[Combined pharmacosurgery as treatment for diabetic macular edema: core pars plana vitrectomy and intravitreal injection of bevacizumab and triamcinolone].

BACKGROUND

The aim of this work is to report the efficacy of a 1.5 mL core pars plana vitrectomy (cppV) combined with isovolumetric substitution with 1.25 mg bevacizumab and 8 mg triamcinolone for the treatment of diabetic macular edema (DME).

METHODS

Data of 73 eyes (60 patients; mean age: 65.4 ± 10.4 years) with diabetic macular edema were retrospectively analysed. Main outcome measures were changes in visual acuity, central macular thickness (CMT) and the need for re-intervention and further treatment modalities, i. e., laser photocoagulation (LPC) or pars plana vitrectomy (ppV). Study eyes were assigned to one of three groups: non-proliferative diabetic retinopathy without ischaemic maculopathy (NPDR I. M.; group I; n = 38 eyes); NPDR with I. M. (group II; n = 17 eyes); proliferative diabetic retinopathy with or without I. M. (group III; n = 18). Mean follow-up times were 9 weeks (T1), 25 weeks (T2) and 44 weeks.

RESULTS

Preoperative mean VA was 0.69 ± 0.4 logMAR. A statistically significant increase in mean VA was observed in all study eyes at 2 months after the initial operation (T1; 0.51 ± 0.22 logMAR; p < 0.01). This remained stable at T 2 (0.52 ± 0.33 logMAR; p = 0.6) and T 3 (0.55 ± 0.35 logMAR; p = 0.99). At baseline mean VA was 0.52 ± 0.21 logMAR in group I, 0.99 ± 0.5 logMAR in group II and 0.77 ± 0.42 logMAR in group III. At T 1 (2 months) the VA change was statistically significant in group II (0.64 ± 0.18 logMAR; p < 0.05) only. In contrast, group I had a highly significant VA gain after 6 months (0.36 ± 0.16; p < 0.01). Patients with PDR (group III) had a non-significant VA gain at T 1 (0.53 ± 0.24; p = 0.08) and remained stable at T 2 and T 3. The mean central macular thickness (CMT) in all study eyes decreased significantly from 393.7 ± 120.6 µm to 269.7 ± 100.2 µm (delta -28 %; p < 0.01) at T 1. Thereafter CMT slightly increased but, on the whole, remained stable at that level. Retreatment with the intravitreal combination therapy was performed in 20 of 73 eyes (27.4 %). Laser photocoagulation was only carried out in more than half of the eyes with PDR (10 / 18; 55.6 %). An increase in IOP was noted in 12 / 73 eyes (16.4 %) at different follow-up, and was controlled using topical medication. Systemic side effects were not reported.

CONCLUSION

Our data show that the majority of the study eyes maintained or improved their visual acuity after pharmacosurgical therapy. Furthermore we observed a reduction of the central macular thickness in almost all study eyes. Only few retreatments and other treatment modalities were needed during the follow-up period. This combind pharmacosurgical treatment may supplement current treatment standards like laser photocoagulation, classical pars plana vitrectomy or intravitreal monotherapy for DME.