Posterior Segment Diabetic Macular Oedema
Collaboration (ATC), occurred in 12 % of the laser alone group, 5 % of the ranibizumab–laser group and 6 % of the TA–laser group.31
DMO remains the leading cause of visual impairment in the working-age population. Emerging pharmacological approaches are being evaluated to treat DMO unresponsive to laser therapy. Many retinal physicians have begun to routinely inject TA as a promising option for the treatment of refractory DMO, although in these cases the intravitreal administration of TA is not FDA approved and has been mostly used off-label. Intravitreal TA has been found to significantly increase the visual acuity and decrease central macular thickness in short-term follow-up. Despite a very favourable systemic safety profile, a significant proportion of patients experience a rise in IOP and cataract development following intravitreal TA injections. The incidence of severe ocular adverse events such as infectious endophthalmitis, pseudoendophthalmitis, retinal toxicity and rhegmatogenous retinal detachment remains on the low side. Recently, a combined strategy of intravitreal injection of TA and laser photocoagulation has been evaluated for the treatment of DMO.31 In this study laser photocoagulation appeared safer and more effective than the combination of intravitreal injection of TA and laser treatment. However, when considering patients that were pseudophakic at baseline, TA in combination with laser resulted in better visual outcomes than laser alone. The results of the combination of TA and laser were comparable to those obtained with
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the combination of laser and ranibizumab in this subgroup of patients after two years of follow-up.31
The rationale for combining laser
photocoagulation and intravitreal TA lies in their synergistic mechanism of action and may offer the chance to reduce the number of intravitreal injections required and so decrease the rate of drug- and injection-related adverse events. However, several vision-threatening side effects have been reported as a result of thermal damage caused by laser procedure.98–100
In recent years
Combining intravitreal TA and sub-threshold laser photocoagulation may be a promising option to obtain good and durable visual outcomes while reducing the side effects correlated to either the laser procedure or the drug.
advances in laser therapy of retinal diseases have been directed at reducing the unnecessary disruptive effect that laser photocoagulation produces in retinal tissues. Several studies have shown the efficacy of sub-threshold laser photocoagulation in treating DMO, producing fewer side effects than conventional laser treatment.101–105
Many questions still remain unanswered concerning the optimal dose of TA for intravitreal use and the side-effect profiles of various commercially available formulations of TA with and without preservatives. Thus, an optimal balance between efficacy and safety profile has yet to be completely determined. Novel steroid implants and anti-VEGF drugs are being evaluated alone or in combination as promising options in the emerging armamentarium for the treatment of DMO. n
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EUROPEAN OPHTHALMIC REVIEW
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