Role of Steroids in the Management of Diabetic Macular Edema and Proliferative Diabetic Retinopathy

Diabetic retinopathy is the most common microvascular complication of diabetes. Early clinical trials have established the efficacy and safety of laser in the treatment of proliferative diabetic retinopathy (PDR) and diabetic macular edema (DME). Despite timely and appropriate use of laser, some patients continue to experience visual loss. The pathogenesis of PDR and DME is multifactorial involving both angiogenic and inflammatory processes. Recent trials have shown that the anti-inflammatory and anti-angiogenic properties of corticosteroids may provide benefit in treating PDR and DME. The exact role of steroids in the treatment for diabetic retinopathy and macular edema remains to be fully elucidated.     

视网膜内新生血管——糖尿病性视网膜病变115例眼底荧光血管造影分析

就115例(217只限)糖尿病性视网膜病变的眼底荧光血管造影进行分析。发现46例(86只限)有视网膜内新生血管,集中发生在Ⅲ期以后。并就其表现形式,与视网膜前新生血管的关系进行了研究。认为视网膜内新生血管可以成为诊断糖尿病性视网膜病变增殖前期的标志,视网膜内界膜的健康状况是视网膜内新生血管转变为视网膜前新生血管的关健。     

Intravitreal triamcinolone for treatment of complicated proliferative diabetic retinopathy and proliferative vitreoretinopathy

BACKGROUND: We present a retrospective evaluation of the clinical outcome and complications associated with intravitreal injection of unaltered triamcinolone acetonide in conjunction with pars plana vitrectomy and silicone oil injection for the treatment of complicated proliferative diabetic retinopathy with tractional retinal detachment and severe proliferative vitreoretinopathy. METHODS: Thirteen eyes of 12 consecutive patients were identified from a computerized patient database. All eyes were operated on by the same surgeon and received 4 mg of unaltered, commercially available triamcinolone acetonide intravitreally, before silicone oil injection. The patients were followed for a mean of 4.7 months (range 1-15 months), and demographic as well as pertinent preoperative and postoperative clinical information was gathered. RESULTS: At the last follow-up visit, vision had improved in 4 eyes, remained stable in 5 eyes, and worsened in 4 eyes. The retina was attached at the end of follow-up in 10 of the 13 eyes. Eight of the 13 eyes did not show any clinical signs of re-roliferation or redetachment during the course of follow-up. The mean intra-ocular pressure did not increase (preoperative value was 10.8+/- 6.22 mm Hg with a range of 0-22 mm Hg; at last follow-up, mean pressure was 9.6 +/-3.86 mm Hg with a cumulative postoperative range of 0-26 mm Hg). Steroid crystals were visible at 1 month postoperatively in 3 eyes and did not hinder fundus examination significantly. Interpretation: The intravitreal injection of low-dose, unaltered triamcinolone acetonide in the setting of pars plana vitrectomy and silicone oil injection for the treatment of proliferative vitreoretinopathy and complicated proliferative diabetic retinopathy appears to be well tolerated. Further controlled study is needed to clearly define the potential beneficial effects of intravitreal steroids in these 2 disease processes.     

TA玻璃体腔注射结合玻璃体切割术治疗PDR

目的:探讨曲安奈德(triamcinolone acetonide,TA)玻璃体腔注射联合玻璃体切割术治疗增殖性糖尿病视网膜病变(proliferative diabetic retinopathy,PDR)的优点和并发症。方法:对36例48眼具有玻璃体积血的PDR眼,术前5～7d玻璃体腔内注入TA0.1mL(40g/L)后行玻璃体切割术,术中玻璃体腔内注入TA0.3～0.5mL以帮助辨认玻璃体后皮质。结果:炎症反应程度:有4眼(8%)术后瞳孔区可见少量渗出膜,术后5～7d渗出吸收;15眼(31%)房水闪辉,术后3～5d,房水闪辉消失。所有病例都没有发现手术后感染。视力改善情况:39眼(81%)视力较手术前有不同程度提高(大于2行),7眼(15%)手术后视力较术前没有改善。眼压变化:玻璃体腔注入TA前后平均眼压比较其差异没有显著性;手术后1wk内监测平均眼压比术前高,其差异有显著性。手术后第3mo和术前相比,其差异没有显著性。结论:TA玻璃体腔注射联合玻璃体切割在治疗PDR中有较好的效果,临床上没有严重的并发症。     

Foveolar Choroidal Hemodynamics in Proliferative Diabetic Retinopathy

PURPOSE: We studied the choroidal circulation in patients with proliferative diabetic retinopathy (PDR) to assess whether choroidal hemodynamic abnormalities may exist in PDR. METHODS: Eighteen eyes of 18 patients with PDR and high-risk characteristics for visual loss were included in this study. Mean duration of diabetes was 20 +/- 9 years (mean +/- SD), hemoglobin A1c was 8.9 +/- 2.3%, and blood glucose at the time of blood flow measurement was 188 +/- 90 mg/dl. Choroidal circulatory parameters obtained in these patients were compared to those of 35 eyes of 35 age and blood pressure matched, healthy controls using a Wilcoxon rank sum test. Laser Doppler flowmetry (Oculix) was used to calculate relative choroidal blood velocity (Chvel), volume (Chvol), and flow (Chflow) in the center of the foveola. RESULTS: No significant differences in average age, mean blood pressure (BPm), or perfusion pressure (PP) were observed between diabetic patients and control subjects. In diabetic patients, Chvol was 0.29 +/- 0.08 (mean +/- 1 SD) arbitrary units (AU); this value was 15% lower than that of control subjects, 0.34 +/- 0.10 AU (p = 0.04). In contrast, average Chvel was not significantly different between subjects with PDR (0.39 +/- 0.07 AU) and control subjects (0.41 +/- 0.07 AU). The average Chflow in subjects with PDR (9.4 +/- 2.9 AU) was 27% lower than that of control subjects (12.8 +/- 4.2 AU; p = 0.003). No significant correlation was detected between the circulatory measurements and age, BPm, or PP. There was a statistically significant negative correlation between duration of diabetes and Chvel (R = -0.55; p = 0.03). CONCLUSIONS: Our results suggest that Chvol and Chflow are significantly reduced in patients with PDR.     

Two-year Course of Visual Acuity in Severe Proliferative Diabetic Retinopathy with Conventional Management: Diabetic Retinopathy Vitrectomy Study (DRVS) Report #1

Seven hundred forty-four eyes with very severe proliferative diabetic retinopathy (PDR) were followed with conventional management over a two-year period. Decreases in visual acuity were more frequent during the first year of follow-up than during the second, and were related to baseline visual acuity level and retinopathy severity. After two years, visual acuity was less than 5/200 in 45% of eyes with more than four disc areas of new vessels and visual acuity of 10/30 to 10/50 at baseline, but in only 14% of eyes with traction retinal detachment not involving the center of the macula and without active new vessels or fresh vitreous hemorrhage at baseline. Vitrectomy, which was undertaken only if retinal detachment involving the center of the macula occurred or if severe vitreous hemorrhage failed to clear after a one-year waiting period, had been carried out in 25% of eyes after two years of follow-up.     

增生型糖尿病性视网膜病变术前玻璃体内注射曲安奈德的价值

目的　探讨术前玻璃体内注射曲安奈德（ｔｒｉａｍｃｉｎｏｌｏｎｅａｃｅｔｏｎｉｄｅ,ＴＡ）对于增生型糖尿病性视网膜病变（ｐｒｏｌｉｆｅｒａｔｉｖｅｄｉ-ａｂｅｔｉｃｒｅｔｉｎｏｐａｔｈｙ,ＰＤＲ）行玻璃体视网膜手术效果的影响。方法　选择我院２０１４年３月至２０１５年６月收治的ＰＤＲ患者（Ⅴ期或Ⅵ期）６０例（６０眼）。随机分为治疗组（术前１周行玻璃体内注射ＴＡ）和对照组（直接行玻璃体切割术）,每组３０例。比较两组患者术中出血情况、医源性视网膜裂孔发生率、眼内填充物的使用、平均手术时间及术后视力。结果　治疗组术中发生中、重度出血率为１６．７％,显著低于对照组的３６．７％,差异有统计学意义（Ｐ＜０．０５）;治疗组术中医源性视网膜裂孔发生率为１０．０％,显著低于对照组的３３．３％,差异有统计学意义（Ｐ＜０．０５）;治疗组硅油填充率为４０．０％,对照组为６０．０％,差异无统计学意义（Ｐ＞０．０５）;治疗组手术时间为（４０．２３±１３．９０）ｍｉｎ,明显短于对照组的（５５．８２±１４．４３）ｍｉｎ,差异有统计学意义（Ｐ＜０．０５）;治疗组术后视力为０．３１６±０．１０１,优于对照组的０．２０２±０．１３２,差异有统计学意义（Ｐ＜０．０５）。结论　ＰＤＲ患者在玻璃体切割术前１周行玻璃体内注射ＴＡ,可降低手术难度,减少术中并发症,进而缩短手术时间,有助于术后视力改善。     

Intravitreal triamcinolone for diabetic macular oedema in Chinese patients: six-month prospective longitudinal pilot study

AIM: To evaluate the safety and efficacy of intravitreal triamcinolone (IVTA) in Chinese patients with diabetic clinical significant macular oedema (CSMO). METHODS: Eighteen eyes of 17 consecutive patients with CSMO were prospectively recruited and treated with a 4 mg injection of IVTA. Best-corrected visual acuity (BCVA) on the ETDRS chart and central macular thickness (CMT) on optical coherence tomography were measured at baseline weeks 1, 2, 3, and months 1, 2, 3, 4, 5 and 6. Side-effects were monitored. RESULTS: All patients completed 6 months of follow up. The mean baseline BCVA and CMT were 1.20 +/- 0.31 logMAR units and 552 +/- 179 microm, respectively. Improvements in CMT and BCVA were observed as early as at 1 and 2 weeks, respectively (P < 0.05). Mean BCVA peaked at 2 months (0.97 +/- 0.38 logMAR units) while mean CMT was maximally reduced at 3 months (326 +/- 145 microm). Improvements in BCVA and CMT were less afterwards but still statistically significant at 6 months; the final mean BCVA and CMT were 0.99 +/- 0.36 logMAR units and 427 +/- 145 microm, respectively. A total of 5/18 (28%) eyes developed a transient increase in intraocular pressure. Cataract progression was noted in 2/12 (17%) of the phakic eyes. CONCLUSIONS: Intravitreal triamcinolone appeared generally safe and effective in Chinese patients with CSMO. Although the improvements in BCVA and CMT were transient, there were residual benefits at 6 months. Due to the transient nature of IVTA, re-treatment seems necessary but the optimal timing and dosage will require further investigations.     

Sterile Endophthalmitis Following Intravitreal Injection of Triamcinolone Acetonide

Purpose: To investigate clinical findings and ocular characteristics of sterile endophthalmitis following intravitreal injection (IVI) of triamcinolone for the treatment of macular edema. Methods: IVI is an institutional practice at our hospital. From March 2002 to January 2003, a total of 21 IVIs of triamcinolone acetonide were performed on 19 patients with macular edema secondary to various retinal disorders. Cases diagnosed as sterile endophthalmitis after IVI of triamcinolone were selected for the study. Fisher's discriminant linear analysis was used to determine whether a significant correlation existed between specific ocular features and the occurrence of post-injection sterile endophthalmitis. Results: Five of 21 eyes (23.8%) had sterile endophthalmitis with hypopyon formation after the injection. Of the five sterile endophthalmitis patients, three were pseudophakic with impaired posterior capsule and four had a diagnosis of Irvine-Gass syndrome. The rate of sterile endophthalmitis was significantly higher in pseudophakic patients with impaired posterior capsule (p = 0.0075) and in patients with Irvine-Gass syndrome (p = 0.0008). The best-corrected visual acuity (BCVA) in these patients remained unchanged or even improved when the inflammation subsided. Conclusion: Pseudophakia with impaired posterior capsule and the diagnosis of cystoid macular edema due to Irvine-Gass syndrome are two risk factors of sterile endophthalmitis following IVI triamcinolone. No loss of BCVA was noted in the patients with post-injection sterile endophthalmitis.     

增殖性糖尿病视网膜病变的玻璃体手术和光凝治疗

目的评价玻璃体手术联合光凝治疗一组增殖性糖尿病视网膜病变(proliferative diabeticretinopathy,PDR)的效果.方法对1997年2月至2000年5月之间经玻璃体手术和激光治疗的一组PDR连续的病例进行回顾性研究.结果共包括79例(男38,女41)、104只眼(右26,左28;双眼25例).发现糖尿病史0.5-37 a(8.5±6.5 a),发现眼病史15 d-8 a(1.5±1.5 a).30只眼有视网膜光凝史,但其中26只眼仅光凝一次.手术采用玻璃体切除、新生血管膜切除或切碎、眼内电凝及光凝;对有活动性出血、视网膜脱离或严重缺血的眼,术毕注入硅油(59只眼).手术中联合白内障摘除63只眼和人工晶状体植入27只眼.术前视力为光感、手动和指数的分别有15、38和22只眼,≥0.02的29只眼(27.8%).术后视力提高的有84只眼(80.8%),不变和下降的20只眼(19.2%).其中,术后视力≥0.1的41只眼(39.4%).术后2只眼发生新生血管性青光眼.结论本组多数PDR眼在手术前未得到有效的光凝治疗.经玻璃体手术和光凝,大多数患眼避免了失明或改善了视力.对视网膜脱离、严重缺血和手术中活动性出血的眼,注入硅油可在手术后及早补充视网膜光凝,以阻止病情恶化.眼科学报2001;17241～244.     

Coordination Skills during Vitrectomy in Treatment of Proliferative Diabetic Retinopathy

 Purpose: To discuss effective nursing and coordination skills for vitrectomy in the treatment of diabetic retinopathy. Methods: Fifty patients (51 eyes) with diabetic retinopathy required vitrectomy were enrolled in this study. Individual nursing service was delivered by strengthening preoperative preparation, providing psychological nursing, and intraoperative observation of the severity of diseases by circulating nurses; meticulous nursing was given postoperatively. Results: All 50 patients underwent surgery successfully. Intraoperatively, patients had stable physical signs. Five patients had postoperative visual acuity0.3. No complicated infection was seen. Conclusion: For patients diagnosed with proliferative diabetic retinopathy requiring vitrectomy, full preparations should be made and psychological nursing should be delivered preoperatively, the severity of diseases and clinical reactions should be closely observed intraoperatively, and proper processing and nursing measures should be taken postoperatively, which collectively enhance surgical success rate, decrease surgical complications, and attain favorable treatment efficacy.     

Detection of Glutamate and -y-aminobutvric Acid in Vitreous of Patients with Proliferative Diabetic Retinopathy

Purpose:To study the levels of glutamate and γ-aminobutyric acid (GABA) in vitreous of patients with proliferative diabetic retinopathy(PDR) and to investigate their roles in retinal ischemia.Method: Vitreous samples were collected from 25 patients (27 eyes) with PDR and 14 patients (14 eyes) with idiopathic macular hole. Glutamate and GAB A detection were performed by high-performance liquid chromatography (HPLC).Results: Patients with PDR had significantly higher concentrations of glutamate and GA-BA than the control group. The glutamate level has a significantly positive correlation with GABA level.Conclusion: Detection of glutamate and GABA in vitreous provides biochemical support for the mechanism and treatment of ischemic retinal damage in patients with PDR. Eye Science 2000; 16: 199-202.     

Intravitreal Combination of Triamcinolone Acetonide and Bevacizumab (Kenacort-Avastin) in Diffuse Diabetic Macular Edema

Purpose: To evaluate the effect of intravitreal injection of the combination of Triamcinolone Acetonide and Bevacizumab in patients with diabetic macular edema.

Materials and Methods: Twenty seven eyes of 17 patients with diabetic macular edema were treated with an intravitreal injection of triamcinolone acetonide (2?mg) combined with bevacizumab (1.25?mg).

Results: During the 6 months follow-up period 24 eyes (89%) had to repeat the treatment according to the monthly follow-up examination.The mean visual acuity and the central macular thickness improved significantly (P<0.05) throughout the follow-up period.

Conclusion: Intravitreal combination of Triamcinolone Acetonide and Bevacizumab seems to be effective in improving visual acuity and macular edema in patients with diabetic maculopathy.     

Trans-Tenon's Retrobulbar Injection of Triamcinolone Acetonide for Diffuse Diabetic Macular Edema

Purpose To determine whether a trans-Tenon's retrobulbar injection of triamcinolone acetonide (TA) is a safe and effective treatment for diffuse diabetic macular edema. Methods Thirty-nine eyes of 30 diabetic patients with persistent macular edema were treated with 20 mg of TA injection. Central macular thickness (CMT) determined by optical coherence tomography (OCT) and visual acuity were evaluated before the injection and at 1, 2, 3, and 6 months, and up to 1 year in some eyes, after the injection. Results The CMT decreased significantly from 478 ± 129 μm (mean ± SD) before injection to 316 ± 102 μm at 1 month, 307 ± 104 μm at 2 months, and 275 ± 89 μm at 3 months after a single injection of TA. A 20% reduction of CMT from the initial value was maintained by a single injection of TA in 27 of 39 eyes (69.2%) at 3 months, in 14 of 22 eyes (63.6%) at 6 months, and in 5 of 7 eyes at 12 months. A recurrence of macular edema was observed in 10% of the eyes at 3 months, and in 22.7% at 6 months. The 17 eyes in which vitrectomy had been carried out had a more significant improvement in CMT than the eyes without vitrectomy. Conclusion A 20-mg trans-Tenon's retrobulbar TA injection is a safe and effective treatment for diabetic macular edema. Jpn J Ophthalmol 2005;49:509–515 ? Japanese Ophthalmological Society 2005     

Risk Factors for Proliferative Diabetic Retinopathy in African Americans with Type 2 Diabetes

Purpose: To assess personal and demographic risk factors for proliferative diabetic retinopathy in African Americans with type 2 diabetes.

Methods: In this prospective, non-interventional, cross-sectional case-control study, 380 African Americans with type 2 diabetes were enrolled. Participants were recruited prospectively and had to have either: (1) absence of diabetic retinopathy after ≥10 years of type 2 diabetes, or (2) presence of proliferative diabetic retinopathy when enrolled. Dilated, 7-field fundus photographs were graded using the Early Treatment Diabetic Retinopathy Study scale. Covariates including hemoglobin A_1C (HbA_1C), blood pressure, height, weight and waist circumference were collected prospectively. Multivariate regression models adjusted for age, sex and site were constructed to assess associations between risk factors and proliferative diabetic retinopathy.

Results: Proliferative diabetic retinopathy was associated with longer duration of diabetes (odds ratio, OR, 1.62, p < 0.001), higher systolic blood pressure (OR 1.65, p < 0.001) and insulin use (OR 6.65, p < 0.001) in the multivariate regression analysis. HbA_1C was associated with proliferative diabetic retinopathy in the univariate analysis (OR 1.31, p = 0.002) but was no longer significant in the multivariate analysis.

Conclusions: In this case-control study of African Americans with type 2 diabetes, duration of diabetes, systolic hypertension and insulin use were strong risk factors for the development of proliferative diabetic retinopathy. Interestingly, HbA_1C did not confer additional risk in this cohort.     

Long-Term Survival Rates of Patients Undergoing Vitrectomy for Proliferative Diabetic Retinopathy

Purpose: Reported 5-year survival rates in patients undergoing vitreous surgery for proliferative diabetic retinopathy (PDR) range from 68–95%. Studies relating survival rates to medical baseline characteristics predate the millennium. This study aimed to update data on life expectancy of patients undergoing vitrectomy for PDR and identify baseline factors which may influence survival.

Methods: A retrospective cohort study of consecutive patients who underwent their first pars-plana vitrectomy for PDR between April 2004 and May 2005 was performed. Survival status on 1 May 2012 was the primary endpoint. The Kaplan-Meier life table method was used to determine survival rates. Univariate and multiple variable Cox proportional hazards regressions were used to identify risk factors for mortality.

Results: A total of 148 patients were included in the study, with a mean age of 54 years (range 20–80 years) at time of surgery. The 3-, 5- and 7-year survival rates were 94%, 86% and 77%, respectively (95% confidence interval, CI, 88–97%, 79–91% and 68–84%, respectively). Renal failure was the most common cause of death. The presence of limb ulcers at baseline was the most important prognostic indicator for mortality, with a hazard ratio of 3.13 (95% CI 1.46–6.71, p = 0.003) and a survival rate at 5 years reduced to 79%.

Conclusion: The 5-year survival rate remains comparable to those reported 20 years ago despite a lowering in threshold for vitrectomy and increased health awareness. Limb ulcers are strongly associated with increasing mortality. Clinicians should remain mindful of the systemic associations of diabetes particularly in advanced retinal disease.     

玻璃体联合手术治疗并发白内障的增生性糖尿病视网膜病变

目的：探讨伴有严重晶状体混浊的增生性糖尿病视网膜病变的玻璃体手术联合白内障吸除及人工晶状体植入的疗效及并发症。方法：需行玻璃体手术且伴有白内障的增生性糖尿病视网膜病变38例(41只眼)，行超声乳化白内障吸除联合玻璃体切割、膜剥离、眼内激光、或长效气体填充、及人工晶状体植入。观察病人手术前后视力变化，裂隙灯下检查眼前段情况，眼底荧光造影检查病人视网膜情况及分析并发症。结果：平均随访9个月。术后36只眼视力提高，占87．8％。眼前节反应轻，并发症少。主要并发症有：高眼压1只眼，角膜水肿1只眼，虹膜红变1只眼。视网膜脱离1只眼。结论：玻璃体联合手术治疗并发白内障的增生性糖尿病视网膜病变是一种方便、安全、有效的手术。     

Mini Review: Changes in the Incidence of and Progression to Proliferative and Sight-Threatening Diabetic Retinopathy Over the Last 30 Years

Purpose: Diabetic retinopathy is a leading cause of blindness worldwide. The last 3 decades have seen major improvements in glycemic and blood pressure control as well as the introduction of national screening programs, and we sought to determine if rates of proliferative diabetic retinopathy have changed as a result.

Methods: We conducted a systematic review to determine whether the incidence and progression rates of proliferative diabetic retinopathy and sight-threatening retinopathy have changed, focusing on large population-based studies with objective assessment of diabetic retinopathy.

Results: Comparisons across different studies is problematic due to different baseline retinopathy severity, different reported outcomes and different follow-up periods, but within these constraints certain trends could be identified. This review provides evidence that the incidence and progression of these conditions has reduced by approximately 2–3 fold over the last 3 decades.

Conclusion: These results have implications for current diabetic retinopathy screening guidelines and has identified future areas where research could be improved.