Purpose. To evaluate efficacy of intravitreal triamcinolone (IVT) and bevacizumab (IVB) as adjunctive treatments to panretinal photocoagulation (PRP) in proliferative diabetic retinopathy (PDR). Methods. In 60 eyes of 45 patients with PDR, PRP (PRP group), PRP with IVT (IVT group), or PRP with IVB (IVB group) was performed. Regression of new vessels (NV), changes in best-corrected visual acuity (BCVA), central macular thickness (CMT), and contrast sensitivity at 1,2, and 6 months were evaluated. Results. Initial mean numbers of active NV and BCVA were 3.45 and 67.35 in the PRP group, 4.35 and 76.65 in the IVT group, and 4.79 and 75.53 in the IVB group. At the 6-month follow-up, numbers of active NV were 2.5 ( ), 1.11 ( ), and 1.11 ( ), and there was a mean loss of 2,6 ( ), 3.9 ( ), and 0.9 letters ( ) in the PRP, IVT, and IVB groups, respectively. Changes in CMT in the PRP and IVT groups were not significant, but significantly increased in the IVB group ( ). Contrast sensitivity remained stable in PRP and IVB groups and slightly decreased in IVT group. Conclusions. Adjunctive use of both triamcinolone and bevacizumab with PRP lead to a greater reduction of active NV than PRP alone in PDR, although no differences were seen between the two of them. 1. Introduction Diabetic retinopathy is one of the leading causes of blindness in the developed world, particularly in patients aged 20 to 74 years [1]. Its estimated prevalence is 70.4% in patients with type 1 diabetes and 54.4% in patients with type 2 diabetes [2, 3]. Microvascular occlusion in the eye caused by the glycation of blood vessel proteins results in local hypoperfusion that leads to retinal ischaemia. Proliferative diabetic retinopathy (PDR) occurs in response to the ischaemia-mediated release of vascular endothelial growth factor (VEGF) into the vitreous cavity [4–6]. It has been shown that retinal neovascularisation is a significant risk factor for severe vision loss in diabetic patients [4]. The Diabetic Retinopathy Study demonstrated that scatter laser panretinal photocoagulation (PRP) reduced the risk of severe vision loss by at least 50% in patients with high-risk PDR compared to a control group [7]. Currently, PRP is the principal therapy for sight-threatening PDR except for patients with a history of extensive vitreous haemorrhaging, which is a contraindication to laser photocoagulation. Intravitreal injections of several drugs in combination with PRP have been shown to achieve more favourable therapeutic outcomes than PRP alone. The adjunctive use of triamcinolone with PRP leads to a
References
[1]
J. Kempen, B. O'Colmain, and M. Leske, “The prevalence of diabetic retinopathy among adults in the United States,” Archives of Ophthalmology, vol. 122, p. 12, 2004.
[2]
R. Klein, B. E. K. Klein, and S. E. Moss, “The Wisconsin Epidemiologic Study of Diabetic Retinopathy. II. Prevalence and risk of diabetic retinopathy when age at diagnosis is less than 30 years,” Archives of Ophthalmology, vol. 102, no. 4, pp. 520–526, 1984.
[3]
R. Klein, B. E. K. Klein, and S. E. Moss, “The Wisconsin Epidemiologic Study of Diabetic Retinopathy. III. Prevalence and risk of diabetic retinopathy when age at diagnosis is 30 or more years,” Archives of Ophthalmology, vol. 102, no. 4, pp. 527–532, 1984.
[4]
A. P. Adamis, J. W. Miller, M. T. Bernal et al., “Increased vascular endothelial growth factor levels in the vitreous of eyes with proliferative diabetic retinopathy,” American Journal of Ophthalmology, vol. 118, no. 4, pp. 445–450, 1994.
[5]
L. P. Aiello, R. L. Avery, P. G. Arrigg et al., “Vascular endothelial growth factor in ocular fluid of patients with diabetic retinopathy and other retinal disorders,” New England Journal of Medicine, vol. 331, no. 22, pp. 1480–1487, 1994.
[6]
J. Pe'er, D. Shweiki, A. Itin, I. Hemo, H. Gnessin, and E. Keshet, “Hypoxia-induced expression of vascular endothelial growth factor by retinal cells is a common factor in neovascularizing ocular diseases,” Laboratory Investigation, vol. 72, no. 6, pp. 638–645, 1995.
[7]
The Diabetic Retinopathy Study Research Group, “Photocoagulation treatment of proliferative diabetic retinopathy. Clinical application of diabetic retinopathy study (DRS) findings, DRS report number 8,” Ophthalmology, vol. 88, no. 7, pp. 583–600, 1981.
[8]
D. N. Zacks and M. W. Johnson, “Combined intravitreal injection of triamcinolone acetonide and panretinal photocoagulation for concomitant diabetic macular edema and proliferative diabetic retinopathy,” Retina, vol. 25, no. 2, pp. 135–140, 2005.
[9]
F. Bandello, A. Polito, D. R. Pognuz, P. Monaco, A. Dimastrogiovanni, and J. Paissios, “Triamcinolone as adjunctive treatment to laser panretinal photocoagulation for proliferative diabetic retinopathy,” Archives of Ophthalmology, vol. 124, no. 5, pp. 643–650, 2006.
[10]
W. M. Zein, B. N. Noureddin, F. A. Jurdi, A. Schakal, and Z. F. Bashshur, “Panretinal photocoagulation and intravitreal triamcinolone acetonide for the management of proliferative diabetic retinopathy with macular edema,” Retina, vol. 26, no. 2, pp. 137–142, 2006.
[11]
R. F. Spaide and Y. L. Fisher, “Intravitreal bevacizumab (Avastin) treatment of proliferative diabetic retinopathy complicated by vitreous hemorrhage,” Retina, vol. 26, no. 3, pp. 275–278, 2006.
[12]
J. O. Mason, P. A. Nixon, and M. F. White, “Intravitreal injection of bevacizumab (Avastin) as adjunctive treatment of proliferative diabetic retinopathy,” American Journal of Ophthalmology, vol. 142, no. 4, pp. 685–688, 2006.
[13]
A. Mirshahi, R. Roohipoor, A. Lashay, S. F. Mohammadi, A. Abdoallahi, and H. Faghihi, “Bevacizumab-augmented retinal laser photocoagulation in proliferative diabetic retinopathy: a randomized double-masked clinical trial,” European Journal of Ophthalmology, vol. 18, no. 2, pp. 263–269, 2008.
[14]
M. Tonello, R. A. Costa, F. P. P. Almeida, J. C. Barbosa, I. U. Scott, and R. Jorge, “Panretinal photocoagulation versus PRP plus intravitreal bevacizumab for high-risk proliferative diabetic retinopathy (IBeHi study),” Acta Ophthalmologica, vol. 86, no. 4, pp. 385–389, 2008.
[15]
A. M. Minnella, C. M. Savastano, L. Ziccardi et al., “Intravitreal bevacizumab (Avastin) in proliferative diabetic retinopathy,” Acta Ophthalmologica, vol. 86, no. 6, pp. 683–687, 2008.
[16]
B. H. Doft and G. Blankenship, “Retinopathy risk factor regression after laser panretinal photocoagulation for proliferative diabetic retinopathy,” Ophthalmology, vol. 91, no. 12, pp. 1453–1457, 1984.
[17]
J. F. Vander, J. S. Duker, W. E. Benson, G. C. Brown, J. A. McNamara, and R. B. Rosenstein, “Long-term stability and visual outcome after favorable initial response of proliferative diabetic retinopathy to panretinal photocoagulation,” Ophthalmology, vol. 98, no. 10, pp. 1575–1579, 1991.
[18]
V. M. Reddy, R. L. Zamora, and R. J. Olk, “Quantitation of retinal ablation in proliferative diabetic retinopathy,” American Journal of Ophthalmology, vol. 119, no. 6, pp. 760–766, 1995.
[19]
W. B. Cho, S. B. Oh, J. W. Moon, and H. C. Kim, “Panretinal photocoagulation combined with intravitreal bevacizumab in high-risk proliferative diabetic retinopathy,” Retina, vol. 29, no. 4, pp. 516–522, 2009.
[20]
Early Treatment Diabetic Retinopathy Study Research Group, “Fundus photographic risk factors for progression of diabetic retinopathy: ETDRS report number 12,” Ophthalmology, vol. 98, no. 5, supplement, pp. 823–833, 1991.
[21]
“Early Treatment Diabetic Retinopathy Study design and baseline patient characteristics: ETDRS report number 7,” Ophthalmology, vol. 98, no. 5, supplement, pp. 741–756, 1991.
[22]
L. T. Chylack, J. K. Wolfe, D. M. Singer et al., “The Lens Opacities Classification System III. The Longitudinal Study of Cataract Study Group,” Archives of Ophthalmology, vol. 111, no. 6, pp. 831–836, 1993.
[23]
T. W. Gardner, A. W. Eller, and T. R. Friberg, “Reduction of severe macular edema in eyes with poor vision after panretinal photocoagulation for proliferative diabetetic retinopathy,” Graefe's Archive for Clinical and Experimental Ophthalmology, vol. 229, no. 4, pp. 323–328, 1991.
[24]
H. R. McDonald and H. Schatz, “Macular edema following panretinal photocoagulation,” Retina, vol. 5, no. 1, pp. 5–10, 1985.
[25]
H. R. McDonald and H. Schatz, “Visual loss following panretinal photocoagulation for proliferative diabetic retinopathy,” Ophthalmology, vol. 92, no. 3, pp. 388–393, 1985.
[26]
U. H. M. Spandau, M. Derse, P. Schmitz-Valckenberg, C. Papoulis, and J. B. Jonas, “Dosage dependency of intravitreal triamcinolone acetonide as treatment for diabetic macular oedema,” British Journal of Ophthalmology, vol. 89, no. 8, pp. 999–1003, 2005.
[27]
G. A. Lalwani, P. J. Rosenfeld, A. E. Fung et al., “A variable-dosing regimen with intravitreal ranibizumab for neovascular age-related macular degeneration: year 2 of the PrONTO Study,” American Journal of Ophthalmology, vol. 148, no. 1, pp. 43.e1–58.e1, 2009.
[28]
A. J. Brucker, H. Qin, A. N. Antoszyk et al., “Observational study of the development of diabetic macular edema following panretinal (scatter) photocoagulation given in 1 or 4 sittings,” Archives of Ophthalmology, vol. 127, no. 2, pp. 132–140, 2009.
[29]
K. S. Choi, J. K. Chung, and S. H. Lim, “Laser photocoagulation combined with intravitreal triamcinolone acetonide injection in proliferative diabetic retinopathy with macular edema,” Korean Journal of Ophthalmology, vol. 21, no. 1, pp. 11–17, 2007.
[30]
W. B. Cho, J. W. Moon, and H. C. Kim, “Intravitreal triamcinolone and bevacizumab as adjunctive treatments to panretinal photocoagulation in diabetic retinopathy,” British Journal of Ophthalmology, vol. 94, no. 7, pp. 858–863, 2010.
[31]
O. O. Maia, B. S. Takahashi, R. A. Costa, I. U. Scott, and W. Y. Takahashi, “Combined laser and intravitreal triamcinolone for proliferative diabetic retinopathy and macular edema: one-year results of a randomized clinical trial,” American Journal of Ophthalmology, vol. 147, no. 2, pp. 291–297, 2009.
[32]
J. E. Kim, J. S. Pollack, D. G. Miller, R. A. Mittra, and R. F. Spaide, “ISIS-DME: a prospective, randomized, dose-escalation intravitreal steroid injection study for refractory diabetic macular edema,” Retina, vol. 28, no. 5, pp. 735–740, 2008.
[33]
H. Funatsu, H. Noma, T. Mimura, S. Eguchi, and S. Hori, “Association of vitreous inflammatory factors with diabetic macular edema,” Ophthalmology, vol. 116, no. 1, pp. 73–79, 2009.
[34]
G. W. Blankenship, “Fifteen-year argon laser and xenon photocoagulation results of Bascom Palmer Eye Institute's patients participating in the diabetic retinopathy study,” Ophthalmology, vol. 98, no. 2, pp. 125–128, 1991.
