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Managing antiVEGF resistance in diabetic macular edema

Session Details

Session Title: Quick Fire Free Paper 1

Session Date/Time: Thursday 11/09/2014 | 08:00-10:00

Paper Time: 08:05

Venue: Boulevard D

First Author: : D.Chakraborty INDIA

Co Author(s): :    T.K Sinha   A. Das   S. Boral   B. DuttaChoudhury     

Abstract Details

Purpose:

The etiology of Diabetic Macular Edema(DME) is multifactorial. Chronic hyperglycemia leads to increased VEGF(vascular endothelial growth factor) levels, endothelial dysfunction, leuckocyte adhesion, decreased pigment epithelium derived factor (PEDF), formation of advanced glycation end products, free radical formation, protein kinase C activation. Antivegf though extensively used in DME, it may not take care of all etiologies. In this study Intravitreal triamcinolone acetonide (IVTA) and focal or modified grid laser were tried when Bevacizumab and or Ranibizumab was not found to decrease macular edema adequately even after 6 months of treatment

Setting:

prospective study conducted in a tertiary care referral hospital

Methods:

Prospective study of 28eyes. Study period jan 2012 to dec 2013 Inclusion Criteria Pseudophakic eyes, with non proliferative diabetic retinopathy having diabetic macular edema, non-responsive to antiVEGF injections, a central macular thickness of >300µ were included. Exclusion criteria Patients with coexistent glaucoma, optic nerve disorder, branch or central retinal vein occlusion, past history of vitreoretinal surgery, anti VEGF injection within last 3 months in either eye, known history of complication during cataract surgery, patients on dialyses & baseline HbA1c >7.0 were excluded. Patients not completing 18 months of followup from first injection were excluded from the study. Snelen visual acuity was converted to decimals for analysis. 4-6 wks after IVTA injection flourescein angiogram and focal / modified grid laser was performed. Statistical methodology : The results were expressed as mean + SD. Continuous variables were compared by the Student’s t-test and categorical variables by Fisher’s exact test. Follow-up data was analyzed by the paired t-test. Correlation between variables was computed using Pearson’s correlation coefficient. A two tailed p value <0.05 was considered to be significant. SPSSÒ version 20.0 (SPSS Inc., Chicago, IL) and MicrosoftÒ Excel Version 14.0 has been used for descriptive statistic

Results:

Total number of eyes completing 18 months followup - 23 eyes, 15males and 8 females. Average age 58.08±5.58yrs. Mean number of Anti VEGF - 4.21±1.53. Mean number of IVTA- 2.39±0.77. Mean VA at baseline- 0.11±0.07 (snellen VA converted to decimals). AAt baseline mean central macular thickness (CMT) was 419.91 µ ±81.83µ. At 6wks after injection meanVA was 0.23±0.10, mean CMT 287.5±34.31µ. At 3months mean VA 0.24µ±0.10, mean CMT 276.69µ±32.3µ. At 6months mean VA 0.25±0.10 , mean CMT 268.61±25.68µ. At 12months mean VA 0.27±0.11, mean CMT 252.39µ±22.13µ. At 18months mean VA 0.26±0.11, mean CMT 250.56µ±26.87µ. Mean number of IVTA 2.39±0.77. Student’s t-test, Fisher’s exact test. paired t-test. Pearson’s correlation coefficient were evaluated.

Conclusions:

Edema formation in DME is hypothesized by 2 theories: – increased permeability of vessels – increased water flux from vascular to tissue compartment Triamcinolone may work may work because it reduces the expression of VEGF and also causes stabilization of membranes -reducing permeability and accumulation of water in the tissue. High vitreous levels of VEGF in DME have been noted in various studies. Anti-VEGFs can induce dramatic reduction of DME but action is shortlived and it has no effect on stabilization of membranes. Repeat anti VEGF injections do not have similar effect. In the current study, pseudophakic patients in whom resolution of macular edema was not seen or was poor with anti VEGF were taken up for intervention. Vision improved & macular thickness decreased with IVTA. 4-6 wks after IVTA flourescein angiogram guided focal or modified grid laser was performed. Repeat injection was based on persistence or increase of macular edema both clinically and on OCT. This study emphasizes that when used judiciously IVTA can be of use in cases of AntiVegf resistant diabetic macular edema.

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