Korean J Ophthalmol.  2011 Oct;25(5):299-304. 10.3341/kjo.2011.25.5.299.

Intravitreal Bevacizumab Alone versus Combined with Macular Photocoagulation in Diabetic Macular Edema

• Lee SJ
• Kim ET
• Moon YS

• KMID: 1098630
• DOI: http://doi.org/10.3341/kjo.2011.25.5.299

Abstract

PURPOSE
To compare the efficacy between intravitreal bevacizumab and combination treatment (bevacizumab and macular photocoagulation) for the treatment of diabetic macular edema (DME). In addtion, changes of DME type were researched using optical coherence tomography.
METHODS
The present study included 90 eyes with bevacizumab injection and 38 eyes with combination treatment. Using chart records, patients were reviewed until 6 months after treatment. The present study compared changes of visual acuity (VA) and macular thickness at each follow up. DME was classified into 4 types and the morphologic pattern was compared.
RESULTS
In patients with the bevacizumab injection only, VA improved from 0.29 +/- 0.18 to 0.48 +/- 0.26 at 1 month and returned to 0.32 +/- 0.20 at 6 months after treatment. In the combination treatment, VA improved from 0.32 +/- 0.22 to 0.52 +/- 0.26 at 1 month and returned to 0.36 +/- 0.18 at 6 months after treatment. There was no significant improvement of VA at the final follow-up with either treatment. There was significant decrease of macular thickness except in the mixed DME type.
CONCLUSIONS
The combination treatment did not yield better VA or macular thickness reduction at 6 months than bevacizumab injection alone. By classifying and observing the change of DME type, determining the treatment objectively and predicting the effectiveness of treatment can be helpful.

Keyword

Bevacizumab; Macular edema; Macular laser photocoagulation

MeSH Terms

Angiogenesis Inhibitors/administration & dosage
Antibodies, Monoclonal, Humanized/*administration & dosage
Diabetic Retinopathy/*complications/diagnosis/therapy
Dose-Response Relationship, Drug
Female
Fluorescein Angiography
Follow-Up Studies
Fundus Oculi
Humans
Intravitreal Injections
Laser Coagulation/*methods
Macular Edema/diagnosis/etiology/*therapy
Male
Microscopy, Acoustic
Middle Aged
Retrospective Studies
Tomography, Optical Coherence
Treatment Outcome
Vascular Endothelial Growth Factor A/antagonists & inhibitors
Visual Acuity

Figure

• 

  Fig. 1 The classification of diabetic macular edema according to optical coherence tomography features. (A) Diffuse macular edema: thickening of the fovea with homogeneous optical reflectivity throughout the whole layer of the retina. (B) Cystoid macular edema: thickening of the fovea forming cystic space with markedly decreased optical reflectivity in the outer retinal layer. (C) Serous retinal detachment: foveal detachment without vitreomacular traction. (D) Mixed macular edema: combination of the above 3 types of macular edema occupying approximately the same proportion, respectively.

• 

  Fig. 2 Comparison of visual acuity between intravitreal avastin and intravitreal avastin plus macular laser photocoagulation combination therapy. The asterisk indicates a statistically significant difference within a group (*p < 0.05).

Reference

1. Klein R, Klein BE, Moss SE, et al. The Wisconsin epidemiologic study of diabetic retinopathy. IV. Diabetic macular edema. Ophthalmology. 1984. 91:1464–1474.

2. Early Treatment Diabetic Retinopathy Study Research Group. Early photocoagulation for diabetic retinopathy. ETDRS report number 9. Ophthalmology. 1991. 98:5 Suppl. 766–785.

3. Akduman L, Olk RJ. Laser photocoagulation of diabetic macular edema. Ophthalmic Surg Lasers. 1997. 28:387–408.

4. Early Treatment Diabetic Retinopathy Study Research Group. Photocoagulation for diabetic macular edema. Early Treatment Diabetic Retinopathy Study report number 1. Arch Ophthalmol. 1985. 103:1796–1806.

5. Early Treatment Diabetic Retinopathy Study Research Group. Treatment techniques and clinical guidelines for photocoagulation of diabetic macular edema. Early Treatment Diabetic Retinopathy Study Report Number 2. Ophthalmology. 1987. 94:761–774.

6. Wilson DJ, Finkelstein D, Quigley HA, Green WR. Macular grid photocoagulation. An experimental study on the primate retina. Arch Ophthalmol. 1988. 106:100–105.

7. Arnarsson A, Stefansson E. Laser treatment and the mechanism of edema reduction in branch retinal vein occlusion. Invest Ophthalmol Vis Sci. 2000. 41:877–879.

8. Schatz H, Madeira D, McDonald HR, Johnson RN. Progressive enlargement of laser scars following grid laser photocoagulation for diffuse diabetic macular edema. Arch Ophthalmol. 1991. 109:1549–1551.

9. Roider J. Laser treatment of retinal diseases by subthreshold laser effects. Semin Ophthalmol. 1999. 14:19–26.

10. Jonas JB, Kreissig I, Sofker A, Degenring RF. Intravitreal injection of triamcinolone for diffuse diabetic macular edema. Arch Ophthalmol. 2003. 121:57–61.

11. Martidis A, Duker JS, Greenberg PB, et al. Intravitreal triamcinolone for refractory diabetic macular edema. Ophthalmology. 2002. 109:920–927.

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

13. Arevalo JF, Fromow-Guerra J, Quiroz-Mercado H, et al. Primary intravitreal bevacizumab (Avastin) for diabetic macular edema: results from the Pan-American Collaborative Retina Study Group at 6-month follow-up. Ophthalmology. 2007. 114:743–750.

14. Bonini-Filho MA, Jorge R, Barbosa JC, et al. Intravitreal injection versus sub-Tenon's infusion of triamcinolone acetonide for refractory diabetic macular edema: a randomized clinical trial. Invest Ophthalmol Vis Sci. 2005. 46:3845–3849.

15. Jonas JB, Spandau UH, Kamppeter BA, et al. Repeated intravitreal high-dosage injections of triamcinolone acetonide for diffuse diabetic macular edema. Ophthalmology. 2006. 113:800–804.

16. Cunningham ET Jr, Adamis AP, Altaweel M, et al. A phase II randomized double-masked trial of pegaptanib, an anti-vascular endothelial growth factor aptamer, for diabetic macular edema. Ophthalmology. 2005. 112:1747–1757.

17. Lam DS, Chan CK, Mohamed S, et al. Intravitreal triamcinolone plus sequential grid laser versus triamcinolone or laser alone for treating diabetic macular edema: six-month outcomes. Ophthalmology. 2007. 114:2162–2167.

18. Kim YG, Yu SY, Kwak HW. The effect of intravitreal triamcinolone acetonide injection according to the diabetic macular edema type. J Korean Ophthalmol Soc. 2005. 46:84–89.

19. Otani T, Kishi S, Maruyama Y. Patterns of diabetic macular edema with optical coherence tomography. Am J Ophthalmol. 1999. 127:688–693.

20. Avitabile T, Longo A, Reibaldi A. Intravitreal triamcinolone compared with macular laser grid photocoagulation for the treatment of cystoid macular edema. Am J Ophthalmol. 2005. 140:695–702.

21. Ahmadieh H, Ramezani A, Shoeibi N, et al. Intravitreal bevacizumab with or without triamcinolone for refractory diabetic macular edema; a placebo-controlled, randomized clinical trial. Graefes Arch Clin Exp Ophthalmol. 2008. 246:483–489.

22. Bak JH, Chung SE, Kang SW. The short-term effect of triple therapy for diabetic macular edema with vitreomacular traction. J Korean Ophthalmol Soc. 2008. 49:1941–1947.

23. Ferris FL 3rd, Patz A. Macular edema. A complication of diabetic retinopathy. Surv Ophthalmol. 1984. 28:Suppl. 452–461.

24. Antcliff RJ, Marshall J. The pathogenesis of edema in diabetic maculopathy. Semin Ophthalmol. 1999. 14:223–232.

25. Cunha-Vaz J. Diabetic macular edema. Eur J Ophthalmol. 1998. 8:127–130.

26. Lobo C, Bernardes R, Faria de Abreu JR, Cunha-Vaz JG. Novel imaging techniques for diabetic macular edema. Doc Ophthalmol. 1999. 97:341–347.

27. Yanoff M, Fine BS, Brucker AJ, Eagle RC Jr. Pathology of human cystoid macular edema. Surv Ophthalmol. 1984. 28:Suppl. 505–511.

28. Fine BS, Brucker AJ. Macular edema and cystoid macular edema. Am J Ophthalmol. 1981. 92:466–481.