Intravitreal conbercept injection with panretinal photocoagulation for high-risk proliferative diabetic retinopathy with vitreous hemorrhage

AIM:To assess the clinical efficacy and safety of combining panretinal photocoagulation(PRP)with intravitreal conbercept(IVC)injections for patients with high-risk proliferative diabetic retinopathy(HR-PDR)complicated by mild or moderate vitreous hemorrhage(VH),with or without diabetic macular edema(DME).METHODS:Patients diagnosed with VH with/without DME secondary to HR-PDR and received PRP combined with IVC injections were recruited in this retrospective study.Upon establishing the patient’s diagnosis,an initial IVC was performed,followed by prompt administration of PRP.In cases who significant bleeding persisted and impeded the laser operation,IVC was sustained before supplementing with PRP.Following the completion of PRP,patients were meticulously monitored for a minimum of six months.Laser therapy and IVC injections were judiciously adjusted based on fundus fluorescein angiography(FFA)results.Therapeutic effect and the incidence of adverse events were observed.RESULTS:Out of 42 patients(74 eyes),29 were male and 13 were female,with a mean age of 59.17±12.74y(33-84y).The diabetic history was between 1wk and 26y,and the interval between the onset of visual symptoms and diagnosis of HR-PDR was 1wk-1y.The affected eye received 2.59±1.87(1-10)IVC injections and underwent 5.5±1.02(4-8)sessions of PRP.Of these,68 eyes received PRP following 1 IVC injection,5 eyes after 2 IVC injections,and 1 eye after 3 IVC injections.Complete absorption of VH was observed in all 74 eyes 5-50wk after initial treatment,with resolution of DME in 51 eyes 3-48wk after initial treatment.A newly developed epiretinal membrane was noted in one eye.Visual acuity significantly improved in 25 eyes.No complications such as glaucoma,retinal detachment,or endophthalmitis were reported.CONCLUSION:The study suggests that the combination of PRP with IVC injections is an effective and safe modality for treating diabetic VH in patients with HR-PDR.

Efficacy comparison of multipoint and single point scanning panretinal laser photocoagulation in non-proliferative diabetic retinopathy treatment

BACKGROUND Non-proliferative diabetic retinopathy(NPDR)poses a significant challenge in diabetes management due to its microvascular changes in the retina.Laser photocoagulation,a conventional therapy,aims to mitigate the risk of progressing to proliferative diabetic retinopathy(PDR).AIM To compare the efficacy and safety of multi-spot vs single-spot scanning panretinal laser photocoagulation in NPDR patients.METHODS Forty-nine NPDR patients(86 eyes)treated between September 2020 and July 2022 were included.They were randomly allocated into single-spot(n=23,40 eyes)and multi-spot(n=26,46 eyes)groups.Treatment outcomes,including bestcorrected visual acuity(BCVA),central macular thickness(CMT),and mean threshold sensitivity,were assessed at predetermined intervals over 12 months.Adverse reactions were also recorded.RESULTS Energy levels did not significantly differ between groups(P>0.05),but the multi-spot group exhibited lower energy density(P<0.05).BCVA and CMT improvements were noted in the multi-spot group at one-month posttreatment(P<0.05).Adverse reaction incidence was similar between groups(P>0.05).CONCLUSION While energy intensity and safety were comparable between modalities,multi-spot scanning demonstrated lower energy density and showed superior short-term improvements in BCVA and CMT for NPDR patients,with reduced laser-induced damage.

Change in subfoveal choroidal thickness after argon laser panretinal photocoagulation

AIMTo evaluate changes in subfoveal choroidal thickness (SFCT) and macular thickness as measured by enhanced depth imaging spectral-domain optical coherence tomography (EDI-OCT) after argon laser panretinal photocoagulation (PRP) in patients with severe diabetic retinopathy.

Effects of intravitreal conbercept before panretinal photocoagulation on lipid exudates in diabetic macular documented by optical coherence tomography

AIM: To evaluate the effects of intravitreal conbercept(IVC) as adjunctive treatments before panretinal photocoagulation(PRP) to decrease hyperreflective dots(HRDs) in Chinese proliferative diabetic retinopathy(PDR) patients. METHODS: Fifty-nine enrolled patients were categorized into 2 groups: single dose IVC(0.5 mg/0.05 m L) 1 wk before PRP(Plus group) or PRP only(PRP group). Six months later, we measured the best corrected visual acuity(BCVA), central macula thickness(CMT) by optical coherence tomography and counted the number of HRDs in different retina layers. RESULTS: The average CMT significantly decreased in Plus group but increased in PRP group. The average BCVA in the Plus group was also significantly better than that in the PRP group. Total HRDs decreased in the Plus group but increased in PRP group significantly. IVC pre-treatment has beneficial effects on reducing HRDs forming in the inner retina layer while the PRP alone increased the HRDs in the outer retina layer. CONCLUSION: IVC is a promising adjunctive treatment to PRP in the treatment of PDR. Single dose IVC one week before PRP is suggested to improve retina blood-retina barrier, decrease lipid exudate and inhibit HRDs development in PDR.

Efficacy and safety of intravitreal ranibizumab with panretinal photocoagulation followed by trabeculectomy compared with Ahmed glaucoma valve implantation in neovascular glaucoma

AIM：To evaluate the efficacy and safety of intravitreal ranibizumab（IVR）with panretinal photocoagulation（PRP）followed by trabeculectomy compared with Ahmed glaucoma valve（AGV）implantation in neovascular glaucoma（NVG）.METHODS：This was a retrospective comparative study.We reviewed the cases of a total of 45 eyes from 45 NVG patients among which 23 eyes underwent AGV implantation and the other 22 underwent trabeculectomy. The causes of neovascular glaucoma included：diabetic retinopathy（25 eyes）,and retinal vein occlusion（20 eyes）.All patients received preoperative IVR combined with postoperative PRP. The mean best-corrected visual acuities（BCVA）were converted to the logarithms of the minimum angle of resolution（log MAR）for the statisitical analyses.Intraocular pressure（IOP）,the log MAR BCVA and surgical complications were evaluated before and after surgery.The follow-up period was 12 mo.RESULTS：A total of 39 cases showed complete regression of iris neovascularization at 7d after injection,and 6 cases showed a small amount of residual iris neovascularization. The success rates were 81.8% and 82.6% at 12 mo after trabeculectomy and AGV implantation,respectively. In the trabeculectomy group,the log MAR BCVA improved at the last follow-up in 14 eyes,remained stable in 6 eyes and decreased in 2 eyes. In 4 cases,slight hyphemas developed after trabeculectomy. A shallow anterior chamber developed in 2 cases and 2 vitreous hemorrhages. In the AGV group,the log MAR BCVA improved in 14 eyes,remained stable in 5 eyes and decreased in 4 eyes. Slight hyphemas developed in 3 cases,and a shallow anterior chamber in 3 cases. The mean postoperative IOP was significantly lower in both groups after surgery（F=545.468,P〈0.05）,and the mean postoperative log MAR BCVA was also significantly improved（F=10.964,P〈0.05）with no significant difference between two groups.CONCLUSION：It is safe and effective to treat NVG with this combined procedure,and we found similar results after IVR＋AGV implantation＋PRP and IVR＋trabeculectomy＋PRP in eyes with NVG.

Simultaneous pars plana vitrectomy,panretinal photocoagulation,cryotherapy,and Ahmed valve implantation for neovascular glaucoma

AIM:To describe and evaluate the efficacy of Ahmed glaucoma valve implantation(AGV)combined with pars plana vitrectomy(PPV)in a single surgical act for the treatment of advanced neovascular glaucoma(NVG).METHODS:Retrospective observational case series included 51 eyes from 50 patients with severe NVG treated with PPV,AGV,and panretinal photocoagulation and/or cryotherapy in a single surgical act during a 13-year period(2005-2018).Preoperative,intraoperative and postoperative data at day 1 and months 1,3,6,21,and 24 were systematically collected.Definition of surgical success was stablished at IOP between 6 and 21 mm Hg with or without topical treatment.RESULTS:Main indications for surgery were NVG secondary to proliferative diabetic retinopathy(39.2%)and central retinal vein occlusion(37.3%).Mean(±SD)preoperative IOP was 42.0±11.2 mm Hg decreasing to 15.5±7.1 mm Hg at 12 mo and 15.8±9.1 mm Hg at 24 mo of follow up.Cumulative incidence of success of IOP control was 76.0%at first postoperative month,reaching 88.3%at 6 mo.Prevalence of successful IOP control at long term was 74.4%at 12 mo and 71.4%at 24 mo.Eye evisceration for unsuccessful NVG management was required in 1 case(2.0%).CONCLUSION:Combination of AGV implantation and PPV in a single act may be a suitable option for severe forms of NVG in a case-by-case basis for effective IOP control and a complete panretinal photocoagulation.

Efficacy of intravitreal conbercept combined with panretinal photocoagulation for severe nonproliferative diabetic retinopathy without macular edema

AIM: To assess efficacy of intravitreal conbercept(IVC) injection in combination with panretinal photocoagulation(PRP) vs PRP alone in patients with severe nonproliferative diabetic retinopathy(SNPDR) without macular edema(ME).METHODS: Forty-eight patients with SNPDR without ME(56 eyes) were divided into the PRP group and IVC+PRP group(the pulse group) in this retrospective clinical study. Conbercept was intravitreally administered to patients in the pulse group 1 wk before treatment with PRP and followed up for 1, 3, and 6 mo. The best-corrected visual acuity(BCVA, log MAR), center foveal thickness(CFT), visual acuity(VA) improvement, and adverse reactions were compared between groups.RESULTS: In the PRP group, the BCVA reduced at 1 and 3 mo before improving at 6 mo. In the pulse group, baseline BCVA decreased continuously at 1 mo, increased at 3 and 6 mo. BCVA in the pulse group was better than that in the PRP group at 1, 3, and 6 mo. There was an increase in CFT in the PRP group during follow-up compared with baseline. In the pulse group, CFT was increased at 1 mo relative to baseline, steadily decreased to the baseline level at 3 and 6 mo. There was a more significant reduction in CFT in the pulse group during follow-up compared with the PRP group. The effective rates of VA in the PRP and the pulse groups were 81.48% and 100%, respectively. CONCLUSION: As PRP pretreatment, a single dose of IVC administration has beneficial effects for preventing PRPinduced foveal thickening and increasing VA in patients with SNPDR without ME.

Treatment of diabetic retinopathy: Recent advances and unresolved challenges

Diabetic retinopathy(DR) is the leading cause of blindness in industrialized countries. Remarkable advances in the diagnosis and treatment of DR have been made during the past 30 years, but several important management questions and treatment deficiencies remain unanswered. The global diabetes epidemic threatens to overwhelm resources and increase the incidence of blindness, necessitating the development of innovative programs to diagnose and treat patients. The introduction and rapid adoption of intravitreal pharmacologic agents, particularly drugs that block the actions of vascular endothelial growth factor(VEGF) and corticosteroids, have changed the goal of DR treatment from stabilization of vision to improvement. Anti-VEGF injections improve visual acuity in patients with diabetic macular edema(DME) from 8-12 letters and improvements with corticosteroids are only slightly less. Unfortunately, a third of patients have an incomplete response to anti-VEGF therapy, but the best second-line therapy remains unknown. Current first-line therapy requires monthly visits and injections; longer acting therapies are needed to free up healthcare resources and improve patient compliance. VEGF suppression may be as effective as panretinal photocoagulation(PRP) for proliferative diabetic retinopathy, but more studies are needed before PRP is abandoned. For over 30 years laser was the mainstay for the treatment of DME, but recent studies question its role in the pharmacologic era. Aggressive treatment improves vision in most patients, but many still do not achieve reading and driving vision. New drugs are needed to add to gains achieved with available therapies.

Review of the management of sight-threatening diabetic retinopathy during pregnancy

Diabetes mellitus(DM)is a noncommunicable disease reaching epidemic proportions around the world.It affects younger individuals,including women of childbearing age.Diabetes can cause diabetic retinopathy(DR),which is potentially sight threatening when severe nonproliferative DR(NPDR),proliferative DR(PDR),or sight-threatening diabetic macular oedema(STDME)develops.Pregnancy is an independent risk factor for the progression of DR.Baseline DR at the onset of pregnancy is an important indicator of progression,with up to 10% of women with baseline NPDR progressing to PDR.Progression to sight-threatening DR(STDR)during pregnancy causes distress to the patient and often necessitates ocular treatment,which may have a systemic effect.Management includes prepregnancy counselling and,when possible,conventional treatment prior to pregnancy.During pregnancy,closer follow-up is required for those with a long duration of DM,poor baseline control of blood sugar and blood pressure,and worse DR,as these are risk factors for progression to STDR.Conventional treatment with anti-vascular endothelial growth factor agents for STDME can potentially lead to foetal loss.Treatment with laser photocoagulation may be preferred,and surgery under general anaesthesia should be avoided.This review provides a management plan for STDR from the perspective of practising ophthalmologists.A review of strategies for maintaining the eyesight of diabetic women with STDR with emphasis on prepregnancy counselling and planning,monitoring and safe treatment during pregnancy,and management of complications is presented.

Flanibizumab Plus Combined Surgery for Treatment o Neovascular Glaucoma with Vitreous Hemorrhage

Background：Neovascular glaucoma （NVG） is a refractory glaucoma.The management of NVG is very difficult,and it is more difficult when combined with vitreous hemorrhage.The aim of this study was to investigate the effects of ranibizumab plus combined surgery for NVG with vitreous hemorrhage.Methods：A total of 26 eyes of 26 NVG patients with vitreous hemorrhage were recruited in this study.The patients aged from 36 to 63 years with a mean age of 51.97 ± 7.60 years.The mean intraocular pressure （IOP） was 46.38 ± 5.75 mmHg （1 mmHg =0.133 kPa） while being treated with the maximum medical therapy.The mean best-corrected visual acuities converted to logarithm of the minimum angle of resolution （logMAR BCVA） was 2.62 ± 0.43.All the patients underwent intravitreal injection of 0.5 mg （0.05 ml） ranibizumab combined with pars plana vitrectomy （PPV）,pars plana lensectomy （PPL） with a preserved anterior capsule,panretinal photocoagulation （PRP）,and trabeculectomy （intravitreal ranibizumab [IVR] ＋ PPV ＋ PPL ＋ PRP ＋ trabeculectomy）.The IOP and logMAR BCVA were the main outcome measures in this study.Results：The follow-up period was 12 months.The mean postoperative IOPs were 26.38 ± 3.75 mmHg,21.36 ± 3.32 mmHg,1 8.57 ± 3.21 mmHg,and 16.68 ± 2.96 mmHg,respectively at 7 days,1 month,3 months,and 12 months after PPV ＋ PPL ＋ PRP ＋ trabeculectomy.At the last follow-up,the mean IOP was significantly lower than the preoperative one （t =6.612,P =0.001）.At 7 days,1 month,3 months,and 12 months after PPV ＋ PPL ＋ PRP ＋ trabeculectomy,the mean logMAR BCVA were 1.30 ± 0.36,1.29 ± 0.37,1.29 ± 0.39,and 1.26 ± 0.29,respectively.At the last follow-up,the mean logMAR BCVA was significantly improved,and the difference was statistically significant compared with preoperative one （t =6.133,P =0.002）.The logMAR BCVA improved in 22 eyes （84.62%）,and remained stable in 4 eyes （15.38%）.The neovascularization in the iris and the angle regressed significantly in all patients 7 days after ranibizumab injection.No serious complications occurred during 12 months of the study.Conclusions：IVR ＋ PPV ＋ PPL ＋ PRP ＋ trabeculectomy can control IOP well and improve BCVA without severe complication for NVG patients with vitreous hemorrhage.