Ratimir Lazić

Treatment of anti-vascular endothelial growth factor-resistant diabetic macular edema with dexamethasone intravitreal implant.

Purpose: To investigate the efficiency of intravitreal dexamethasone implant in patients with chronic diabetic macular edema nonresponsive to three consecutive monthly intravitreal injections of anti–vascular endothelial growth factor administered previously. Methods: Fifteen patients (16 eyes) were included in this 4-month prospective clinical trial. Main observed outcomes were the changes between initial and monthly visits in best-corrected visual acuity, central foveal thickness, and intraocular pressure (IOP). Patients included had central foveal thickness of >225 &mgr;m (measured by optical coherence tomography) and were nonresponsive to previously administered 3 consecutive monthly intravitreal injections of 1.25-mg bevacizumab. Administration of intravitreal dexamethasone implant was performed at baseline, and patients were followed-up monthly. Results: Statistically significant changes from baseline were observed in best-corrected visual acuity (at 2 months), central foveal thickness (at 1, 2, and 3 months), and IOP (at Months 1, 2, and 3) as follows: mean best-corrected visual acuity significantly increased from 0.29 Snellen lines at baseline to 0.39 lines after 2 months (P = 0.0381). At Months 1, 2, and 3, the mean central foveal thickness significantly decreased, from 462 &mgr;m at baseline, to 366 &mgr;m (P = 0.0343), 346 &mgr;m (P = 0.0288), and 355 &mgr;m (P = 0.0370), respectively. When compared with baseline IOP of 15.38 mmHg (12–19 mmHg), IOP increased significantly at Months 1, 2, and 3: 18.93 mmHg (range, 16–24 mmHg; P = 0.0003), 19.5 mmHg (range, 16–27 mmHg; P = 0.0003), and 17.5 mmHg (range, 15–21 mmHg; P = 0.0048), respectively. Conclusion: Dexamethasone intravitreal implant may present an alternative option in the treatment of chronic diabetic macular edema nonresponsive to three consecutive monthly bevacizumab injections administered previously. However, IOP measures were only slightly increased. It seems that the effect of dexamethasone may last till 4 months after initial injection.

Potential beneficial role of sevelamer hydrochloride in diabetic retinopathy

Patients with chronic kidney disease (CKD) experience co-morbid illnesses, including cardiovascular disease and retinopathy. Sevelamer hydrochloride (Renagel®); a non-calcium phosphate binder reduces coronary artery and aortic calcification as compared to calcium containing phosphate binders and additionally effects inflammatory biomarkers such as C-reactive protein (CRP), and lowers LDL cholesterol in patients with CKD. Since retinopathy is proven to be associated with increased coronary calcification, shared pathophysiological processes may contribute to both microvascular and macrovascular disease. We here suggest three different mechanisms of possible sevelamers influence on the retinopathy: (1) by direct effect on the microvasculature through lowering CRP and LDL, involved in endothelial dysfunction and atherogenesis, (2) indirectly by attenuation of vascular calcification of aorta and carotid internal artery, it reduces ischaemia and improves circulation in the opthalmic artery and hence postponing retinopathy, (3) through hypertension by reducing atherosclerosis and calcification of carotid arteries, sevelamer decreases stiffness and intima-media wall thickness, therefore lowering blood pressure, which is well known to increase progression of diabetic retinopathy. So far no studies have yet been published on the direct influence of sevelamer on the retinopathy which we believe has good theoretical background. With its combined macrovascular and microvascular effect, sevelamer could potentially postpone and/or decrease retinopathy in diabetic patients with hypertension, and that are on hemodialysis or even predialysis patients.

Treatment of Neovascular Age Related Macular Degeneration

Until the end of the last century, no intervention could alter the natural history of the disease. Only in the last few decades, the retina specialists began to intervene in order to minimize the visual loss in those patients. Last ten years have been especially exciting as the new treatment modalities emerged and for the first time we could not only halt the progression of the deterioration, but rather improve vision in some patients.

Autologous Neurosensory Retinal Free Flap Treatment for a Large Macular Hole

A patient presented with a large chronic macular hole (MH) of 700 μm. Best-corrected visual acuity (BCVA) was 20/200. Since the MHs edges were attached and stiff, an autologous neurosensory retinal flap was harvested and placed into the MH to close it. Perfluoro-n-octane heavy liquid (PFC) was instilled over the flap and exchanged with silicone oil (1,000 cs). Seven days postoperatively, the MH was closed, with a BCVA of 20/80 that improved to 20/60 at months 1 and 3. Optical coherence tomography and angiography showed patch incorporation with fovea formation and normal circulation. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e89-e92.].