OUTCOME OF PROLIFERATIVE DIABETIC RETINOPATHY AT KIKUYU EYE UNIT AFTER TREATMENT WITH PANRETINAL PHOTOCOAGULATION ALONE AND PANRETINAL PHOTOCOAGULATION COMBINED WITHBEVACIZUMAB: A RETROSPECTIVE AUDIT”
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Status: 
Ongoing

ABSTRACT

 

Background: The gold standard for treating proliferative diabetic retinopathy has been pan-retinal photocoagulation.  In order to hasten the therapeutic effects and reduce macular oedema, pan retinal photocoagulation (PRP) augmented with intravitreal bevacizumab is currently being tried.

 

Methodology: This was a hospital based retrospective audit conducted from January 2009 to November 2011, at Kikuyu Eye Unit in Kenya, to evaluate the outcomes of treating PDR with PRP alone or in combination with bevacizumab.

 

The outcome measure was improvement or worsening of PDR in terms of resolution of neovascularisations, vitreous haemorrhage; change in Snellens visual acuity; development of tractional retinal detachment, macula holes and retinal ischaemia; and the need for further treatment.

 

Data was collected retrospectively using a semi-structured questionnaire and analysed with EpiInfo version 3.5.3.

Results: Medical records of 90 eyes of 89 patients with PDR were reviewed. 48(53%) treated with PRP only and 42(47%) with PRP+ intra-vitreous Bevacizumab (IVB). All eyes with neovascularisations demonstrated complete regression on fundus examination after treatment with PRP+IVB at 6week whereas of those treated with PRP only, 22/33(67%), had resolved neovascularisations at 3 months follow up period.

Of the 30 eyes that had VH at baseline, 32% (6/19) was reported as resolved after PRP+IVB at 6 weeks whereas only 9% (1/11) was reported as resolved after PRP only treatment at 3-4months.

Vitreous haemorrhage developed in 14% (5/37) of the eyes that had no Vitreous haemorrhage at baseline, after treatment with PRP only. None of the eyes with no Vitreous haemorrhage at baseline treated with PRP augmented with bevacizumab developed it post treatment.

TRD was seen in 36% (15/42) and 17% (8/48) after PRP+ IVB and PRP only treatment respectively at the follow up visit.  Macular holes were seen in 5% (2/42) of eyes after PRP+IVB treatment whereas none developed after PRP only. Retinal ischaemic macula developed in 7% (3/42) and 2% (1/48) of the eyes after treatment with PRP+IVB and PRP only respectively.

For eyes treated with PRP only and PRP+IVB, 25/48(45%) and 19/42(52%) required further treatment respectively. Of the 44 eyes that needed further treatment, the majority 16/19(84%) initially treated with PRP IVB, needed it due to tractional related complications, compared with 8/25(32%) in the PRP only group. Further treatment for persistent neovascularisations was needed in 8/48(17%) and 0/42(0%) for PRP only and PRP+IVB respectively, whereas for vitreous haemorrhage, it was 9/48(19%) and 3/42(7%) respectively.

The most common further treatment modality given was vitrectomy + delamination and retinal detachment surgery, performed in 75% (6/8) of the eyes that eventually got further treatment after PRP+IVB. Only 14% (2/15) were treated with this after PRP. However the most common retreatment modality after PRP was either additional PRP only or IVB only seen in 80% (12/15). Considering the overall sample which underwent either treatment modality, 4.2% (2/48) and 14.3% (6/42) underwent vitrectomy +/- delamination and Retinal detachment surgery after PRP only and PRP+IVB respectively.

Overall visual acuity analysis showed that VA worsened in 5/48 (10.4%) and 11/42 (26.2%) after PRP only and PRP+IVB respectively. However, visual acuity remained stable or improved in 43/48 (89.6%) and 31/42 (73.8%) after PRP only and PRP+IVB respectively.

Conclusion: PRP has good outcomes of PDR in terms of reduced rates of progression to TRD, development of macula holes and development of ischaemia as well as stabilisation of visual acuity. PRP augmented with bevacizumab has shown good rates of regression of neovascularisations and resolution of coexisting vitreous haemorrhage. 

Recommendation: A randomized clinical trial   is needed to determine the best way of managing PDR, taking into consideration the advanced stage of PDR at which the majority of patients present for treatment. Intravitreal Bevacizumab should be administered with caution and close follow up, only in centres with the ability to perform Pars plana Vitrectomy, due to the higher rates of TRD seen with its administration

 

Collaborators: 

DR ZIPPORAH PHIRI

DR MARGRET NJUGUNA

DR KAHAKI KIMANI

DR AMOS KIBATA

DR SHAFFIQUE JAFFERJI

PCEA KIKUYU HOSPITAL EYE UNIT

Start Month: 
January
Start Year: 
2012
End Month: 
3
End Year: 
2013