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Standardization of laser treatment for diabetic retinopathy and other ocular fundus diseases

Panretinal photocoagulation (PRP) and macular photocoagulation (MPC) are the gold standard treatments for proliferative diabetic retinopathy (DR) and diabetic macular edema. With the development of equipment and technology advancement, photocoagulation has been gradually applied in many Eye Centers all over China. However, there are still several problems such as no standardized guideline and undesirable therapeutic effects. In this article we will summarize the indications and techniques of photocoagulation, and when and how to apply drug treatments for retinal diseases; aim at improving the criterion and clinical effects of photocoagulation.

The functional and morphological changes of macular after panretinal photocoagulation in the patients with diabetic retinopathy

Objective　To observe the functional and morphological changes of macular after panretinal photocoagulation（PRP）in the patients with diabetic retinopathy（DR）.Methods　A total of 57 eyes of 34 patients with DR undergoing PRP were enrolled in this prospective and self-reflection study. Comparatively analyze the changes of the best visual acuity（BCVA）, optical coherence tomography (OCT) and multi-focal electroretinography (mfERG) before PRP,20 days, 3 months and more than 9 months after PRP. Statistical analyses were performed by wilcoxon, chisquare, Dunnett-t, LSD-t tests and spearman related analyses. The changes of macular function and foveal retinal thickness before and after PRP were comparatively analyzed.Results　BCVA of all patients reduced at 9 months after PRP（P=0.022）.The amplitude density of mfERG P1 of ring 2 decreased at 20 days after PRP（P=0.039）,then recovered at 3 months and decreased again at 9 months（P=0.014）.The amplitude density of mfERG P1 of ring 3-5 decreased at 20 days,3 months and more than 9 months after PRP（20 days: ring 3: P=0.000,ring 4: P=0.001, ring 5: P=0.000；3 months: ring 3:P=0.000, ring 4: P=0.006, ring 5: P=0.001; more than 9 months: ring 3: P=0.000,ring 4: P=0.000, ring 5: P=0.000）. The amplitude density of mfERG P1 of ring 1 was significantly lower at 9 months after PRP（P=0.050）. The foveal retinal thickness increased at 20 days after PRP(P=0.007), then recovered at 3 months or later. Cystoid macular degeneration was found in 6 eyes(10.5%) at 20 days after PRP.Conclusions　After the treatment of PRP, there were some extend reduction of the macular function, a transient increase on foveal retinal thickness. Combined mfERG and OCT can be a comprehensively and objectively assessment of macular function and morphology.

Intravitreal injection with bevacizumab combined with extra panretinal photocoagulation for highrisk proliferative diabetic retinopathy

Objective　To evaluate the therapeutic effect of intravitreal injection with bevacizumab (Avastin) (IVB)combined with extra panretinal photocoagulation (E-PRP) for highrisk proliferative diabetic retinopathy (PDR).Methods　A total of 57 eyes of 53 patients with highrisk PDR underwent intravitreal injection combined with E-PRP. The examinations of vision acuity, intraocular pressure, iris fluorescein angiography (IFA),fundus photos and fundus fluorescein angiography (FFA) were performed on all of the patients before and 1,2,3,and 6 months after the treatment; the results of the examinations before and after the treatment were compared and analyzed.The average follow up was 6 months.Results　The mean visual acuity was (0.143plusmn;0.072) before the treatment and (0.218plusmn;0.128) 7 days after the tretment; the difference was significant (t=-7.940, Plt;0.05). The mean visual acuity 1,3,and 6 months after E-PRP (0.228plusmn;0.138, 0.223plusmn;0.125,0.220plusmn;0.134, respectively) differed much from that before IVB (Plt;0.05), but not so much from that after IVB (Pgt;0.05).The mean intraocular pressure of 21 eyes which had the neovascularization of pupil margin and iris surface before and 7 days after IVB was (26.632plusmn;2.629) and (19.316plusmn;3.092) mm Hg(1 mm Hg=0.133 kPa), respectively; the difference was significant (t=12.838, Plt;0.05) . The mean intraocular pressure 1,3,and 6 months after E-PRP was (16.947plusmn;2.345),(16.474plusmn;1.611), and (16.421plusmn;4.702) mm Hg, respectively, which differed much from that before and after IVB (Plt;0.05). Neovascularization on the disc and the retinae of 57 eyes were subsided partly, and a significant reduction or disappeared of the area of retinal neovascularization and the blood vessel leakage were observed 7 days after IVB. The neovascularization of pupil margin and iris surface of 21 eyes disappeared, and the IFA leakage decreased. The results of FFA 2 months after E-PRP showed that the one-off efficiency of E-PRP was 68.4%;12 eyes (21.1%) needed an additional laser, in which 6 eyes (10.5%) underwent vitreous surgery. Conclusion　IVB combined with E-PRP as a treatment for highrisk PDR may improve the regression of retinal neovascularization and the reduction of vascular permeability,and prevent or reduce the complications and improve the therapeutic effect.

Intravitreal triamcinolone injection combined with or without macular grid laser photocoagulation to treat macular edema

Objective To compare the efficacy of intravitreal triamcinolone(IVTA) injection and IVTA combined with macular laser grid photocoagulation（MLGP）to treat macular edema.Methods Consecutive 89 patients （109 eyes）diagnosed with macular edema by examinations of ocular fundus and optical coherence tomography (OCT).The visual acuity was hand moving-0.8 (0.19plusmn;0.13)；the intraocular pressure（IOP）ranged from 7 mm Hg to 21 mm Hg（1 mm Hg=0.133 kPa）and the average IOP was 13.78 mm Hg.All the patients received OCT and microperimetry examinations，the central macular thickness was （570plusmn;182）mu;m；the average light sensitivity was （5.07plusmn;3.94） dB and the fixation percentage was 70.67% within 4 deg;area around the macular fovea. All the patients received IVTA treatment，39 patients（48 eyes）further received MLGP 1 month later (IVTAMLGP group). The remaining 50 patients (61 eyes) without MLGP treatment was the IVTA group. Best corrected visual acuity (BCVA),IOP,lens,OCT and microprimetry examinations before and after IVTA (1,3,6,12 months) were followed and analyzed.Results　On the 12th months，the BCVA in IVTAMLGP and IVTA group was （0.41plusmn;0.20）、（0.24plusmn;0.19）respectively (P＜0.05)；the central macular thickness was （309plusmn;187） and （487plusmn;206） mu;m respectively（P＜0.05）；the mean light sensitivity of 4deg; central macular was （8.24plusmn;4.64）and（6.30plusmn;3.22）dB respectively（P＜0.05）；the fixation percentage was（87.01plusmn;19.70）% and（78.85plusmn;20.41）% respectively （P＜0.05）. During the followup recurrent macular edema was noticed in 28 eyes of IVTA group and 8 eyes of IVTAMLGP group.Conclusions　IVTA combined with MLG was more effective than IVTA to cure macular edema.

Therapeutic effect of laser photocoagulation on diabetic retinopathy at different stages

bjective　To observe the therapeutic effect of laser photocoagulation on diabetic retinopathy (DR)at different stages.Methods　A total of 534 eyes of 304 patients with DR diagnosed by fundus fluorescein angiography (FFA) were enrolled in this study. In the 534 eyes, 92 with nonproliferative DR (NPDR) had the bestcorrected visual acuity(BCVA) of 0.52plusmn;0.32,108 with preproliferative DR (PPDR) had the BCVA of 0.49plusmn;0.23,196 with early PDR had the BCVA of 0.20plusmn;0.31,and 138 with highrisk PDR had the BCVA of 0.17plusmn;0.22． According to the rules of ETDRS, retinal photocoagu1ation,pan retinal photocoagu1ation or extrapanretinal photocoagu1ation were performed on the paitents with NPDR,PPDR,and highrisk PDR,respectivelyThe patients were followed up for 10-18 months after the operations and the results of the examinations at the last time were regarded as the criteria for judgement. The examination of BCVA and ocular fundus and FFA were performed with the time interval of 3 months．The judgement for BCVA was(1)improved:improved ge;2 lines;(2) kept still: changed within 2 lines;(3)decreased:decreased ge;2 lines.And the effect on BCVA was positve when it was improved or kept still.The judgement for the therapeutic effect on DR was:retinal edeama was alleviated,leakage of hemorrhage was obsorbed,microaneurysm disappeared or decreased, neovascularization (NV) was relieved completely or partly,nonperfusion area disappeared or narrowed, and no new NV or nonperfusion area came into being. Results After the operations, BCVA in NPDR,PPDR and early PDR groups was improved or kept still in 73(79.3%),83(76.9%)，and 146 eyes (74.5%), respectively,without any statistical difference among these three groups（P＞0.05）.BCVA in highrisk PDR group was significant lower than that in the NPDR,PPDR,and early PDR groups (P＜0.05). The positive rate of therapeutic effect on DR was 89.1%,85.2%,82.7% in NPDR,PPDR,and early PDR groups, respectively without any statistical difference among the groups(P＞0.05). The positive rate of therapeutic effect on DR in highrisk PDR group was significant lower than that in the NPDR,PPDR,and early PDR groups(P＜0.05). Conclusion　The prognosis of DR at different stages after laser photocoagulation is different;timely and effective laser photocoagulation is important to prevent the development of the disease and decrease the blindness rate.

微脉冲激光治疗中心性浆液性脉络膜视网膜病变的临床疗效

Comparison of the efficacy of multi-point or single-point mode of 577 nm laser in the treatment of diabetic retinopathy

ObjectiveTo compare the therapeutic effects of 577 nm laser panretinal photocoagulation (PRP) between one time multi-point scanning mode and multiple time single-point mode in the treatment of eyes with non-proliferative diabetic retinopathy (NPDR). MethodsThis is a prospective controlled study from August 2013 to February 2014. A total of 29 patients (46 eyes) with clinically diagnosed severe NPDR were randomly divided into two groups including the treatment group (12 patients, 22 eyes) and the control group (17 patients, 224 eyes). The treatment group received one time PRP of multi-point scanning mode, and the control group received 3-4 times of PRP with single-point mode. In order to evaluate its efficacy, the best corrected visual acuity was measured before treatment, and 1 day, 1, 2, 6 and 12 months after treatment. The average threshold sensitivity, a/b-wave amplitude of flash ERG (F-ERG) in the 30°-60° visual field, and fundus fluorescein angiography (FFA) of the change were also compared between the 2 groups. The laser energy and the number of laser spots were compared, and the laser energy density was calculated. ResultsThe response rate was 86.4% and 79.2%, respectively in the treatment and control group, the difference was not statistically significant (χ2=0.414, P > 0.05). Compare to the pre-treatment measurement, the average threshold sensitivity, a/b-wave amplitude of F-ERG in the 30°-60° visual field were reduced at 1 day after treatment both in treatment and control group, the differences were statistically significant (P < 0.05). The average threshold sensitivity, a/b-wave amplitude of F-ERG were no difference between treatment and control group at 2m, 6m and 12m after treatment (P > 0.05). The average laser power, number of laser spots and energy density were (537.50±64.69) mW and (339.09±132.09) mW, (1934.32±426.38) points and (2061.42±375.49) points, (0.35±0.12) mW o ms/μm2 and (1.95±0.86) mW·ms/μm2 in the treatment group and the control group, respectively. The average laser power and energy density was statistically different between the 2 groups (P < 0.05), while the number of laser spots was no difference (P > 0.05). Conclusions577 nm multi-point scanning laser can complete the PRP at one time, and achieve the same therapeutic outcomes with the single-point mode which need several times to complete the PRP in the eyes with severe NPDR, and have lower energy density, and thus relative minor function damage.