J Korean Ophthalmol Soc.  2016 Dec;57(12):1903-1909. 10.3341/jkos.2016.57.12.1903.

Intravitreal Bevacizumab versus Intravitreal Bevacizumab Combined with Posterior Subtenon Triamcinolone Acetonide for Diabetic Macular Edema

• Lee JH
• Chung HY
• Lee KM
• Park YS
• Sohn JH
• Hwang DJ

• KMID: 2362708
• DOI: http://doi.org/10.3341/jkos.2016.57.12.1903

Abstract

PURPOSE
To investigate the outcome of intravitreal bevacizumab (IVB) combined with posterior subtenon triamcinolone acetonide injections compared to IVB injection alone in patients with diabetic macular edema (DME).
METHODS
IVB injection (IVB group) and combination therapy injection (combination group) were administered to 35 eyes and 31 eyes, respectively, diagnosed with proliferative diabetic retinopathy combined with DME. Changes in best corrected visual acuity (BCVA), central macular thickness (CMT), total macular volume (TMV), amount of hard exudates and intraocular pressure (IOP) were compared retrospectively between groups prior to injection and 1, 2 and 3 months after injection.
RESULTS
BCVA changes in both groups were only statistically significant at 4 weeks after injection. Reduction of CMT and TMV was maintained for 1 month after treatment in all groups, but CMT and TMV deteriorated 2 months after treatment. No significant differences in BCVA, CMT or TMV were detected between the IVB and combination groups. The amount of hard exudates were only significantly decreased at month 3 in the combination group whereas the amount of hard exudates was not significantly different at 3 months in the IVB group (at baseline 2,899 ± 2,314 pixels vs. at 3 months 2,536 ± 1,981 pixels, p-value = 0.041). IOP showed no significant difference between the groups. Elevated IOP or endophthalmitis were not observed.
CONCLUSIONS
In terms of BCVA improvement, subtenon triamcinolone provided no additional benefit on CMT and TMV reduction. However, combination therapy was effective in reducing the amount of hard exudates at 3 months.

Keyword

Bevacizumab; Diabetic macular edema; Hard exudates; Triamcinolone

MeSH Terms

Bevacizumab*
Diabetic Retinopathy
Endophthalmitis
Exudates and Transudates
Humans
Intraocular Pressure
Macular Edema*
Retrospective Studies
Triamcinolone Acetonide*
Triamcinolone*
Visual Acuity
Bevacizumab
Triamcinolone
Triamcinolone Acetonide

Figure

• 

  Figure 1. Measuring the amount of hard exudates with color fundus photography and the Photoshop program. The selected area by the magic wand tool is expressed in pixels by the histogram option.

• 

  Figure 2. Changes in parameters of both groups during the follow-up after injection. (A) Visual acuity. (B) Spectral domain optical coherence tomography (SD-OCT) measurements of central macular thickness. (C) SD-OCT measurements of total macular volume. (D) Intraocular pressure. IVB = intravitreal bevacizumab.

• 

  Figure 3. Changes in amount of hard exudates (in pixels) detected by fundus photography and the Photoshop program of both groups during the follow-up after injection. IVB = intravitreal bevacizumab.

Reference

References

1. Photocoagulation for diabetic macular edema. Early Treatment Diabetic Retinopathy Study report number 1. Early Treatment Diabetic Retinopathy Study research group. Arch Ophthalmol. 1985; 103:1796–806.

2. Focal photocoagulation treatment of diabetic macular edema. Relationship of treatment effect to fluorescein angiographic and other retinal characteristics at baseline: ETDRS report no. 19. Early Treatment Diabetic Retinopathy Study Research Group. Arch Ophthalmol. 1995; 113:1144–55.

3. Paccola L, Costa RA, Folgosa MS, et al. Intravitreal triamcinolone versus bevacizumab for treatment of refractory diabetic macular oedema (IBEME study). Br J Ophthalmol. 2008; 92:76–80.

4. Massin P, Audren F, Haouchine B, et al. Intravitreal triamcinolone acetonide for diabeitc diffuse macular edema: preliminary results of a prospective controlled trial. Ophthalmology. 2004; 111:218–24. discussion 224–5.

5. Lewis H, Abrams GW, Blumenkranz MS, Campo RV. Vitrectomy for diabetic macular traction and edema associated with posterior hyaloidal traction. Ophthalmology. 1992; 99:753–9.

6. Massin P, Bandello F, Garweg JG, et al. Safety and efficacy of abdominal in diabetic macular edema (RESOLVE Study): a 12-month, randomized, controlled, double-masked, multicenter phase II study. Diabetes Care. 2010; 33:2399–405.

7. Kim M, Lee P, Kim Y, et al. Effect of intravitreal bevacizumab based on optical coherence tomography patterns of diabetic abdominal edema. Ophthalmologica. 2011; 226:138–44.

8. Wu PC, Lai CH, Chen CL, Kuo CN. Optical coherence abdominal patterns in diabetic macula edema can predict the effects of intravitreal bevacizumab injection as primary treatment. J Ocul Pharmacol Ther. 2012; 28:59–64.

9. Lee K, Chung H, Park Y, Sohn J. Efficacy of intravitreal antiabdominal endothelial growth factor or steroid injection in diabetic abdominal edema according to fluid turbidity in optical coherence tomography. Korean J Ophthalmol. 2014; 28:298–305.

10. Jeon S, Lee WK. Effect of intravitreal triamcinolone in diabetic macular edema unresponsive to intravitreal bevacizumab. Retina. 2014; 34:1606–11.

11. Choi YJ, Oh IK, Oh JR, Huh K. Intravitreal versus posterior subtenon injection of triamcinolone acetonide for diabetic macular edema. Korean J Ophthalmol. 2006; 20:205–9.

12. Cellini M, Pazzaglia A, Zamparini E, et al. Intravitreal vs. subtenon triamcinolone acetonide for the treatment of diabetic cystoid abdominal edema. BMC Ophthalmol. 2008; 8:5.

13. Jeon S, Lee WK. Effect of intravitreal bevacizumab on diabetic macular edema with hard exudates. Clin Ophthalmol. 2014; 8:1479–86.

14. Kim HD, Kang KD, Choi KS, et al. Combined therapy with abdominal bevacizumab and posterior subtenon triamcinolone abdominal injection in diabetic macular oedema. Acta Ophthalmol. 2014; 92:e589–90.

15. Ahmadieh H, Ramezani A, Shoeibi N, et al. Intravitreal abdominal with or without triamcinolone for refractory diabetic macular edema; a placebo-controlled, randomized clinical trial. Graefes Arch Clin Exp Ophthalmol. 2008; 246:483–9.

16. Haritoglou C, Kook D, Neubauer A, et al. Intravitreal bevacizumab (Avastin) therapy for persistent diffuse diabetic macular edema. Retina. 2006; 26:999–1005.

17. Soheilian M, Ramezani A, Bijanzadeh B, et al. Intravitreal abdominal (avastin) injection alone or combined with triamcinolone versus macular photocoagulation as primary treatment of diabetic macular edema. Retina. 2007; 27:1187–95.

18. Lee YJ, Choi KS, Lee SJ. Treatment of diabetic macular edema: a comparative study. J Korean Ophthalmol Soc. 2010; 51:849–59.

19. Kim HD, Choi KS, Lee SJ. Combined therapy of intravitreal abdominal and posterior subtenon triamcinolone acetonide abdominal in diabetic macular edema. J Korean Ophthalmol Soc. 2009; 50:1652–6.

20. Ciardella AP, Klancnik J, Schiff W, et al. Intravitreal triamcinolone for the treatment of refractory diabetic macular oedema with hard exudates: an optical coherence tomography study. Br J Ophthalmol. 2004; 88:1131–6.

21. Avci R, Kaderli B. Intravitreal triamcinolone injection for chronic diabetic macular oedema with severe hard exudates. Graefes Arch Clin Exp Ophthalmol. 2006; 244:28–35.

22. Khairallah M, Zeghidi H, Ladjimi A, et al. Primary intravitreal abdominal acetonide for diabetic massive macular hard exudates. Retina. 2005; 25:835–9.

23. Deák GG, Bolz M, Kriechbaum K, et al. Effect of retinal photo-coagulation on intraretinal lipid exudates in diabetic macular abdominal documented by optical coherence tomography. Ophthalmology. 2010; 117:773–9.