PURPOSE. To compare the changes in macular sensitivity (microperimetry) and macular thickness with different degrees of diabetic macular edema. METHODS. Sixty-one eyes of 32 consecutive diabetic patients were included in this cross-sectional study. All included eyes underwent functional and morphologic examination of the macular area. Best corrected visual acuity (ETDRS charts), macular sensitivity, and macular thickness were quantified. Lesion-related macular sensitivity and retinal fixation were investigated with an advanced, automatic microperimeter. Optical coherence tomography (OCT) was used to quantify macular thickness. RESULTS. The 61 included eyes were graded, by two retinal specialists, for diabetic macular edema as follows: 16 were graded as no macular edema (NE), 30 as non- clinically significant macular edema (NCSME), and 15 as clinically significant macular edema (CSME). Macular thickness significantly increased from the NE to the CSME group (P < 0.0001), whereas macular sensitivity significantly decreased from the NE to the CSME group (P < 0.0021). A significant correlation coefficient was noted between retinal sensitivity and normalized macular thickness (r = -0.37, P < 0.0001). Linear regression analysis showed a decrease of 0.83 dB (P < 0.0001) for every 10% of deviation of retinal thickness from normal values. Visual acuity and central macular sensitivity correlated significantly in the NCSME group (r = -0.6, P = 0.0008), but not in the NE (r = -0.144, P = 0.6) or in the CSME (r = -0.46, P = 0.11) groups. CONCLUSIONS. Macular edema may be better documented by adding macular sensitivity mapping by microperimetry to macular thickness measurement by OCT and visual acuity determination because macular sensitivity seems to be a relevant explanatory variable of visual function, independent of macular thickness data. Moreover, microperimetry may be of value in predicting the outcome of diabetic macular edema, because it incorporates a functional measure that may supplement the predictive value of OCT and visual acuity.

Diabetic macular edema: correlation between microperimetry and optical coherence tomography findings.

Purpose
To evaluate the effect of three intravitreal injections of bevacizumab (IVB) alone or combined with triamcinolone (IVT) in the first injection for treatment of refractory diabetic macular edema (DME).

Intravitreal bevacizumab with or without triamcinolone for refractory diabetic macular edema; a placebo-controlled, randomized clinical trial.

Diabetic retinopathy is the leading cause of blindness in working age individuals in developed countries. Most cases of diabetes related vision loss result from breakdown of the blood-retinal barrier with resultant diabetic macular edema (DME). For over 30 years, laser photocoagulation has been the standard therapy for DME, but most eyes do not experience significant improvements in visual acuity. Intravitreal injections of drugs that inhibit the action of vascular endothelial growth factor (VEGF) lead to gains in vision, but can be expensive and need to be repeated frequently. In addition to VEGF-mediated breakdown of the blood-retinal barrier, recent evidence suggests that inflammation plays an important role in the development of DME. Recognizing this, physicians have injected steroids into the vitreous and developers have created sustained release implants. Intravitreal injections of triamcinolone acetonide lead to rapid resolution of macular edema and significant short-term improvements in visual acuity, but unfortunately, visual acuities diminish when treatment is continued through 2 years. However, intravitreal triamcinolone remains an attractive treatment option for eyes that are pseudophakic, scheduled to undergo cataract surgery, resistant to laser photocoagulation, or require urgent panretinal photocoagulation for proliferative retinopathy. In controlled trials, intraocular implants that slowly release dexamethasone and fluocinolone show promise in reducing macular edema and improving visual acuity. The high incidences of drug related cataracts and glaucoma, however, require that corticosteroids be used cautiously and that patients be selected carefully. The increasing number of patients with DME, the burgeoning cost of medical care and the continuing development of intravitreal steroids suggest that the use of these agents will likely increase in coming years.

Corticosteroid Use for Diabetic Macular Edema: Old Fad or New Trend?

Objective To evaluate intravitreal injection of triamcinolone acetonide before laser panretinal photocoagulation (PRP) in the treatment of proliferative diabetic retinopathy. Methods This interventional case series included 9 patients with bilateral proliferative diabetic retinopathy. One eye received intravitreal triamcinolone before PRP (injected eye) and the other, PRP alone (control eye). The main outcome measures were the change in planimetric area of fluorescein leakage from retinal neovascularization and in central macular thickness on optical coherence tomography at 3, 6, 9, and 12 months. Secondary end points were change in vision, intraocular pressure, and cataract progression. Results All patients completed 9 months and 5 patients, 12 months of follow-up. Initial mean (SD) planimetric area of fluorescein leakage and central macular thickness were 7.22 (5.70) mm 2 and 372.11 (91.88) μm in injected eyes and 9.08 (6.17) mm 2 and 355.33 (115.23) μm in control eyes, respectively. At the 9- and 12-month intervals, the planimetric area of fluorescein leakage decreased by 86% and 88% in injected eyes and 33% and 50% in controls, respectively. Central macular thickness significantly decreased in injected eyes and increased in control eyes. Vision slightly improved in injected eyes and worsened in control eyes. Conclusion Intravitreal injection of triamcinolone before PRP may be useful in improving the effects of PRP in eyes with proliferative diabetic retinopathy by reducing neovascularization and macular thickening.

https://jamanetwork.com/journals/jamaophthalmology/articlepdf/417669/ecs60008.pdf

Triamcinolone as Adjunctive Treatment to Laser Panretinal Photocoagulation for Proliferative Diabetic Retinopathy

Combined Laser and Intravitreal Triamcinolone for Proliferative Diabetic Retinopathy and Macular Edema : One-year Results of a Randomized Clinical Trial

PURPOSE: To evaluate the correlation between improvement in visual acuity and the reduction of foveal thickness after a single intravitreal injection of 4 mg of triamcinolone in diabetic macular edema. DESIGN: Prospective, interventional, nonrandomized clinical trial. METHOD: PATIENTS: In a prospective study 24 eyes with diabetic macular edema were treated with an intravitreal injection of 4 mg of triamcinolone acetonide. MAIN OUTCOME MEASURES: Best-corrected logMAR visual acuity and optical coherence tomography were performed at baseline and 3 months after the treatment. RESULTS: At baseline the average foveal thickness was 462±154 μm(95%confidence interval, 397-527μm) and at 3 months 257 ±114 μm (95%confidence interval, 209-305 μm) (P .0001). The best-corrected logMAR average visual acuity was 60.5±10.5 (95%confidence interval, 56.0-65.0) ETDRS letters at baseline compared with 65.5±11.1 (95%confidence interval, 60.8-70.1) 3 months after the injection (P=.0001). There was no correlation between the improvement in visual acuity and the reduction of foveal thickness (r=0.054, P=.8), but there was a correlation between reduction in foveal thickness and the age of the patients (r=0.53, P=.008). CONCLUSION: A single injection of 4 mg of intravitreal triamcinolone acetonide effectively reduces the foveal thickness in diabetic macular edema and improves visual acuity, but there does not appear to be a strong correlation between the reduction of foveal thickness and the improvement in visual acuity.

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Papers

Relation between reduction of foveal thickness and visual acuity in diabetic macular edema treated with intravitreal triamcinolone