Diabetic macular oedema and visual loss: relationship to location,severity and duration

Purpose: To assess the relationship between visual acuity (VA) and diabetic macular oedema (DMO) in relation to the location of retinal thickening and the severity and duration of central macular thickening. Methods: Data from 584 eyes in 340 placebo‐treated patients in the 3‐years‐long Protein Kinase C Diabetic Retinopathy Study (PKC‐DRS2) trial were used to investigate the relationship between VA and DMO. Eligible eyes had moderately severe to very severe non‐proliferative diabetic retinopathy and VA of at least 45 letters on Early Treatment Diabetic Retinopathy Study (ETDRS) charts (Snellen equivalent = 20/125). Diabetic retinopathy and DMO status were assessed using stereo photographs. Results: Nearly one third of study eyes had foveal centre‐involving DMO at the start of the trial. Sustained moderate visual loss was found in 36 eyes, most commonly associated with DMO at the centre of the fovea in 73% of eyes. There was a strong relationship (p < 0.001) between foveal centre involvement with DMO and mean VA. Mean VA decreased with increasing retinal thickness at the centre (p < 0.001) and increasing duration of centre‐involving DMO (p < 0.001). Conclusion: This study documents the relationship between duration of DMO and progressive vision loss, and the key role of central foveal involvement in patients with diabetic retinopathy. These data will help to develop future strategies to prevent vision loss.     

Short-term effects of intravitreal triamcinolone on retinal vascular leakage and trunk vessel diameters in diabetic macular oedema

PURPOSE: To assess retinal vascular permeability and vessel diameter changes after intravitreal triamcinolone acetonide (IVTA) injection in eyes with persistent foveal thickening after photocoagulation for diabetic macular oedema (DMO). METHODS: We calculated the blood-retinal barrier permeability as measured by vitreous fluorophotometry, artery and venous vessel diameter at the temporal vascular arcades as measured on digital fundus photos, and retinal thickness as measured by optical coherence tomography. Seven patients with type 2 diabetes and DMO were examined immediately before and 1 week after IVTA 2 mg. The study was designed as an open-label interventional case series using the fellow eyes as untreated controls. RESULTS: One week after IVTA, we observed that, compared with baseline values, blood-retinal barrier permeability had decreased to 27.2 +/- 3.6% (p < 0.0001), retinal artery diameter had decreased to 94.9 +/- 0.02% (p = 0.05), retinal vein diameter had decreased to 89.2 +/- 0.03% (p = 0.02) and foveal thickness had decreased to 68.7 +/- 6.9% (p = 0.004). Visual acuity (VA) improved by 7.4 +/- 2.2 letters (p = 0.01). No significant change was observed in control eyes except that mean VA deteriorated by 2.6 +/- 0.9 letters (p = 0.03). Changes in permeability were closely correlated to changes in retinal thickness (R = 0.84) and venoule diameter (R = 0.93) in treated eyes. CONCLUSIONS: Intravitreal injection of triamcinolone acetonide in eyes with DMO is followed by a marked reduction in retinal vascular leakage and a concomitant reduction in retinal vessel calibre.     

The predictive value of optical coherence tomography after grid laser photocoagulation for diffuse diabetic macular oedema

Purpose: To assess the predictive value of optical coherence tomography (OCT) mapping of retinal thickness and intraretinal morphological changes after macular grid for diffuse diabetic macular oedema (DMO). Methods: We carried out a prospective, non‐controlled, case series study, in which 28 consecutive eyes with previously untreated diffuse DMO underwent fundus photography and OCT at baseline and at 1, 3 and 6 months after treatment. Results: Macular photocoagulation was followed by a significant reduction in retinal thickness in the foveal centre (? 80 μm) and in the foveal subfield (? 65 μm) from baseline to 6 months (p < 0.01). The bulk of the reduction in retinal thickness and macular volume was manifest after 1 month. No significant change in retinal thickness occurred from 1 to 3 months or from 1 to 6 months in any macular subfield (p > 0.05). The relative decrease in retinal thickness at 6 months was highest in the foveal centre (? 22%), followed by the foveal region (? 18%), the inner parafoveal region (? 8%), and the outer parafoveal region (? 2%). Thus, the effect of photocoagulation on retinal thickness decreased with increasing eccentricity (p < 0.025). Overall, there was no statistically significant change in best corrected visual acuity (BCVA) between baseline and follow‐up (p < 0.05), but changes in foveal subfield thickness and changes in VA were highly correlated (r = 0.66, p < 0.0001). Visual outcome (final BCVA) and final foveal subfield thickness at 6 months were correlated with the pattern of intraretinal morphological changes at baseline (Spearman’s correlation coefficient r = ? 0.41, p = 0.03 and r = 0.45, p = 0.02, respectively). In addition, visual outcome (final BCVA) and final foveal subfield thickness at 6 months were correlated with baseline foveal thickness (Spearman’s correlation coefficient (r = ? 0.37, p = 0.05 and r = 0.5, p = 0.01, respectively). Conclusions: It seems that the 1‐month time‐point after macular laser treatment is a critical point for establishing the outcome of this modality of management of DMO. Baseline OCT mapping of intraretinal fluid accumulation patterns and foveal thickness can help to predict the final visual outcome and final foveal thickness, but not the absolute change in either of these parameters after macular laser therapy.     

Retinal sensitivity and fixation changes 1 year after triamcinolone acetonide assisted internal limiting membrane peeling for macular hole surgery – a MP‐1 microperimetric study

Acta Ophthalmol. 2010: 88: e222–e227

Abstract.

Purpose: To evaluate microperimetric changes 1 year after macular hole surgery with triamcinolone acetonide assisted internal limiting membrane (ILM) peeling. Methods: Twenty‐two eyes of 22 patients with stage 3 and 4 idiopathic macular holes of <6 months’ duration underwent vitrectomy with triamcinolone acetonide assisted ILM peeling. Best corrected visual acuity (BCVA) (logarithm of the minimum angle of resolution), and central retinal sensitivity were documented before and 1, 3, 6, and 12 months after surgery. Macular sensitivity (mean sensitivity in decibels ‐dB), and stability and location of fixation (preferred retinal locus) were determined using MP‐1 microperimetry (Nidek). The MP‐1 microperimetry sensitivity map was overlaid onto infrared images recorded on a Heidelberg scanning laser ophthalmoscope using dedicated MP‐1 software to evaluate the fixation location before surgery. Anatomical success was evaluated with optical coherence tomography (OCT). Optical coherence tomography scans were recorded on an OCT 3000 scanner. Results: Anatomical success was achieved in all 22 eyes. All patients completed 1 year follow‐up. No recurrence of macular hole was seen in any patients in the follow‐up period. The mean BCVA improved from 0.75 ± 0.2 before surgery to 0.31 ± 0.1 logMAR at the last visit (p < 0.001). Mean sensitivity improved from 3.7 ± 0.6 to 5.3 ± 1.0 dB at the last visit (p < 0.001). Before surgery, the preferred retinal locus was located on the margin of the hole in all, in 18 eyes on its upper part and in four eyes to the side or on its lower part. Preoperatively, 12 eyes were stable and 10 were relatively unstable, but 12 month after surgery, fixation stability had improved, and 20 eyes were stable and two were relatively unstable. Conclusions: MP‐1 microperimetry sensitivity map overlaid onto an infrared image using dedicated MP‐1 software can be used successfully to evaluate fixation location in patients with a macular hole before surgery. With microperimetry findings, we can also measure functional macular changes more precisely than using BCVA alone after macular hole surgery. Our results also showed that retinal sensitivity and fixation properties were improved after vitrectomy with triamcinolone acetonide assisted ILM peeling in patients with idiopathic macular hole.     

Relationship between macular pigment and visual acuity in eyes with early age‐related macular degeneration

Purpose: Today the extent to which MP impacts visual function in early AMD remains unclear. This study examines the relationship between macular pigment optical density (MPOD) and high‐contrast visual acuity (HC‐VA) and low‐contrast visual acuity (LC‐VA) in eyes with early age‐related macular degeneration (AMD). Methods: Measurements were made in 22 subjects with early AMD and 27 healthy control subjects. Distance best‐corrected VA was measured using HC (96%) and LC (10%) Bailey‐Lovie logMAR letter charts under photopic luminance conditions. MPOD was determined at the fovea through apparent motion photometry using the cathode ray tube‐based Metropsis psychophysical vision test (Cambridge Research Systems). Results: No significant differences in foveal MPOD were detected between the control eyes (0.30 ± 0.24 log units) and eyes with early AMD (0.27 ± 0.15 log units). Neither were differences detected between the two groups in mean HC‐ and LC‐VA. Foveal MPOD showed significant correlation with both photopic HC‐VA (r = ?0.47, p = 0.0008) and LC‐VA (r = ?0.46, p = 0.0008) such that as MPOD increased, photopic HC‐VA and LC‐VA improved (lower logMAR values). Conclusions: Low MP levels were related to worse visual function in both healthy eyes and eyes with early AMD. Our findings provide direction for future studies designed to improve retinal function through the use of oral supplements known to increase MP levels, especially in eyes with AMD and a low MPOD.     

Comparison of retinal thickness and fundus‐related microperimetry with visual acuity in uveitic macular oedema

Purpose: Macular oedema is a common complication and vision‐limiting factor in uveitis. The aim of this study was to compare retinal thickness as measured by optical coherence tomography and photoreceptor function as measured by fundus‐related microperimetry with respect to their correlation with visual acuity. Methods: Prospective observational monocentre study. Thirty‐one patients (53 eyes) with endogenous uveitis and fluorescein angiographically confirmed macular oedema were evaluated. Foveal thickness was analysed using spectral‐domain (Spectralis^TM; Heidelberg Engineering, Heidelberg, Germany) OCT and retinal sensitivity was assessed using fundus‐related microperimetry (MP1; Nidek Technologies, Padova, Italy). All findings were correlated with best‐corrected visual acuity (BCVA). Results: Foveal thickness was correlated with BCVA [p = 0.005, r = 0.38, 95% confidence interval (CI) 0.12–0.59]. For microperimetry measurements, a negative correlation with logMAR visual acuity was found. Fixation abnormalities were not associated with poor visual acuity, increased foveal thickness or retinal sensitivity. In eyes with cystoid changes in the outer plexiform and inner nuclear layer, foveal thickness was increased (p < 0.0001). Epiretinal membrane formation was present in 70%. In these eyes, foveal thickness was significantly increased (p = 0.003) and visual acuity was worse (p = 0.08). Conclusion: Foveal thickness and fundus‐related microperimetry were correlated with visual acuity. Cystoid changes in the outer plexiform and inner nuclear layer and the presence of epiretinal membrane were associated with poor visual acuity. Fixation abnormalities were not associated with poor visual acuity.     

Comparing intravitreal triamcinolone acetonide and bevacizumab injections for the treatment of diabetic macular oedema: a randomized double‐blind study

Purpose: To compare the effect of a single intravitreal injection of triamcinolone acetonide and bevacizumab in reducing macular thickness, which was measured by optical coherence tomography (OCT) in patients with diabetic macular oedema (DMO). Methods: The patients received a single intravitreal injection of 1.25 mg bevacizumab in one randomly selected eye and 4.0 mg triamcinolone acetonide in the contralateral eye. Central foveal thickness measurement (CFT) with OCT was taken at the initial visit and at the 4‐week, 12‐week and 24‐week visits. Results: Eleven patients (22 eyes) were enrolled and statistically analysed. CFT reduced in the eyes treated with triamcinolone and those treated with bevacizumab in weeks 4 and 12 (p < 0.05). At the 24‐week follow‐up, no significant difference was noted, relative to the initial visit. Comparing the two groups treated with different drugs, a statistically significant difference in CFT in weeks 4 and 12 was noted, with a more significant reduction in triamcinolone‐treated eyes (p < 0.05). Regarding visual acuity (VA), patients treated with triamcinolone had improvement in VA at 4‐week (p = 0.02) and 12‐week follow‐up (p = 0.01), while the group treated with bevacizumab had VA improvement at 4 ‐week follow‐up (p = 0.02). Among the eyes treated with triamcinolone, intraocular pressure (IOP) measurement of more than 21 mmHg was found in three eyes (27.3%). Conclusions: Intravitreal triamcinolone proved to be more efficient in reducing DMO, providing longer lasting visual improvement, relative to bevacizumab. Eyes treated with triamcinolone had the highest percentage increase in IOP. Further studies are needed to corroborate these findings.     

Optical coherence tomography and vessel diameter changes after intravitreal bevacizumab in diabetic macular oedema

Purpose: To assess the effect of intravitreal bevacizumab on diabetic macular oedema (DMO) and retinal vessel calibres. Methods: We performed a consecutive case series study in which 10 consecutive eyes with diffuse DMO, two of which had not previously been treated, received an intravitreal injection of bevacizumab 1 mg, which was followed by two more injections at 6‐week intervals. Fundus photography and optical coherence tomography (OCT) were carried out at baseline immediately before injection and at 1, 2.5 and 4 months after the first injection. Outcome measures were best corrected visual acuity (BCVA) in Early Treatment Diabetic Retinopathy Study letters, macular volume, foveal subfield thickness and vessel diameter measurement. Results: Intravitreal administration of bevacizumab was followed by a mean increase in BCVA of 7.3 ± 17 (mean ± standard deviation) letters between baseline and month 4, which was 1 month after the last injection (p < 0.0001). This was accompanied by a reduction in mean macular volume from 9.90 ± 1.9 mm³ to 8.96 ± 2.4 mm³ (p = 0.002) and in foveal subfield thickness from 447 ± 117 μm to 388 ± 117 μm (p = 0.03). Two eyes with early proliferative diabetic retinopathy lost all signs of proliferation without any evidence of fibrosis. Although there was a trend towards vasoconstriction, the changes in vessel diameters (arteries and veins) after 4 months of intravitreal Avastin injection were not statistically significant (p = 0.9 and p = 0.17, respectively). Foveal thickness in non‐injected fellow eyes with DMO changed from 428 ± 153 μm at baseline to 383 ± 151 μm at 4 months (p = 0.1), which did not reach statistical significance. Conclusions: Intravitreal bevacizumab 1 mg every 6 weeks was followed by a moderate reduction in DMO without normalization of foveal and macular thickness. Our observations suggest that a larger study where patients are examined sooner after injection is needed to elucidate the potential relationship between changes in retinal vessel diameters and thickness changes in DMO.     

Chemokines in aqueous humour before and after intravitreal triamcinolone acetonide in eyes with macular oedema associated with branch retinal vein occlusion

Purpose: To determine the aqueous humour levels of chemokines before and after an intravitreal injection of triamcinolone acetonide (IVTA) in eyes with macular oedema associated with a branch retinal vein occlusion (ME‐BRVO). Design: Single‐centre, prospective, consecutive interventional case series. Participants: Seventeen eyes of 17 consecutive patients with ME‐BRVO who underwent IVTA were studied. Seven eyes without retinal vascular disease served as control. Intervention: All patients with ME‐BRVO underwent IVTA. Main outcome measures: The optical coherence tomographically determined foveal thickness (FT) and the aqueous humour levels of inflammatory chemokines of the C‐C subfamily, including eotaxin, monocyte chemotactic protein‐1 (MCP‐1), macrophage inflammatory protein‐1α (MIP‐1α), β (MIP‐1β), and RANTES was determined before the IVTA (baseline) and at 1 week after the IVTA. Results: At the baseline, only MCP‐1 and MIP‐1β were detected in the aqueous, and MIP‐1β was significantly higher in eyes with a ME‐BRVO than in controls (p = 0.004). The level of both of these chemokines was not correlated with the FT (p = 0.654 and p = 0.608, respectively). One week after IVTA, the FT was significantly decreased (p < 0.001), and the levels of MCP‐1 and MIP‐1β were also significantly reduced (p < 0.001 and p = 0.044, respectively). The decrease in the FT was correlated with the decrease in only MIP‐1β (r = 0.58, p = 0.020). Conclusions: Alterations of the aqueous level of MIP‐1β reflect the improvement of the macular oedema after IVTA in eyes with ME‐BRVO. This indicates that the steroid‐dependent ME‐BRVO was closely related with the level of MIP‐1β.     

Systematic review of intravitreal bevacizumab injection for treatment of primary diabetic macular oedema

Purpose: To compare intravitreal bevacizumab (IVB) injection versus macular photocoagulation (MPC) or a combination of intravitreal bevacizumab and intravitreal triamcinolone acetonide (IVB/IVTA) injection in improving visual acuity (VA) of patients with primary diabetic macular oedema (DMO). Methods: The following databases were searched: Medline (1950 – December week 3, 2009), The Cochrane Library (Issue 4, 2009), EMBASE (up to 24 December 2009), and the TRIP database (up to 23 December 2009), using no language or other limits. Randomized controlled trials were included that consisted of patients with primary DMO (not with refractory DMO), those comparing IVB injection with MPC or IVB/IVTA injection, those reporting VA outcomes, and those having a minimum follow‐up of 6 weeks. Results: In the four randomized clinical trials comparing IVB injection with MPC, IVB injection demonstrated significantly greater improvement in VA at 6 weeks, but not at 12 weeks. In the three randomized clinical trials comparing IVB injection with IVB/IVTA, IVB injection demonstrated greater improvement in VA at 6 weeks but the benefit was again no longer significant at 12 weeks. No adjunctive effect of IVTA was demonstrated. Conclusions: Intravitreal bevacizumab injection is effective in improving VA in patients with primary DMO for 6 weeks, but the benefits are no longer present 12 weeks following the injection.     

Macular function by multifocal electroretinogram in diabetic macular edema after intravitreal triamcinolone acetonide injection

PURPOSE: The purpose of this study was to assess macular function by multifocal electroretinography (mfERG) in eyes with diabetic macular edema (DME) after intravitreal triamcinolone acetonide (IVTA) injection. METHODS: Fifteen eyes of 15 patients with DME scheduled for 4 mg IVTA injection were prospectively recruited. The response to treatment was monitored functionally by visual acuity (VA) measurement and mfERG and anatomically by foveal thickness measured by optical coherence tomography (OCT). The first-order kernel P1 mfERG responses from 0 to 7 degrees (central) and 7 to 25 degrees (peripheral) were grouped and analyzed. Changes in functional parameters (VAs and the P1 mfERG response amplitudes and peak latencies) and morphometric parameters (OCT foveal thickness) in eyes with DME 1 and 3 months after IVTA injection were compared with baseline values by Student t test. RESULTS: The mean baseline logMAR value for VAs of the patients before treatment was 0.49+/-0.26. After treatment, it was 0.27+/-0.23 at 1 month and 0.26+/-0.18 at 3 months, and differences from pretreatment values were significant (for each, p<0.001). There were statistically significant decreases in the mean foveal thickness at 1 and 3 months after treatment compared with pretreatment values (for each, p<0.001). There were also statistically significant increases in the mean P1 response amplitude for both central and peripheral groups at all examinations compared with pretreatment (for each, p<0.001). The mean P1 peak latencies for both the central and peripheral groups were shortened, but not significantly. CONCLUSIONS: As well as the reduction in DME and improvement in VA, IVTA injection improves macular function as assessed by mfERG in diabetic patients.     

Structural and functional outcomes after treatment of uveitic macular oedema: an optical coherence tomography and multifocal electroretinogram study

Background: The aim was to evaluate the correlation between the anatomical and functional outcomes before and after treatment of uveitic macular oedema. Methods: Thirty‐three eyes of 33 patients with uveitic macular oedema were included in the present study. Visual acuity (VA), optical coherence tomography (OCT) and multifocal electroretinogram (mfERG) were measured before and after treatment of the macular oedema. Correlation analyses between VA, OCT and mfERG parameters were performed. Results: The VA and mfERG measurements showed statistically significant improvement after treatment of the macular oedema (p < 0.01) and OCT‐measured central foveal thickness decreased significantly from 434 ± 135 µm before treatment to 267 ± 92 µm after treatment (p < 0.001). Correlation analyses showed that uveitic central foveal thickness before treatment was correlated with mfERG N1 response amplitude of area 1 (Spearman's r = ‐0.62, p < 0.001). VA (logMAR) after treatment had a negative correlation with the mfERG N1 response amplitude of area 1 (Spearman's r = ‐0.56, p = 0.001). Also, there was no correlation between the final VA and pre‐treatment OCT and mfERG measurements. Conclusion: This study deals with cystoid macular oedema associated with recurrent uveitis. In cystoid macular oedema, the value of mfERG before treatment is related to the central foveal thickness and VA. In contrast, after treatment the decrease of macular thickness is not always followed by an improvement of mfERG and VA. This supports the view that in uveitic macular oedema, the decrease in macular thickness after treatment may not be used as a predictor of improvement of macular function.     

Intravitreal triamcinolone as adjunctive treatment to laser panretinal photocoagulation for concomitant proliferative diabetic retinopathy and clinically significant macular oedema

Purpose: To evaluate the effect of intravitreal injections of triamcinolone acetonide (IVTA) combined with panretinal photocoagulation (PRP) on visual acuity (VA) and foveal thickness in patients with concomitant high‐risk proliferative diabetic retinopathy (PDR) and clinically significant macular oedema (CSMO). Methods: This retrospective interventional case series included seven eyes diagnosed with both high‐risk PDR and CSMO that underwent PRP and a single injection of 4 mg of IVTA. The main outcome measures were VA and foveal thickness, measured by optical coherence tomography (OCT) before treatment and throughout the follow‐up period. Results: Median follow‐up was 301 days (range 180–715 days). Foveal thickness data were available for four of seven eyes. Before the combined treatment, median LogMAR (logarithm of the minimum angle of resolution) VA and median foveal thickness were 1 (Snellen 20/200, range 20/40–20/800) and 559 µm (range 333–689 µm), respectively. After treatment, median vision improved to LogMAR 0.544 (Snellen 20/70, range 20/40–20/1000) (P = 0.13). Vision improved or remained stable in six of seven eyes. Median foveal thickness at final follow‐up was 436 µm (range 259–623 µm) (P = 0.15). Foveal thickness decreased or remained stable in all eyes. Conclusion: The addition of IVTA to PRP in the treatment of eyes with high‐risk PDR and CSMO may prevent PRP‐induced foveal thickening and loss of vision.     

Morphological and Functional Retinal Assessment in Epiretinal Membrane Surgery

Purpose: To analyze functional and morphological findings after surgery for idiopathic epiretinal macular membrane (IEMM). Materials and Methods: Twenty eyes of 20 patients affected by IEMM underwent 23-Gauge surgery. Morphological and functional examinations were assessed at baseline and at 30, 90, and 180 days after surgery. SD-OCT evaluated foveal morphology and thickness, photoreceptor inner/outer segment junction, and external limiting membrane. Functional assessment evaluated visual acuity, retinal sensitivity, and fixation patterns. Statistical analysis was performed with the Student’s t test and Pearson correlation test. Results: Mean central retinal thickness (CRT), visual acuity (VA), and retinal sensitivity (RS) at baseline were respectively 494.90 ± 38.73 µm, 0.55 ± 0.08 LogMAR, and 11.13±1.02; after surgery, at day 180, we observed a significant decrease in mean CRT to 326.90±32.68 µm, an increase in mean VA to 0.33 ± 0.05 LogMAR (p < 0.05), and in mean RS to 13.25 ± 0.73 dB (p < 0.05). A stable fixation increased from 40% of patients at baseline to 75% of patients at day 180 (p < 0.05). Discussion: IEMM surgery results in continuous improvement in visual function, not only at month one but also beyond month six, due to the progressive reduction of residual intraretinal edema and recomposition of retinal layers.     

Intravitreal triamcinolone for the treatment of ischemic macular edema associated with branch retinal vein occlusion

PURPOSE: To evaluate the safety and efficacy of intravitreal triamcinolone acetonide (IVTA) for ischemic macular edema associated with branch retinal vein occlusion (BRVO) and foveal ischemia. DESIGN: Prospective interventional case series. METHODS: setting: Clinical practice. study population: Eighteen eyes of 18 patients with macular edema associated with BRVO and foveal ischemia. intervention: Four mg IVTA. main outcome measures: Visual acuity (VA), optical coherence tomography, macular thickness measurements, and treatment-related complications. RESULTS: The mean duration of BRVO before treatment was 14 months. All patients were followed for a minimum of nine months, and 12 patients completed 12 months follow-up. The mean logarithm of the minimum angle of resolution (logMAR) VA improved significantly from 0.81 +/- 0.36 at baseline to 0.65 +/- 0.30 at one month (P = .03) but did not vary significantly from baseline at three, six, nine, and 12 months. Macular thickness improved significantly in all eyes from a mean of 400 +/- 134 mum preinjection, to 228 +/- 58 mum at one month (P < .01) and 256 +/- 121 mum at three months (P < .01) but did not vary significantly from baseline at six, nine, and 12 months. Eight eyes developed posterior subcapsular cataract, intraocular pressure (IOP) exceeded 21 mm Hg in four eyes, and two eyes developed vitreomacular traction during follow-up. CONCLUSIONS: IVTA is effective in reducing ischemic macular edema associated with BRVO and foveal capillary nonperfusion. This reduction is often associated with a temporary improvement in VA. Raised IOP and development of posterior subcapsular cataract are disadvantages of this treatment.     

Combined intravitreal bevacizumab and triamcinolone in exudative age‐related macular degeneration

Acta Ophthalmol. 2010: 88: 630–634

Abstract.

Purpose: We report on the combined application of intravitreal bevacizumab and triamcinolone acetonide for treatment of exudative age‐related macular degeneration (AMD). Methods: The clinical interventional case‐series study included 16 patients (16 eyes) with exudative AMD who had previously received 3.5 ± 1.8 mono‐injections of bevacizumab (1.5 mg) without significant improvement in visual acuity (VA) or reduction in macular exudation. All patients underwent a combined intravitreal injection of bevacizumab (1.5 mg) and triamcinolone acetonide (about 20 mg). Main outcome measures were VA and macular thickness as determined by optical coherence tomography. All patients were re‐examined at 2–3 months after the intervention. Results: Visual acuity improved significantly (p = 0.03) from 0.80 ± 0.40 logMAR prior to the combined injection to 0.65 ± 0.42 logMAR at 3 months after the injection. An improvement of ≥ 1 Snellen line was found in eight subjects, an increase of ≥ 2 lines in five subjects, and an improvement of ≥ 3 lines in two subjects. One patient lost 1 line and one patient lost 3 lines. Central retinal thickness decreased significantly from 272 ± 62 μm to 220 ± 47 μm (p = 0.03). At the 6‐month follow‐up examination, central retinal thickness had increased again to 319 ± 142 μm, which was not significantly (p = 0.30) different from baseline measurements. Conclusions: The combined intravitreal application of bevacizumab and triamcinolone may temporarily be helpful in the treatment of exudative AMD if previous intravitreal bevacizumab mono‐injections have failed to improve vision and reduce macular oedema.     

Retinal sensitivity improvement after intravitreal triamcinolone acetonide injection for macular edema secondary to branch retinal vein occlusion

Purpose:

To evaluate the effect of intravitreal triamcinolone acetonide (IVTA) on retinal sensitivity in cases of macular edema(ME) secondary to branch retinal vein occlusion (BRVO).

Materials and Methods:

Total of 14 eyes of 14 cases of BRVO were included in this prospective study. In each eye, at baseline and 1, 3, and 6 months after IVTA injection, logMAR visual acuity, central 4° retinal sensitivity by MP-1 microperimetry, and optical coherence tomography foveal thickness were assessed.

Results:

Cases ages ranged from 60 to 79 years (mean 68 ± 8 years). At 1, 3, and 6 months, the logMAR visual acuity had increased from 0.71 ± 0.21 to 0.42 ± 0.21, 0.46 ± 0.30, and 0.46 ± 0.27; the mean foveal thickness had decreased from 540 ± 88 μm to 254 ± 51 μm, 288 ± 84 μm, and 280 ± 91 μm; and the mean retinal sensitivity had increased from 4.7 ± 2.5 dB to 7.9 ± 2.7 dB, 8.2 ± 3.6 dB, and 8.3 ± 4.6 dB, respectively.

Conclusion:

In eyes with ME secondary to BRVO, IVTA injections result in a significant increase in not only the visual acuity but also the central 4° retinal sensitivity in 6 months follow-up.     

Fundus microperimetry patterns of fixation in type 2 diabetic patients with diffuse macular edema

BACKGROUND: Recently developed fundus microperimetry (MP-1; Nidek Technologies, Srl. Vigonza PD, Italy) was used to evaluate fixation patterns and retinal sensitivity in patients who had clinically significant macular edema with a diffuse pattern and type 2 diabetes mellitus. METHODS: In a prospective, observational case series study, 84 consecutive patients with type 2 diabetes (84 eyes) who had clinically significant macular edema with a diffuse pattern were studied by means of MP-1. Main outcome measures were fixation stability and position and mean retinal sensitivities within the central 2 degrees and 8 degrees areas. Logarithm of the minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA) was evaluated by means of an Early Treatment of Diabetic Retinopathy Study chart. Foveal thickness was measured by Stratus optical coherence tomography (OCT; Carl Zeiss Meditec, Inc., Dublin, CA). Age, duration of diabetes, hemoglobin A1c (HbA1c) levels, duration of symptoms, history of panretinal photocoagulation, vitreomacular adhesion, and cystoid macular changes were documented. Patients were grouped according to both position of fixation (central or eccentric) and stability of fixation (stable or unstable). Statistical analyses included independent samples t-test, binomial test, Bonferroni correction for multiple comparisons, and generalized linear model univariate analysis. RESULTS: Of 84 eyes, 44 (52.4%) had central fixation, and 40 (47.6%) had eccentric fixation. Of 84 eyes, 34 (40.5%) had stable fixation, and 50 (59.5%) had unstable fixation. In the whole sample, mean central 2 degrees retinal sensitivity +/- SD was 6.26 +/- 3.19 dB (range, 0-14.80 dB), and mean central 8 degrees retinal sensitivity +/- SD was 7.62 +/- 2.55 (range, 3.85-14.90 dB); logMAR BCVA ranged from 0.1 to 1.3 (mean +/- SD, 0.6 +/- 0.29). Mean OCT foveal thickness +/- SD was 300.77 +/- 66.93 m (range, 220-525 m). Both comparisons between groups (stable vs. unstable and central vs. eccentric) showed statistically significant differences in mean logMAR BCVA, mean central 2 degrees and 8 degrees retinal sensitivities, and mean OCT foveal thickness. Duration of symptoms was significantly longer and HbA1c levels were higher in the groups with deterioration of stability or centrality of fixation. The prevalence of cystoid macular changes was significantly higher in the groups with eccentric or unstable fixation (P < 0.001). Generalized linear model statistical analysis showed that logMAR BCVA was significantly associated with stability of fixation (P = 0.020), mean central 8 degrees retinal sensitivity (P < 0.001), and mean OCT foveal thickness (P < 0.001). The interaction between stability of fixation and mean OCT foveal thickness showed a statistically significant association with logMAR BCVA (P = 0.003). Some eyes with eccentric fixation presented with stable fixation, especially in the presence of long-lasting symptoms, and had better visual acuity than eyes with central, but unstable fixation. CONCLUSION: Visual acuity, central retinal sensitivity, foveal thickness, duration of symptoms, HbA1c levels, and presence of cystoid macular changes were strongly associated with fixation impairment in type 2 diabetic patients who had clinically significant macular edema with a diffuse pattern. Stability of fixation and foveal thickness play a major role in conditioning BCVA.     

Photodynamic therapy with intravitreal application of triamcinolone acetonide in age‐related macular degeneration: functional results in 54 patients

Purpose: This study aimed to investigate the functional results, efficacy and complications after photodynamic therapy (PDT) combined with intravitreal triamcinolone acetonide injection (IVTA) in patients with choroidal neovascularization (CNV) caused by age‐related macular degeneration (AMD). Methods: A retrospective analysis of clinical data for 54 patients with CNV resulting from AMD was carried out. All patients had a follow‐up of 12 months. The patients were treated with standardized PDT and IVTA (4 mg) as a first‐line treatment or following PDT failure. Visual acuity (VA), greatest linear diameter (GLD) of the CNV and foveal thickness were evaluated. Results: Mean VA at baseline was 0.8 logMAR (0.4–1.4). After 12 months VA improved (> 2 lines) in 20.4% of patients and stabilized (± 2 lines) in 64.8%. There was no statistical significance in VA outcome between patients undergoing first‐line treatment and patients with PDT failure; however, fewer PDT treatments were required to stop CNV activity in patients undergoing first‐line treatment. At 12 months, a reduction in foveal thickness was seen in 67.7% of patients and a reduction in CNV GLD in 32.7%. Complications occurred in 22% of patients and included a transient rise in intraocular pressure, cataract and sterile hypopyon. Conclusions: Our analysis shows that fewer PDT treatments were required to stop CNV activity when triamcinolone was used as first‐line treatment. We can thus conclude that PDT combines synergistically with IVTA and the combination may lead to a cost reduction compared with PDT therapy alone. The overall complication rate of 22% is high and must be compared with complication rates caused by new intravitreal anti‐VEGF (vascular endothelial growth factor) drugs in combination with PDT.     

Prospective comparisons of intravitreal injections of triamcinolone acetonide and bevacizumab for macular oedema due to branch retinal vein occlusion

Purpose: To compare the efficacy of intravitreal injections of triamcinolone acetonide (TA) and that of bevacizumab for macular oedema because of branch retinal vein occlusion (BRVO). Design: Prospective, comparative, randomized, interventional clinical trial. Methods: Forty‐three eyes of 43 patients with macular oedema because of BRVO were randomly assigned to 4‐mg intravitreal injections of TA (IVTA)(21 patients, IVTA group) or 1.25‐mg intravitreal injections of bevacizumab (IVB) (22 patients, IVB group) and followed for 12 months. No additional treatments were administered for 3 months after the initial injection; additional injections were administered when macular oedema recurred between 3 and 12 months after the initial injection. The best‐corrected visual acuity (BCVA) and the central retinal thickness (CRT) were measured at baseline and monthly. The main outcome measures were changes in the logarithm of the minimal angle of resolution BCVA and CRT from baseline to 12 months. Results: Eighteen eyes of 18 patients in the IVTA group and 18 eyes of 18 patients in the IVB group completed follow‐up at 12 months. The mean improvements in BCVA from baseline to 12 months were 0.12 in the IVTA group and 0.33 in the IVB group, which was significantly (p = 0.032) higher than in the IVTA group. There was no significant difference between the two groups in the mean reduction in CRT from baseline to 12 months after the initial injection. Two eyes in the IVTA group required intraocular pressure–lowering medications. Conclusion: Intravitreal injection of bevacizumab may be of greater benefit than that of TA for macular oedema because of BRVO.