力（BCVA）治疗后较治疗前提高，其中2项研究随访1个月时差异有统计学意义，随访2，3，4，5，6个月差异无统计学意义；在不良反应发生率方面，IVR+IVT组眼压升高并发症风险明显高于IVR组；2组在发生皮质性白内障方面，差异无统计学意义；在注射次数上，IVR+IVT组较IVR组明显减少，差异有统计学意义。结论 IVR+IVT与IVR治疗视网膜静脉阻塞继发黄斑水肿均有效，在随访3个月降低CMT和随访1个月改善BCVA方面存在统计学差异。IVR+IVT治疗虽增加眼压升高风险，但注射次数较IVR减少，同时也减轻患者经济负担。临床医师可根据实际情况，酌情选取合适治疗手段。     

视网膜静脉阻塞78例临床分析

目的探讨视网膜静脉阻塞（RVO）患者在病程不同时期采取的主要治疗方法及临床疗效。方法对78例（81眼）RVO患者的临床资料进行回顾性分析。81眼中视网膜中央静脉阻塞（CRVO）21眼,经药物治疗17眼,激光治疗4眼;视网膜分支静脉阻塞（BRVO）58眼,经药物治疗45眼,激光治疗13眼;视网膜黄斑分支静脉阻塞（MBRVO）2眼,采用药物治疗,分析不同治疗方法的治疗效果。结果单纯药物治疗64眼,有效56眼（87.5%）;激光治疗17眼,有效14眼（82.4%）。结论RVO应定期随访观察,在病程中的不同时期,需分别采取药物治疗、激光光凝疗法。     

78例视网膜静脉阻塞临床分析

目的探讨视网膜静脉阻塞（RVO）患者在病程不同时期采取的主要治疗方法及临床疗效。方法对78例（81眼）ROV患者的临床资料进行回顾性分析。81眼中视网膜中央静脉阻塞（CR-VO）21眼，经药物治疗17眼，眼光治疗4眼；视网膜分支静脉阻塞（BRVO）58眼，经药物治疗45眼，激光治疗13眼；视网膜黄斑分支静脉阻塞（MBRVO）2眼，采用药物治疗，分析不同治疗方法的治疗效果。结果单纯药物治疗63眼，有效54眼（61．9％）；激光治疗17眼，有效14眼（82．3％）。结论RVO应定期随访观察，在病程中的不同时期，需分别采取以药物、激光光凝。     

玻璃体内注射雷珠单抗与曲安奈德治疗视网膜静脉阻塞继发黄斑囊样水肿的疗效比较

目的：比较玻璃体内注射雷珠单抗与曲安奈德治疗视网膜静脉阻塞（ retinal vein occlusion ,RVO）继发黄斑囊样水肿（ cystoidmacular edema ,CME）的疗效及安全性。方法97例RVO继发CME患者按治疗方法分为雷珠单抗组（n＝47）和曲安奈德组（n＝50）。雷珠单抗组给予玻璃体内注射雷珠单抗0．5 mg（0．05 ml）;曲安奈德组给予玻璃体内注射雷珠单抗4．0 mg（0．1 ml）。治疗后随访6个月,比较2组最佳矫正视力（best corrected visual acuity,BC－VA）、黄斑中心凹厚度（ central macular thickness ,CMT）、眼压及并发症发生率。结果2组治疗后各时间点BCVA均较治疗前显著提高（P＜0．05）,但2组间比较差异无统计学意义（P＞0．05）。2组治疗后各时间点CMT均较治疗前显著降低（P＜0．05）,但2组间比较差异无统计学意义（P＞0．05）。雷珠单抗组治疗后各时间点眼压与治疗前比较差异无统计学意义（ P＞0．05）;曲安奈德组治疗后各时间点眼压均较治疗前和雷珠单抗组显著提高（ P＜0．05）。曲安奈德组和雷珠单抗组眼压升高发生率比较,差异有统计学意义（P＜0．05）。结论玻璃体内注射雷珠单抗治疗RVO继发CME,可有效提高BCVA、降低CMT,其效果与曲安奈德相当,且安全性更高。     

3种视网膜新生血管抑制药治疗湿性AMD的临床对比研究

目的:比较3种视网膜新生血管抑制药治疗湿性老年黄斑变性(AMD)的临床疗效,探讨其临床应用价值。方法:按照随机数字法将2013年8月-2016年10月某院收治的114例(114眼)湿性AMD患者分为A、B、C 3组,每组38例。A组患者静脉输注维替泊芬结合光动力疗法,B组与C组患者分别玻璃体内腔注射雷珠单抗与康柏西普,均每月给药1次,治疗3个月,随访3个月。比较治疗前及治疗后1个月、3个月、6个月3组患者的裸眼视力、黄斑中心视网膜厚度、脉络膜新生血管(CNV)渗漏面积以及并发症发生情况。结果:治疗前,3组患者的裸眼视力、黄斑中心视网膜厚度及CNV渗漏面积比较差异无显著性(P>0.05),治疗后,3组患者的裸眼视力均显著提高、黄斑中心视网膜厚度及CNV渗漏面积均显著减小(P<0.05)。A组在治疗后1、3个月的裸眼视力显著低于B与C组、黄斑中心视网膜厚度及CNV渗漏面积显著大于B与C组(P<0.05),C组在治疗后1个月的裸眼视力显著低于B组、黄斑中心视网膜厚度及CNV渗漏面积显著大于B组(P<0.05);治疗后6个月,3组患者的裸眼视力、黄斑中心视网膜厚度及CNV渗漏面积比较差异无显著性(P>0.05);3组患者并发症的发生率差异无显著性(P>0.05)。结论:在湿性AMD的临床治疗中,雷珠单抗的前期效果明显,但3种药物的后期效果相当。     

治疗视网膜分支静脉阻塞性黄斑水肿的临床疗效观察

目的评价曲安奈德玻璃体腔内注射治疗分支静脉阻塞性黄斑水肿的疗效及并发症。方法26例患者诊为分支静脉阻塞性黄斑水肿的共计26只眼,每只眼接受注射曲安奈德4mg（4mg/0.1ml）,检查注射前、后的视力、眼底、眼压、荧光造影及OCT。结果平均随访时间为5个月（1～8个月）,平均视力：注射前0.1,注射后1d：0.29;3d：0.55;1m：0.64;3m：0.59.与治疗前相比,有显著性差异。平均黄斑厚度：注射前（931.60±312.37）μm,注射后：1周：（297.05±84.23）μm;1个月：（221.53±51.67）μm;3个月：（185.54±49.16）μm,与治疗前比较有显著性差异。术后高眼压的发生率为34.62%,经药物或ALT治疗,眼压均恢复正常水平。无一例发生眼内炎。结论眼内注射曲安奈德可明显的改善视力及减轻因分支静脉阻塞而导致的黄斑水肿,但其疗效并非持久,且存在一些并发症。     

Comparative efficacy of bevacizumab,ranibizumab, and aflibercept for treatment of macular edema secondary to retinal vein occlusion: a systematic review and network meta-analysis

Introduction: Anti-vascular endothelial growth factor (VEGF) therapy has become the most commonly used treatment for macular edema secondary to retinal vein occlusion (RVO). Although its superior efficacy as compared to other interventions has been proven, there is a lack of evidence for relative efficacy among anti-VEGF drugs.

Areas covered: This work systematically reviewed and compared the efficacy of intravitreal bevacizumab, ranibizumab, and aflibercept for treating macular edema due to RVO. PubMed, EMBASE, and the Cochrane Library were searched from their inception until October 2017. Eleven randomized controlled trials (18 articles; 1830 adult patients) were identified. The proportion of patients who gained at least 15 letters in best-corrected visual acuity (BCVA), mean change from baseline in BCVA, and mean change from baseline in central macular thickness (CMT) were reported and these efficacy outcomes at 6 months were analyzed in network meta-analysis.

Expert commentary: Apparently, bevacizumab, ranibizumab, and aflibercept were significantly superior to sham injection in terms of BCVA improvement and CMT reduction and had good safety profiles. However, there were no statistically significant differences in any outcomes among anti-VEGF drugs. In selecting an anti-VEGF drug for individual patients, other factors including affordability, drug availability, and patient characteristics should be considered.     

Dexamethasone: intravitreal implant

Macular oedema is one of the complications of retinal vein occlusion. About half of the patients recover spontaneously within 3 to 6 months. There is currently no drug that improves outcome. An intravitreal implant delivering 0.7 mg of dexamethasone has been authorised for the treatment of macular oedema in this setting. Clinical assessment is based on two double-blind randomised trials including a total of 1267 patients, comparing treatment with intravitreal implants delivering about 0.7 mg or 0.35 mg of dexamethasone, versus a sham procedure. Despite a more rapid initial improvement with dexamethasone, the number of patients whose reading ability improved at 6 months did not significantly differ between the groups. A retrospective subgroup analysis raised the possibility that dexamethasone implants may be beneficial in patients with central retinal vein occlusion. The adverse effects of dexamethasone intravitreal implants are the same as those of intraocular steroid injections, including elevated intraocular pressure (25% of patients), cataracts (27%), conjunctival haemorrhage (20%), and ocular pain. In practice, dexamethasone intravitreal implants do not have a positive harm-benefit balance in most patients with macular oedema following retinal vein occlusion. More rapid recovery after central vein occlusion remains to be confirmed. Pending such studies, it is better to avoid using dexamethasone implants. Patients should instead receive ophthalmologic monitoring to detect and manage possible complications, and any risk factors should be treated.     

Targeted pharmacotherapy of retinal diseases with ranibizumab

Diseases of retinal and/or choroidal blood vessels are the most prevalent causes of moderate and severe vision loss in developed countries. Vascular endothelial growth factor (VEGF)-A plays a critical role in the pathogenesis of many of these diseases. Ranibizumab is a humanized antigen-binding fragment that binds all isoforms of VEGF-A. Intraocular injections of ranibizumab cause significant visual improvement in approximately 40% of patients with choroidal neovascularization due to age-related macular degeneration (AMD). Pilot trials have indicated that intraocular injections of ranibizumab also provide benefits in patients with macular edema due to diabetic retinopathy or retinal vein occlusions. Based upon several case series, bevacizumab, a full-length humanized monoclonal antibody that binds all isoforms of VEGF-A, improves vision in patients with choroidal neovascularization due to AMD and other diseases. Case series also suggest that bevacizumab can cause regression of retinal neovascularization in patients with proliferative diabetic retinopathy. Taken together, results with ranibizumab and bevacizumab suggest that potent antagonists of VEGF will provide the foundation of treatment for a wide variety of diseases complicated by retinal or choroidal neovascularization, or by excessive vascular leakage leading to macular edema.     

雷珠单抗对视网膜中央静脉阻塞继发黄斑水肿患者黄斑区视网膜血流参数的影响

目的 观察视网膜中央静脉阻塞(CRVO)继发黄斑水肿患者黄斑区视网膜血流参数以及观察雷珠单抗治疗前后黄斑区视网膜血流参数的变化。 方法 前瞻性对照研究。纳入2015年11月至2017年1月在襄阳市中心医院眼科就诊的CRVO继发黄斑水肿的患者33例为CRVO组,同时纳入健康人30例为对照组。所有CRVO继发黄斑水肿患者接受玻璃体腔内雷珠单抗注射治疗。用RTVue-100光学相干断层扫描血流成像技术3 mm×3 mm扫描模式测量研究对象黄斑区视网膜血管密度以及中央凹无血管区域(FAZ)面积。 结果 CRVO组的黄斑区视网膜浅层血管密度与深层血管密度分别为43.03%±5.11%以及47.00%±7.54%,对照组浅层以及深层视网膜血管密度分别为63.23%±5.50%以及61.43%±7.90%,两组之间均差异有统计学意义(P<0.001)。CRVO组FAZ面积为(0.49±0.08) mm²,对照组为(0.28±0.07) mm²,CRVO组FAZ面积明显小于对照组,均差异有统计学意义(P<0.001)。球内注射雷珠单抗后,CRVO组视网膜浅层与深层血管密度以及FAZ面积均未发生明显变化。 结论 相对于健康人,CRVO继发黄斑水肿的视网膜血管密度较低,FAZ面积偏大。CRVO继发黄斑水肿患者接受球内雷珠单抗治疗后,视网膜血管密度以及FAZ面积未见明显变化。     

Influence of serous retinal detachment on the outcome of ranibizumab treatment in diabetic macular oedema

Purpose: The purpose of this study was to evaluate the influence of serous retinal detachment (SRD) on the outcome of intravitreal ranibizumab (IVR) therapy in diabetic macular oedema (DME).

Materials and methods: Fifty-one eyes with cystoid macular oedema (CME) and SRD (study group) and 57 eyes with only CME (control group) that received pro re nata (PRN) IVR injections during a 6-month period were retrospectively evaluated. The outcome measures included changes in the central macular thickness (CMT) and best corrected visual acuity (BCVA) and injection numbers.

Results: The mean initial CMT in the study and control groups was 467?±?101 and 440?±?89?µm, respectively. The mean BCVA in the study and control groups was 0.75?±?0.38 and 0.59?±?0.36 logarithm of minimal angle of resolution (LogMAR), respectively (p?=?0.010). The study group received a mean of 2.2?±?0.92 injections, whereas the control group received a mean of 2.54?±?0.9 injections. The decrease in CMT was greater, but not significantly greater, in the study group than in the control group.

Conclusion: The presence of SRD resulted in a less favourable visual acuity (VA) outcome with IVR. Disruption of the ellipsoid zone and abnormality of the foveal avascular zone at the baseline examination were correlated with a lower VA. Both of the pathologies occurred more frequently in the SRD group.     

阿柏西普T&E方案与雷珠单抗3+prn方案治疗初发DME的回顾性对照研究

目的：回顾性对照研究阿柏西普T&E方案与雷珠单抗3+prn方案治疗初发糖尿病黄斑水肿（DME）的有效性、安全性和治疗成本。方法：采用回顾性方法对比初发DME患者61只眼。31只接受阿柏西普T&E方案,30只接受雷珠单抗3+prn方案。评估基线、3个月、6个月、12个月的最佳矫正视力（BCVA）、黄斑中心厚度（CMT）、不良反应。对比2组随访期末的注射次数和治疗成本。结果：在12个月随访期末,2组平均BCVA均提高（P<0.01）,组间相比无统计学差异（P=0.498）;2组CMT均改善（P<0.01）,组间相比无统计学差异（P=0.140）。阿柏西普T&E方案组注射次数（7.3±1.5）低于雷珠单抗3+prn方案组（8.2±1.7）,差异有统计学意义（P=0.02）。阿柏西普T&E方案组治疗成本低于雷珠单抗3+prn方案组。结论：在真实世界中,阿柏西普T&E方案与雷珠单抗3+prn方案治疗初发DME均有效安全,但阿柏西普T&E方案需要的注射次数更少,治疗成本更低。     

Anti-vascular endothelial growth factor therapies in ophthalmology: current use,controversies and the future

Use of anti-vascular endothelial growth factor (VEGF) therapies was introduced for the treatment of ocular disorders in 2005. In the UK, the current licensed and NICE approved indications are for the treatment of neovascular age-related macular degeneration (nAMD), diabetic macular oedema (DMO), macular oedema secondary to a retinal vein occlusion (RVO) and choroidal neovascularization in pathological myopia. These diagnoses alone account for two-thirds of the main causes of legally registrable visual impairment and blindness. Ranibizumab (Lucentis®; Genentech/Novartis), a drug specifically designed for intraocular use, is the primary licensed medication. Controversially however, clinicians have been using an unlicensed cheaper drug, bevacizumab (Avastin®; Genentech/Roche), originally designed for systemic administration, with a similar mode of action and shown to have a similar efficacy. However, there are fears of greater side effects with bevacizumab though studies have not been sufficiently powered to show statistical difference. In the current global economic climate, anti-VEGF treatment places huge financial and logistical pressure on already strained health care systems. Bevacizumab is considerably more cost effective than ranibizumab, and thus using bevacizumab would widen access to treatment particularly in developing countries. This licensing issue also places clinicians in a difficult medico-legal position especially in Europe, where doctors are duty bound to use a licensed drug for a particular indication if this is available. As the indications of anti-VEGF therapies expand and the cost of health care provision becomes more expensive, the controversies surrounding their use will inevitably become more important.     

醋甲唑胺与吸收剂对视网膜分支静脉阻塞激光光凝术后黄斑水肿的疗效

目的探讨联合口服醋甲唑胺与吸收剂对视网膜分支静脉阻塞激光光凝术后黄斑水肿的临床疗效。方法将42例(42眼)视网膜分支静脉阻塞激光光凝术后的患者随机分为2组,治疗组口服醋甲唑胺联合吸收剂,对照组单纯口服吸收剂,对比两组患者在治疗后1个月的视力及黄斑水肿的变化情况。结果激光光凝术后,口服醋甲唑胺联合吸收剂的患者1个月时视力提高(59.1%vs.25.0%,P<0.05)、黄斑水肿消失(63.6%vs.30.0%,P<0.05)均优于单纯口服吸收剂的患者。结论联合应用醋甲唑胺与吸收剂治疗视网膜分支静脉阻塞激光光凝术后黄斑水肿更有效。