抗VEGF药物治疗不同类型糖尿病黄斑水肿的疗效评估

Efficacy evaluation of anti-vascular endothelial growth factor drugs in the treatment of different types of diabetic macular edema

目的观察不同抗血管内皮生长因子(VEGF)药物治疗不同类型糖尿病黄斑水肿(DME)的疗效差异,明确何种抗VEGF药物效果最佳。方法回顾性队列研究。纳入2018年10月至2021年11月于丽水市中心医院眼科确诊的DME患者,以及2022年1月至2023年7月于湘西自治州人民医院眼科确诊的DME患者共149例205眼。收集患者全身性基本资料,测量患眼最佳矫正视力(BCVA),检测患者黄斑中心凹视网膜厚度(CFT)。依据OCT形态特征,将DME分为囊样黄斑水肿(CME)型[CME组(57眼)]、弥漫性黄斑水肿(DRT)型[DRT组(78眼)]、浆液性视网膜脱离(SRD)型[SRD组(31眼)]以及混合型[混合型组(39眼)]。根据不同治疗方案患者玻璃体内注射阿柏西普(IVA)[IVA组(55眼)]、康柏西普(IVC)[IVC组(64眼)]、雷珠单抗(IVR)[IVR组(80眼)]、雷珠单抗和阿柏西普(IVR+IVA)[IVR+IVA组(6眼)]换药治疗,每月1次,此后按需治疗。对比分析不同药物对不同OCT类型患眼治疗前后BCVA与CFT的差异。结果CME组、DRT组、SRD组及混合型组患者一般资料除体重指数外比较,差异均无统计学意义(均为P>0.05),SRD组患者BMI最低。治疗前,4组患者BCVA(logMAR)与CFT比较,差异均有统计学意义(均为P<0.05),DRT组患者基线视力最好,DRT组CFT值最低。IVA组、IVC组及IVR组患者治疗前、治疗后1 d及1个月BCVA(logMAR)比较,差异有统计学意义(F=34.553,P<0.001),而不同药物类型之间的BCVA(logMAR)差异无统计学意义(F=1.312,P=0.272)。CME组、DRT组、SRD组及混合型组患者治疗前、治疗后1 d及1个月BCVA(logMAR)比较,差异有统计学意义(F=32.564,P<0.001),且不同OCT类型间BCVA(logMAR)比较,差异有统计学意义(F=5.227,P=0.002),治疗后DRT组患者视力最佳,SRD组患者视力最差。CME组、DRT组、SRD组及混合型组患者术前及术后1个月CFT降低值比较,差异有统计学意义(χ^(2)=58.279,P<0.001),而IVA组、IVR组及IVC组患者术前及术后1个月的CFT降低值比较,差异无统计学意义(F=0.978,P=0.378)。在混合型组中,IVA亚组与IVR亚组患者治疗前、治疗后1 d以及1个月BCVA(logMAR)比较,差异有统计学意义(P=0.023),且IVA亚组患者视力优于IVR亚组。结论抗VEGF药物可有效降低不同OCT类型DME患眼CFT,提高BCVA。然而,疗效主要与OCT分型有关,DRT型组应答最佳,SRD型组视力最差。不同药物的效果差异不明显,仅在混合型组中发现IVA优于IVR。

Objective To observe the differences in the efficacy of different anti-vascular endothelial growth factor(VEGF)drugs in treating different types of diabetic macular edema(DME)and clarify which anti-VEGF drug is the most effective.Methods A retrospective cohort study was conducted on 149 patients(205 eyes)diagnosed with DME in the Ophthalmology Department of Lishui Municipal Central Hospital from October 2018 to November 2021 and diagnosed with DME in the Ophthalmology Department of Xiangxi Autonomous Prefecture People’s Hospital from January 2022 to July 2023.General data of the patients were collected.The best-corrected visual acuity(BCVA)and the central foveal thickness(CFT)were measured.According to the morphological characteristics shown by optical coherence tomography(OCT),DME was classified into the cystoid macular edema(CME)type[CME group(57 eyes)],diffuse retinal thickening(DRT)type[DRT group(78 eyes)],serous retinal detachment(SRD)type[SRD group(31 eyes)],and mixed type[mixed group(39 eyes)].Patients were treated with the intravitreal injection of aflibercept(IVA)[IVA group(55 eyes)],conbercept(IVC)[IVC group(64 eyes)],ranibizumab(IVR)[IVR group(80 eyes)],and ranibizumab and aflibercept(IVR+IVA)[IVR+IVA group(6 eyes)],as per the 1+PRN regimen(once a month and as needed thereafter).The differences in BCVA and CFT before and after treatment with different drugs for different OCT types of eyes were compared and analyzed.Results There was no significant difference in the general data of patients among the CME group,DRT group,SRD group,and mixed group,except body mass index(BMI)(all P>0.05),and the BMI of patients in the SRD group was the lowest.Before treatment,the 4 groups showed significant differences in BCVA(logMAR)and CFT(all P<0.05).The baseline visual acuity of patients in the DRT group was the best,while the baseline CFT was the lowest.There was a significant difference in BCVA(logMAR)before treatment,1 day and 1 month after treatment in the IVA,IVC and IVR groups(F=34.553,P<0.001),while there was no significant difference in BCVA(logMAR)among different drug types(F=1.312,P=0.272).The differences in BCVA(logMAR)before treatment,1 day after treatment,and 1 month after treatment were statistically significant in the CME,DRT and SRD groups(F=32.564,P<0.001)and among different OCT types(F=5.227,P=0.002);after treatment,the visual acuity of patients in the DRT group was the best,and the visual acuity of patients in the SRD group was the poorest.The CFT reduction(difference between before treatment and 1 month after treatment)showed a significant difference in the CME,DRT,SRD and mixed groups(χ^(2)=58.279,P<0.001)but no significant difference in the IVA,IVR and IVC groups(F=0.978,P=0.378).In the mixed group,the difference in BCVA(logMAR)between the IVA subgroup and the IVR subgroup before treatment,1 day after treatment,and 1 month after treatment was statistically significant(P=0.023),and the visual acuity of patients in the IVA subgroup was better than that of patients in the IVR subgroup.Conclusion Anti-VEGF drugs can effectively reduce CFT and increase BCVA in DME eyes with different OCT types.However,the efficacy is mainly related to the OCT types,with the best response in the DRT group and the worst visual acuity in the SRD group.The difference in effectiveness between drugs is not significant,and only IVA is found to be superior to IVR in the mixed group.