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Graefe's Archive For Clinical and... Feb 2023To review the literature on the application of bioinformatics and artificial intelligence (AI) for analysis of biofluid biomarkers in retinal vein occlusion (RVO) and... (Review)
Review
PURPOSE
To review the literature on the application of bioinformatics and artificial intelligence (AI) for analysis of biofluid biomarkers in retinal vein occlusion (RVO) and their potential utility in clinical decision-making.
METHODS
We systematically searched MEDLINE, Embase, Cochrane, and Web of Science databases for articles reporting on AI or bioinformatics in RVO involving biofluids from inception to August 2021. Simple AI was categorized as logistics regressions of any type. Risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Tools.
RESULTS
Among 10,264 studies screened, 14 eligible articles, encompassing 578 RVO patients, met the inclusion criteria. The use and reporting of AI and bioinformatics was heterogenous. Four articles performed proteomic analyses, two of which integrated AI tools such as discriminant analysis, probabilistic clustering, and string pathway analysis. A metabolomic study used AI tools for clustering, classification, and predictive modeling such as orthogonal partial least squares discriminant analysis. However, most studies used simple AI (n = 9). Vitreous humor sample levels of interleukin-6 (IL-6), vascular endothelial growth factor (VEGF), and aqueous humor levels of intercellular adhesion molecule-1 and IL-8 were implicated in the pathogenesis of branch RVO with macular edema. IL-6 and VEGF may predict visual acuity after intravitreal injections or vitrectomy, respectively. Metabolomics and Kyoto Encyclopedia of Genes and Genomes enrichment analysis identified the metabolic signature of central RVO to be related to lower aqueous humor concentration of carbohydrates and amino acids. Risk of bias was low or moderate for included studies.
CONCLUSION
Bioinformatics has applications for analysis of proteomics and metabolomics present in biofluids in RVO with AI for clinical decision-making and advancing the future of RVO precision medicine. However, multiple limitations such as simple AI use, small sample volume, inconsistent feasibility of office-based sampling, lack of longitudinal follow-up, lack of sampling before and after RVO, and lack of healthy controls must be addressed in future studies.
Topics: Humans; Angiogenesis Inhibitors; Artificial Intelligence; Computational Biology; Interleukin-6; Intravitreal Injections; Proteomics; Retinal Diseases; Retinal Vein Occlusion; Vascular Endothelial Growth Factor A
PubMed: 35925451
DOI: 10.1007/s00417-022-05769-5 -
Forensic Science International Jan 2020Body fluid analysis has played a crucial role in ascertaining various characteristics and has greatly aided in reconstructing events during crime scene investigation. It...
Body fluid analysis has played a crucial role in ascertaining various characteristics and has greatly aided in reconstructing events during crime scene investigation. It is often presumed that crimes that involve violence and mental disturbances such as murder or sexual assault provide good sources of body fluids such as blood, saliva, semen, vaginal secretions, urine and tears. Tears are secreted in response to any emotional or stressful situations and may be found deposited on surfaces such as bedding, tissue paper or cloth. In the absence of the commonly noted body fluids such as blood or saliva, tears can play an important role that can lead to personal identification by examining the biochemistry and molecular aspects to obtain a full DNA profile. Additionally, identification of an individual may be done by carefully observing certain unique eye characteristics such as heterochromia which is highly individualistic. Characteristics of eyewear such as spectacles and contact lenses have unique properties and prescription criteria for correcting an individual's eyesight that can provide vital clues in understanding the visual ability of an individual. In crime scene investigation, the presence or absence of eyewear provides immense evidentiary value that has greatly aided in solving cases such as Janet Abaroa's Murder. This paper provides a systematic review of the possibility of using tears and eyewear for the purpose of forensic investigation and to statistically support the inferences with prescription databases which may be initiated across different populations. Forensic Optometry is yet to get streamlined along with the routinely followed investigative techniques and scientifically explored although no standard protocols exist to analyse eyewear. The use of behavioural optometry is gaining attention in the context of driving laws of different countries and is a simple but powerful indicator of abnormal behaviour. It is speculated that the last seen image referred to as an 'Optogram' of an individual may be captured in the retina since our eyes functions like a camera. Although this claim is considerably unexplored, it is quite possible that the last seen image of a criminal, objects or a place may be noted that can positively help in linking individuals at the scene of crime or identify the primary crime location. In this review, the potential for new insights into the analysis of tears, eye and eyewear characteristics have been explored.
Topics: Contact Lenses; DNA; DNA Fingerprinting; Databases, Factual; Epithelium, Corneal; Eye; Eye Movements; Eyeglasses; Forensic Sciences; Humans; Postmortem Changes; Prescriptions; Specimen Handling; Substance-Related Disorders; Tears; Vitreous Body
PubMed: 31785512
DOI: 10.1016/j.forsciint.2019.110055 -
Danish Medical Journal May 2016Non-physicians such as nurses are trained to give injections into the vitreous body of the eye to meet the increasing demand for intravitreal therapy with vascular... (Review)
Review
INTRODUCTION
Non-physicians such as nurses are trained to give injections into the vitreous body of the eye to meet the increasing demand for intravitreal therapy with vascular endothelial growth factor inhibitors against common eye diseases, e.g. age-related macular degeneration and diabetic retinopathy. We systematically reviewed the existing literature to provide an overview of the experiences in this transformational process.
METHODS
We searched for literature on 22 September 2015 using PubMed, Embase, the Cochrane Library, CINAHL and the Web of Science. Eligible studies had to address any outcome based on non-physician delivered intravitreal therapy regardless of the study design. Being non-physician was defined as the injecting personnel not being a physician, but no further restrictions were made.
RESULTS
Five studies were included with a total of 31,303 injections having been performed by 16 nurses. The studies found that having nurses perform the intravitreal injections produced to a short-term capacity improvement and liberated physicians for other clinical work. Training was provided through courses and direct supervision. The rates of endophthalmitis were 0-0.40‰, which is comparable to reported rates when the intravitreal therapy is given by physicians.
CONCLUSION
Non-physician delivered intravitreal therapy seems feasible and safe.
Topics: Chronic Disease; Delegation, Professional; Humans; Intravitreal Injections; Ophthalmology; Retinal Diseases; Vascular Endothelial Growth Factors
PubMed: 27127016
DOI: No ID Found -
International Journal of Legal Medicine Sep 2023Post-mortem interval (PMI) is the cornerstone of the forensic field to investigate. The examination technique by seeing the changes in the body such as algor mortis,... (Review)
Review
BACKGROUND
Post-mortem interval (PMI) is the cornerstone of the forensic field to investigate. The examination technique by seeing the changes in the body such as algor mortis, rigor mortis, and livor mortis is a traditional technique in which accuracy is influenced by many factors. A biomolecular technique that uses microRNA (miRNA) biomarkers is developing because miRNA has good stability than other RNA, so it meets the requirements to be used for PMI estimation.
METHOD
Following the PRISMA guidelines, journals were taken from 5 databases: Scopus, Science Direct, PubMed, Embase, and Springer. The review was carried out by two people. Inclusion criteria in this review are original research, published in the last 10 years, discussing miRNA as a biomarker for PMI estimation, and free full access. While exclusion criteria are not original research and not using English.
RESULT
Eighteen journals were reviewed in this study. The study was conducted using test animals (rats) and human samples with tissue sources taken from the liver, skeletal muscle, blood, bone, heart, skin, saliva, semen, brain, lung, vitreous humor, spleen, and kidney. miRNA expression levels after death showed different results based on miRNA target, tissue source, and others.
DISCUSSION
The results of each study are different due to the use of different types of miRNA targets and tissue sources. miRNA has great potential to estimate PMI in forensic science, but it is necessary to control the influencing factors to obtain an accurate conclusion.
Topics: Humans; Animals; Rats; MicroRNAs; Autopsy; Postmortem Changes; Forensic Medicine; Forensic Sciences; Biomarkers
PubMed: 37253884
DOI: 10.1007/s00414-023-03015-z -
Acta Ophthalmologica Aug 2022The pathophysiology of diabetic macular oedema (DME) remains poorly understood. Proteomic analysis of the vitreous using mass spectrometry (MS) can potentially identify... (Review)
Review
The pathophysiology of diabetic macular oedema (DME) remains poorly understood. Proteomic analysis of the vitreous using mass spectrometry (MS) can potentially identify proteins of pathophysiological importance. In this systematic review, we summarize the available evidence on protein changes in DME detected by MS. We systematically searched 13 literature databases on 19 September 2021. Eligible studies were defined as those using samples from human eyes with DME analysed with MS. Two authors assessed the studies for eligibility, extracted data and evaluated risk of bias independently. Six eligible studies were identified. All were designed in a cross-sectional fashion comparing results to either a non-diabetic control group or a control group without DME. A total of 62 eyes from 60 patients contributed as study group and 48 eyes from 48 patients served as control group. Proteomic analyses revealed significant differences in the vitreous protein levels in patients with DME when compared with controls. Three studies or more identified increased contents of apolipoprotein A-I, apolipoprotein A-II, apolipoprotein A-IV, apolipoprotein C-III, gelsolin, pigment epithelium-derived factor, serum albumin, transthyretin, vitamin D-binding protein in DME. Two studies found increased levels of complement factors B and C3. Protein changes reproduced across the studies suggested that DME was associated with retinal lipid accumulation, angiogenesis, retinal protective mechanisms, inflammation and complement activation. Proteome studies support the multifactorial pathogenesis of DME as proteins with highly different biological functions are regulated in DME. An important number of proteins differ, provide pathophysiological insight and suggest the direction for future research.
Topics: Cross-Sectional Studies; Diabetes Mellitus; Diabetic Retinopathy; Humans; Macular Edema; Proteomics; Vitreous Body
PubMed: 35507578
DOI: 10.1111/aos.15168 -
Acta Ophthalmologica Dec 2020Asteroid hyalosis is defined by the presence of white, snowball-like non-crystalline vitreous opacities that move with the vitreous and appear to be anchored to its... (Meta-Analysis)
Meta-Analysis
Asteroid hyalosis is defined by the presence of white, snowball-like non-crystalline vitreous opacities that move with the vitreous and appear to be anchored to its matrix. Asteroid hyalosis commonly occurs in the absence of other identifiable ocular abnormalities and is usually an incidental finding. The vitreous opacities are usually invisible to the patient and asymptomatic, but asteroid hyalosis can be a significant obstacle to the examination of the fundus. The prevalence increases dramatically with age. The aetiology is unknown. We systematically reviewed the literature for epidemiological data, qualitatively reviewed available studies, conducted meta-analyses with demographical stratifications, evaluated temporal changes and estimated the future prevalence using forecasting analysis. Nine eligible studies were identified with data on 104 569 individuals. The overall population prevalence of asteroid hyalosis was 0.75% (95% confidence interval: 0.39-1.21%); however, the prevalence was highly age-dependent, ranging from 0.27% (95% confidence interval 0.12-0.49%) in individuals aged 0-39 years and gradually increasing to 3.07% (95% confidence interval 1.90-4.50%) in individuals aged ≥80 years. Male gender was an additional risk factor (odds ratio 1.80, 95% confidence interval 1.32-2.45, p = 0.00017). The estimated global prevalence was 10.7 million subjects in year 1950, which is expected to increase to 41.5 million in year 2020 and 91.2 million in year 2100. The prevalence of asteroid hyalosis is relevant because it impacts the utility of diagnostic strategies, especially screening methods for conditions such as diabetic retinopathy.
Topics: Eye Diseases; Global Health; Humans; Prevalence; Vitreous Body
PubMed: 32410360
DOI: 10.1111/aos.14465 -
JAMA Network Open Feb 2020Diagnosing posterior chamber ocular abnormalities typically requires specialist assessment. Point-of-care ultrasonography (POCUS) performed by nonspecialists, if... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Diagnosing posterior chamber ocular abnormalities typically requires specialist assessment. Point-of-care ultrasonography (POCUS) performed by nonspecialists, if accurate, could negate the need for urgent ophthalmologist evaluation.
OBJECTIVE
This meta-analysis sought to define the diagnostic test characteristics of emergency practitioner-performed ocular POCUS to diagnose multiple posterior chamber abnormalities in adults.
DATA SOURCES
PubMed (OVID), MEDLINE, EMBASE, Cochrane, CINAHL, and SCOPUS were searched from inception through June 2019 without restrictions. Conference abstracts and trial registries were also searched. Bibliographies of included studies and relevant reviews were manually searched, and experts in the field were queried.
STUDY SELECTION
Included studies compared ocular POCUS performed by emergency practitioners with a reference standard of ophthalmologist evaluation. Pediatric studies were excluded. All 116 studies identified during abstract screening as potentially relevant underwent full-text review by multiple authors, and 9 studies were included.
DATA EXTRACTION AND SYNTHESIS
In accordance with PRISMA guidelines, multiple authors extracted data from included studies. Results were meta-analyzed for each diagnosis using a bivariate random-effects model. Data analysis was performed in July 2019.
MAIN OUTCOMES AND MEASURES
The outcomes of interest were diagnostic test characteristics of ocular POCUS for the following diagnoses: retinal detachment, vitreous hemorrhage, vitreous detachment, intraocular foreign body, globe rupture, and lens dislocation.
RESULTS
Nine studies (1189 eyes) were included. All studies evaluated retinal detachment, but up to 5 studies assessed each of the other diagnoses of interest. For retinal detachment, sensitivity was 0.94 (95% CI, 0.88-0.97) and specificity was 0.94 (95% CI, 0.85-0.98). Sensitivity and specificity were 0.90 (95% CI, 0.65-0.98) and 0.92 (95% CI, 0.75-0.98), respectively, for vitreous hemorrhage and were 0.67 (95% CI, 0.51-0.81) and 0.89 (95% CI, 0.53-0.98), respectively, for vitreous detachment. Sensitivity and specificity were high for lens dislocation (0.97 [95% CI, 0.83-0.99] and 0.99 [95% CI, 0.97-1.00]), intraocular foreign body (1.00 [95% CI, 0.81-1.00] and 0.99 [95% CI, 0.99-1.00]), and globe rupture (1.00 [95% CI, 0.63-1.00] and 0.99 [95% CI, 0.99-1.00]). Results were generally unchanged in sensitivity analyses of studies with low risk of bias.
CONCLUSIONS AND RELEVANCE
This study suggests that emergency practitioner-performed ocular POCUS is an accurate test to assess for retinal detachment in adults. Its utility in diagnosing other posterior chamber abnormalities is promising but needs further study.
Topics: Eye Diseases; Humans; Point-of-Care Systems; Posterior Eye Segment; Retinal Detachment; Ultrasonography
PubMed: 32074291
DOI: 10.1001/jamanetworkopen.2019.21460 -
The Cochrane Database of Systematic... Feb 2017Endophthalmitis refers to severe infection within the eye that involves the aqueous humor or vitreous humor, or both, and threatens vision. Most cases of endophthalmitis... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Endophthalmitis refers to severe infection within the eye that involves the aqueous humor or vitreous humor, or both, and threatens vision. Most cases of endophthalmitis are exogenous (i.e. due to inoculation of organisms from an outside source), and most exogenous endophthalmitis is acute and occurs after an intraocular procedure. The mainstay of treatment is emergent administration of broad-spectrum intravitreous antibiotics. Due to their anti-inflammatory effects, steroids in conjunction with antibiotics have been proposed to be beneficial in endophthalmitis management.
OBJECTIVES
To assess the effects of antibiotics combined with steroids versus antibiotics alone for the treatment of acute endophthalmitis following intraocular surgery or intravitreous injection.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 11), MEDLINE Ovid (1946 to 8 December 2016), Embase Ovid (1980 to 8 December 2016), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to 8 December 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch); searched 8 December 2016, ClinicalTrials.gov (www.clinicaltrials.gov); searched 8 December 2016, and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 8 December 2016. We did not use any date or language restrictions in the electronic searches for trials.
SELECTION CRITERIA
We included randomized controlled trials comparing the effectiveness of adjunctive steroids with antibiotics alone in the management of acute, clinically diagnosed endophthalmitis following intraocular surgery or intravitreous injection. We excluded trials with participants with endogenous endophthalmitis unless outcomes were reported by source of infection. We imposed no restrictions on the method or order of administration, dose, frequency, or duration of antibiotics and steroids.
DATA COLLECTION AND ANALYSIS
Two review authors independently screened the search results, assessed risk of bias, and extracted data using methods expected by Cochrane. We contacted study authors to try to obtain missing information or information to clarify risk of bias. We conducted a meta-analysis for any outcomes that were reported by at least two studies. Outcomes reported from single studies were summarized in the text. We assessed the certainty of the evidence using GRADE.
MAIN RESULTS
We included three trials with a total of 95 randomized participants in this review and identified one ongoing trial. The studies were conducted in South Africa, India, and the Netherlands. Out of the 92 analyzed participants, 91 participants were diagnosed with endophthalmitis following cataract surgery. In the remaining participant, endophthalmitis was attributable to penetrating keratoplasty. All studies used intravitreous dexamethasone for adjunctive steroid therapy and a combination of two intravitreous antibiotics that provided gram-positive and gram-negative coverage for the antibiotic therapy. We judged one trial to be at overall low risk of bias and two studies to be at overall unclear risk of bias due to lack of reporting of study methods. None of the three trials had been registered in a clinical trial register.While none of the included studies reported the primary outcome of complete resolution of endophthalmitis as defined in our protocol, one study reported combined anatomical and functional success (i.e. proportion of participants with intraocular pressure of at least 5 mmHg and visual acuity of at least 6/120). Very low-certainty evidence suggested no difference in combined success when comparing adjunctive steroid antibiotics alone (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.80 to 1.45; 32 participants). Low-certainty evidence from two studies showed that a higher proportion of participants who received adjunctive dexamethasone had a good visual outcome (Snellen visual acuity 6/6 to 6/18) at three months compared with those in the antibiotics-alone group (RR 1.95, 95% CI 1.05 to 3.60; 60 participants). Similarly, low-certainty evidence from one study suggested that more participants in the dexamethasone group had a good visual outcome at 12 months compared to those who did not receive dexamethasone (RR 2.00, 95% CI 0.98 to 4.08; 28 participants). Investigators of one study reported improvement in visual acuity, but we could not estimate the effect of adjunctive steroid therapy because the study investigators did not provide standard deviations or standard errors. Two studies reported adverse events (retinal detachment, hypotony, proliferative vitreoretinopathy, and seclusion of pupil). The total numbers of adverse events were 8 out of 30 (26.7%) for those who received dexamethasone versus 6 out of 30 (20.0%) for those who did not. We could only perform a pooled analysis for the occurrence of retinal detachment; any difference between the two treatment groups was uncertain (RR 1.57, 95% CI 0.50 to 4.90; 60 participants) (very low-certainty evidence). No study reported intraocular pressure or cost outcomes.
AUTHORS' CONCLUSIONS
Current evidence on the effectiveness of adjunctive steroid therapy versus antibiotics alone in the management of acute endophthalmitis after intraocular surgery is inadequate. We found no studies that had enrolled cases of acute endophthalmitis following intravitreous injection. A combined analysis of two studies suggests adjunctive steroids may provide a higher probability of having a good visual outcome at three months than not using adjunctive steroids. However, considering that most of the confidence intervals crossed the null and that this review was limited in scope and applicability to clinical practice, it is not possible to conclude whether the use adjunctive steroids is effective at this time. Any future trials should examine whether adjunctive steroids may be useful in certain clinical settings such as type of causative organism or etiology. These studies should include outcomes that take patient's symptoms and clinical examination into account, report outcomes in a uniform and consistent manner, and follow up at short- and long-term intervals.
Topics: Acute Disease; Anti-Bacterial Agents; Cataract Extraction; Chemotherapy, Adjuvant; Dexamethasone; Endophthalmitis; Glucocorticoids; Humans; Intravitreal Injections; Keratoplasty, Penetrating; Postoperative Complications
PubMed: 28225198
DOI: 10.1002/14651858.CD012131.pub2 -
International Ophthalmology Mar 2024It is commonly accepted that phacoemulsification surgery is a risk factor for the development of posterior vitreous detachment (PVD) and may accelerate the process. This...
PURPOSE
It is commonly accepted that phacoemulsification surgery is a risk factor for the development of posterior vitreous detachment (PVD) and may accelerate the process. This is an important consideration particularly in cases involving young patients who pre-operatively have no PVD, given the increased risk of retinal tears and detachments.
METHODS
A comprehensive literature search was conducted to identify studies reporting incidence of PVD post-uncomplicated phacoemulsification surgery. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was used for search strategy. Of 3071 titles, 7 studies met the inclusion criteria; The outcomes measured were PVD occurrence by (1) time, (2) type, (3) age, (4) gender and (5) axial length, with all statistical analysis performed using Review Manager.
RESULTS
A total of 2034 eyes were included for analysis with a mean follow-up time of 28.3 months. 33.3% of patients developed a PVD, either partial or complete, with rates increasing in a time dependent manner. No significant difference was noted in sub-group analysis by age, gender or axial length.
CONCLUSIONS
The results from our systematic review show that uncomplicated phacoemulsification accelerates the physiological process of PVD development. Pre-operative evaluation of the vitreoretinal interface should be performed with careful post-operative follow-up advised in those without a pre-existing PVD.
Topics: Humans; Vitreous Detachment; Phacoemulsification; Prospective Studies; Vitreous Body; Retinal Perforations; Retinal Detachment
PubMed: 38512501
DOI: 10.1007/s10792-024-03091-z -
The Cochrane Database of Systematic... Nov 2020Diabetic macular edema (DME) is secondary to leakage from diseased retinal capillaries with thickening of central retina, and is an important cause of poor central... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Diabetic macular edema (DME) is secondary to leakage from diseased retinal capillaries with thickening of central retina, and is an important cause of poor central visual acuity in people with diabetic retinopathy. Intravitreal steroids have been used to reduce retinal thickness and improve vision in people with DME.
OBJECTIVES
To assess the effectiveness and safety of intravitreal steroid therapy compared with other treatments for DME.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase on 15 May, 2019. We also searched reference lists, Science Citation Index, conference proceedings, and relevant trial registers. We conducted a top up search on 21 October, 2020.
SELECTION CRITERIA
We included randomized controlled trials that evaluated any type of intravitreal steroids as monotherapy against any other intervention (e.g. observation, laser photocoagulation, anti-vascular endothelial growth factor (antiVEGF) for DME.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed study eligibility and risk of bias and extracted data. Where appropriate, we performed meta-analyses.
MAIN RESULTS
We included 10 trials (4348 participants, 4505 eyes). These trials compared intravitreal steroid therapies versus other treatments, including intravitreal antiVEGF therapy, laser photocoagulation, and sham injection. Most trials had an overall unclear or high risk of bias. One trial (701 eyes ) compared intravitreal dexamethasone implant 0.7mg with sham. We found moderate-certainty evidence that dexamethasone leads to slightly more improvement of visual acuity than sham at 12 months (mean difference [MD] -0.08 logMAR, 95% confidence interval [CI] -0.12 to -0.05 logMAR). Regarding improvement of three or more lines of visual acuity, there was moderate-certainty evidence in favor of dexamethasone at 12 months, but the CI covered the null value (risk ratio (RR) 1.39, 95% CI 0.91 to 2.12). Regarding adverse events, dexamethasone increased by about four times the risk of cataract progression and the risk of using intraocular pressure (IOP)-lowering medications compared to sham (RR 3.89, 95% CI 2.75 to 5.50 and RR 4.54, 95% CI 3.19 to 6.46, respectively; moderate-certainty evidence); about 4 in 10 participants treated with dexamethasone needed IOP-lowering medications. Two trials (451 eyes) compared intravitreal dexamethasone implant 0.7mg with intravitreal antiVEGF (bevacizumab and ranibizumab). There was moderate-certainty evidence that visual acuity improved slightly less with dexamethasone compared with antiVEGF at 12 months (MD 0.07 logMAR, 95% CI 0.04 to 0.09 logMAR; 2 trials; 451 participants/eyes; I = 0%). The RR of gain of three or more lines of visual acuity was inconsistent between trials, with one trial finding no evidence of a difference between dexamethasone and bevacizumab at 12 months (RR 0.99, 95% CI 0.70 to 1.40; 1 trial; 88 eyes), and the other, larger trial finding the chances of vision gain were half with dexamethasone compared with ranibizumab (RR 0.50, 95% CI 0.32 to 0.79; 1 trial; 432 participants). The certainty of evidence was low. Cataract progression and the need for IOP-lowering medications increased more than 4 times with dexamethasone implant compared to antiVEGF (moderate-certainty evidence). One trial (560 eyes) compared intravitreal fluocinolone implant 0.19mg with sham. There was moderate-certainty evidence that visual acuity improved slightly more with fluocinolone at 12 months (MD -0.04 logMAR, 95% CI -0.06 to -0.01 logMAR). There was moderate-certainty evidence that an improvement in visual acuity of three or more lines was more common with fluocinolone than with sham at 12 months (RR 1.79, 95% CI 1.16 to 2.78). Fluocinolone also increased the risk of cataract progression (RR 1.63, 95% CI 1.35 to 1.97; participants = 335; moderate-certainty evidence), which occurred in about 8 in 10 participants, and the use of IOP-lowering medications (RR 2.72, 95% CI 1.87 to 3.98; participants = 558; moderate-certainty evidence), which were needed in 2 to 3 out of 10 participants. One small trial with 43 participants (69 eyes) compared intravitreal triamcinolone acetonide injection 4 mg with sham. There may be a benefit in visual acuity at 24 months (MD -0.11 logMAR, 95% CI -0.20 to -0.03 logMAR), but the certainty of evidence is low. Differences in adverse effects were poorly reported in this trial. Two trials (615 eyes) compared intravitreal triamcinolone acetonide injection 4mg with laser photocoagulation and reached discordant results. The smaller trial (31 eyes followed up to 9 months) found more visual acuity improvement with triamcinolone (MD -0.18 logMAR, 95% CI -0.29 to -0.07 logMAR), but a larger, multicenter trial (584 eyes, 12-month follow-up) found no evidence of a difference regarding change in visual acuity (MD 0.02 logMAR, 95% CI -0.03 to 0.07 logMAR) or gain of three or more lines of visual acuity (RR 0.85, 95% CI 0.55 to 1.30) (overall low-certainty evidence). Cataract progression was about three times more likely (RR 2.68, 95% CI 2.21 to 3.24; moderate-certainty evidence) and the use of IOP-lowering medications was about four times more likely (RR 3.92, 95% CI 2.59 to 5.96; participants = 627; studies = 2; I = 0%; moderate-certainty evidence) with triamcinolone. About 1 in 3 participants needed IOP-lowering medication. One small trial (30 eyes) compared intravitreal triamcinolone acetonide injection 4mg with intravitreal antiVEGF (bevacizumab or ranibizumab). Visual acuity may be worse with triamcinolone at 12 months (MD 0.18 logMAR, 95% CI 0.10 to 0.26 logMAR); the certainty of evidence is low. Adverse effects were poorly reported in this trial. Four trials reported data on pseudophakic participants, for whom cataract is not a concern. These trials found no decrease in visual acuity in the second treatment year due to cataract progression.
AUTHORS' CONCLUSIONS
Intravitreal steroids may improve vision in people with DME compared to sham or control. Effects were small, about one line of vision or less in most comparisons. More evidence is available for dexamethasone or fluocinolone implants when compared to sham, and the evidence is limited and inconsistent for the comparison of dexamethasone with antiVEGF treatment. Any benefits should be weighed against IOP elevation, the use of IOP-lowering medication and, in phakic patients, the progression of cataract. The need for glaucoma surgery is also increased, but remains rare.
Topics: Anti-Inflammatory Agents; Bevacizumab; Bias; Confidence Intervals; Dexamethasone; Diabetic Retinopathy; Drug Implants; Fluocinolone Acetonide; Glucocorticoids; Humans; Intravitreal Injections; Macular Edema; Randomized Controlled Trials as Topic; Ranibizumab; Steroids; Triamcinolone; Vascular Endothelial Growth Factor A; Visual Acuity; Vitreous Body
PubMed: 33206392
DOI: 10.1002/14651858.CD005656.pub3