Combined Laser and Intravitreal Triamcinolone for Proliferative Diabetic Retinopathy and Macular Edema: One-year Results of a Randomized Clinical Trial

Maia, Otacílio de Oliveira; Takahashi, Beatriz Sayuri; Costa, Rogério A.; Scott, Ingrid U.; Takahashi, Walter Yukihiko

doi:10.1016/j.ajo.2008.08.024

Cited by 57 publications

(31 citation statements)

References 32 publications

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“…The role of IVTA as adjunctive treatment to panretinal photocoagulation (PRP) for patients with proliferative diabetic retinopathy (PDR) and DME is being evaluated, and clinical studies have demonstrated the effectiveness of combination in preventing exacerbations of macular edema with improvement in visual acuity and macular thickness in patients having PDR and DME [49][50][51]63,64] . However, a recent study demonstrated no beneficial effect of combined IVTA plus PRP and macular photocoagulation in coexisting high-risk PDR and DME in terms of visual acuity and macular thickness compared with standard treatment [65] .…”

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confidence: 99%

Clinical trials on corticosteroids for diabetic macular edema

Dhibi

Arévalo

2013

WJD

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Diabetic macular edema (DME) is a common cause of visual impairment in diabetic patients. It is caused by an increase in the permeability of the perifoveal capillaries and a disruption of the blood retinal-barrier. The pathogenesis of DME is multifactorial. Several therapeutic modalities have been proposed for the treatment of DME. Corticosteroid treatments have emerged as an alternative therapy for persistent DME or refractory to conventional laser photocoagulation and other modalities, due to anti-inflammatory, anti-vascular endothelial growth factor and anti-proliferative effects. Many studies have demonstrated the beneficial therapeutic effect of corticosteroids with improvement to both retinal thickness and visual acuity in short-term on the treatment of DME. Peribulbar and intravitreal injections have been used to deliver steroids for DME with frequent injections due to the chronic and recurrent nature of the disease. Steroid-related side effects include elevated intraocular pressure, cataract, and injection related complications such as endophthalmitis, vitreous hemorrhage, and retinal detachment particularly with intravitreal steroid injections. In order to reduce the risks, complications and frequent dosing of intravitreal steroids, intravitreal implants have been developed recently to provide sustained release of corticosteroids and reduce repeated intravitreal injections for the management of DME.© 2013 Baishideng Publishing Group Co., Limited. All rights reserved.Key words: Corticosteroids; Diabetic macular edema; Intravitreal triamcinolone acetonide injection; Intravitreal steroid sustained-release implants; Peribulbar steroid injections; Subtenon's steroid Injections Core tip: Despite the documented ocular side effects of corticosteroids by the time being they are still considered as one of the essential effective adjunct modalities for the treatment of diabetic macular edema especially in refractory and persistent cases.

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Clinical trials on corticosteroids for diabetic macular edema

Dhibi

Arévalo

2013

WJD

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“…Unoki (2009) 130 reported that for 80% power, a total of 40 eyes in each treatment group was required. In Maia (2009), 127 it was reported that a total of 18 eyes of 18 patients was required for 80% power. However, after adjusting for a 20% lost to follow-up, the sample size required to reach the same study power increased to 22 eyes.…”

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confidence: 99%

“…These studies 119,120,[127][128][129][130] are described narratively below and a detailed summary is given in …”

Section: Laser In Combination With Steroidsmentioning

confidence: 99%

“…The aim of the study 127 was to determine the adjunctive effects of IVTA in combination with PRP and MPC in 22 patients with PDR and CSMO. Patients were followed up for 12 months.…”

Section: Maia 2009mentioning

confidence: 99%

“…127 In DRCRN (2011), 120 central randomisation was provided via the DRCRN website. In Unoki (2009), 130 participants were randomised using a stratification method.…”

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Pan-retinal photocoagulation and other forms of laser treatment and drug therapies for non-proliferative diabetic retinopathy: systematic review and economic evaluation

Royle

Mistry

Auguste

et al. 2015

Health Technol Assess

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BackgroundDiabetic retinopathy is an important cause of visual loss. Laser photocoagulation preserves vision in diabetic retinopathy but is currently used at the stage of proliferative diabetic retinopathy (PDR).ObjectivesThe primary aim was to assess the clinical effectiveness and cost-effectiveness of pan-retinal photocoagulation (PRP) given at the non-proliferative stage of diabetic retinopathy (NPDR) compared with waiting until the high-risk PDR (HR-PDR) stage was reached. There have been recent advances in laser photocoagulation techniques, and in the use of laser treatments combined with anti-vascular endothelial growth factor (VEGF) drugs or injected steroids. Our secondary questions were: (1) If PRP were to be used in NPDR, which form of laser treatment should be used? and (2) Is adjuvant therapy with intravitreal drugs clinically effective and cost-effective in PRP?Eligibility criteriaRandomised controlled trials (RCTs) for efficacy but other designs also used.Data sourcesMEDLINE and EMBASE to February 2014, Web of Science.Review methodsSystematic review and economic modelling.ResultsThe Early Treatment Diabetic Retinopathy Study (ETDRS), published in 1991, was the only trial designed to determine the best time to initiate PRP. It randomised one eye of 3711 patients with mild-to-severe NPDR or early PDR to early photocoagulation, and the other to deferral of PRP until HR-PDR developed. The risk of severe visual loss after 5 years for eyes assigned to PRP for NPDR or early PDR compared with deferral of PRP was reduced by 23% (relative risk 0.77, 99% confidence interval 0.56 to 1.06). However, the ETDRS did not provide results separately for NPDR and early PDR. In economic modelling, the base case found that early PRP could be more effective and less costly than deferred PRP. Sensitivity analyses gave similar results, with early PRP continuing to dominate or having low incremental cost-effectiveness ratio. However, there are substantial uncertainties. For our secondary aims we found 12 trials of lasers in DR, with 982 patients in total, ranging from 40 to 150. Most were in PDR but five included some patients with severe NPDR. Three compared multi-spot pattern lasers against argon laser. RCTs comparing laser applied in a lighter manner (less-intensive burns) with conventional methods (more intense burns) reported little difference in efficacy but fewer adverse effects. One RCT suggested that selective laser treatment targeting only ischaemic areas was effective. Observational studies showed that the most important adverse effect of PRP was macular oedema (MO), which can cause visual impairment, usually temporary. Ten trials of laser and anti-VEGF or steroid drug combinations were consistent in reporting a reduction in risk of PRP-induced MO.LimitationThe current evidence is insufficient to recommend PRP for severe NPDR.ConclusionsThere is, as yet, no convincing evidence that modern laser systems are more effective than the argon laser used in ETDRS, but they appear to have fewer adverse effects. We recommend a trial of PRP for severe NPDR and early PDR compared with deferring PRP till the HR-PDR stage. The trial would use modern laser technologies, and investigate the value adjuvant prophylactic anti-VEGF or steroid drugs.Study registrationThis study is registered as PROSPERO CRD42013005408.FundingThe National Institute for Health Research Health Technology Assessment programme.

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Diabetic retinopathy and other ocular complications

Tan

Wong

2015

International Textbook of Diabetes Mellitus

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Combined Laser and Intravitreal Triamcinolone for Proliferative Diabetic Retinopathy and Macular Edema: One-year Results of a Randomized Clinical Trial

Cited by 57 publications

References 32 publications

Clinical trials on corticosteroids for diabetic macular edema

Clinical trials on corticosteroids for diabetic macular edema

Pan-retinal photocoagulation and other forms of laser treatment and drug therapies for non-proliferative diabetic retinopathy: systematic review and economic evaluation

Diabetic retinopathy and other ocular complications

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