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JAMA Aug 2007Diabetic retinopathy (DR) is the leading cause of blindness in the working-aged population in the United States. There are many new interventions for DR, but evidence to... (Review)
Review
CONTEXT
Diabetic retinopathy (DR) is the leading cause of blindness in the working-aged population in the United States. There are many new interventions for DR, but evidence to support their use is uncertain.
OBJECTIVE
To review the best evidence for primary and secondary intervention in the management of DR, including diabetic macular edema.
EVIDENCE ACQUISITION
Systematic review of all English-language articles, retrieved using a keyword search of MEDLINE (1966 through May 2007), EMBASE, Cochrane Collaboration, the Association for Research in Vision and Ophthalmology database, and the National Institutes of Health Clinical Trials Database, and followed by manual searches of reference lists of selected major review articles. All English-language randomized controlled trials (RCTs) with more than 12 months of follow-up and meta-analyses were included. Delphi consensus criteria were used to identify well-conducted studies.
EVIDENCE SYNTHESIS
Forty-four studies (including 3 meta-analyses) met the inclusion criteria. Tight glycemic and blood pressure control reduces the incidence and progression of DR. Pan-retinal laser photocoagulation reduces the risk of moderate and severe visual loss by 50% in patients with severe nonproliferative and proliferative retinopathy. Focal laser photocoagulation reduces the risk of moderate visual loss by 50% to 70% in eyes with macular edema. Early vitrectomy improves visual recovery in patients with proliferative retinopathy and severe vitreous hemorrhage. Intravitreal injections of steroids may be considered in eyes with persistent loss of vision when conventional treatment has failed. There is insufficient evidence for the efficacy or safety of lipid-lowering therapy, medical interventions, or antivascular endothelial growth factors on the incidence or progression of DR.
CONCLUSIONS
Tight glycemic and blood pressure control remains the cornerstone in the primary prevention of DR. Pan-retinal and focal retinal laser photocoagulation reduces the risk of visual loss in patients with severe DR and macular edema, respectively. There is currently insufficient evidence to recommend routine use of other treatments.
Topics: Angiogenesis Inhibitors; Antihypertensive Agents; Blood Glucose; Blood Pressure; Diabetic Retinopathy; Glucocorticoids; Humans; Hypolipidemic Agents; Laser Coagulation; Light Coagulation; Macular Edema; Vitrectomy
PubMed: 17712074
DOI: 10.1001/jama.298.8.902 -
Ophthalmology May 2007To assess the evidence on interventions to improve visual acuity (VA) and to treat macular edema and/or neovascularization secondary to branch retinal vein occlusion... (Review)
Review
TOPIC
To assess the evidence on interventions to improve visual acuity (VA) and to treat macular edema and/or neovascularization secondary to branch retinal vein occlusion (BRVO).
CLINICAL RELEVANCE
Branch retinal vein occlusion is the second most common retinal vascular disease.
METHODS/LITERATURE REVIEWED
English and non-English articles were retrieved using a keyword search of Medline (1966 onwards), Embase, the Cochrane Collaboration, the National Institute of Health Clinical Trials Database, and the Association for Research in Vision and Ophthalmology Annual Meeting Abstract Database (2003-2005). This was supplemented by hand searching references of review articles. Two investigators independently identified all randomized clinical trials (RCTs) with more than 3 months' follow-up.
RESULTS
From 4332 citations retrieved, 12 RCTs were identified. There were 5 RCTs on laser photocoagulation. Grid macular laser photocoagulation was effective in improving VA in 1 large multicenter RCT, the Branch Vein Occlusion Study (BVOS), but 2 smaller RCTs found no significant difference. The BVOS showed that scatter retinal laser photocoagulation was effective in preventing neovascularization and vitreous hemorrhage in patients with neovascularization, but a subsequent RCT found no significant effect. Randomized clinical trials evaluating intravitreal steroids (n = 2), hemodilution (n = 3), ticlopidine (n = 1), and troxerutin (n = 1) showed limited or no benefit.
CONCLUSIONS
There is limited level I evidence for any interventions for BRVO. The BVOS showed that macular grid laser photocoagulation is an effective treatment for macular edema and improves vision in eyes with VA of 20/40 to 20/200, and that scatter laser photocoagulation can effectively treat neovascularization. The effectiveness of many new treatments is unsupported by current evidence.
Topics: Angiogenesis Inhibitors; Evidence-Based Medicine; Glucocorticoids; Hemodilution; Humans; Laser Coagulation; Macular Edema; Ophthalmologic Surgical Procedures; Randomized Controlled Trials as Topic; Retinal Neovascularization; Retinal Vein Occlusion; Visual Acuity; Vitrectomy; Vitreous Hemorrhage
PubMed: 17397923
DOI: 10.1016/j.ophtha.2007.01.010 -
BMJ Clinical Evidence Nov 2007Diabetic retinopathy is the most common cause of blindness in the UK, with older people and those with worse diabetic control, hypertension, and hyperlipidaemia being... (Review)
Review
INTRODUCTION
Diabetic retinopathy is the most common cause of blindness in the UK, with older people and those with worse diabetic control, hypertension, and hyperlipidaemia being most at risk. Diabetic retinopathy can cause microaneurysms, haemorrhages, exudates, changes to blood vessels, and retinal thickening.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments in people with diabetic retinopathy? What are the effects of treatments for vitreous haemorrhage? We searched: Medline, Embase, The Cochrane Library and other important databases up to November March 2007 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 29 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: peripheral retinal laser photocoagulation, focal and grid laser photocoagulation for maculopathy, corticosteroids for macular oedema, and vitrectomy for vitreous haemorrhage.
Topics: Diabetic Retinopathy; Humans; Laser Coagulation; Macular Edema; Visual Acuity; Vitreous Body
PubMed: 19450351
DOI: No ID Found -
Journal of Neurology, Neurosurgery, and... Mar 2004To review systematically the frequency and prognostic significance of vitreous haemorrhage in patients with subarachnoid haemorrhage (Terson's syndrome). (Review)
Review
OBJECTIVE
To review systematically the frequency and prognostic significance of vitreous haemorrhage in patients with subarachnoid haemorrhage (Terson's syndrome).
METHODS
Papers relating to vitreous haemorrhage in patients with subarachnoid haemorrhage were retrieved. The only studies considered were those with at least 10 consecutive cases of subarachnoid haemorrhage with or without vitreous haemorrhage. The frequency of vitreous haemorrhage in such cases was calculated in prospective and retrospective studies. Mortality was compared in patients with and without Terson's syndrome.
RESULTS
154 papers were reviewed. Three prospective studies and six retrospective studies satisfied the inclusion criteria. Of 181 patients with subarachnoid haemorrhage assessed prospectively (mean age, 51.7 years), 24 (13%) had vitreous haemorrhage; among 1086 retrospective records, 37 (3%) had documented vitreous haemorrhage (p<0.001). Patients with Terson's syndrome had higher Hunt and Hess grades than those without (mean grade, 3.6 v 2.6). Patients with Terson's syndrome were also more likely to die (13 of 30 (43%) v 31 of 342 (9%); odds ratio 4.8; p<0.001).
CONCLUSIONS
Prospective studies show a higher frequency of Terson's syndrome than retrospective studies, suggesting that vitreous haemorrhage is not well documented. Vitreous haemorrhage is an adverse prognostic finding in patients with subarachnoid haemorrhage.
Topics: Comorbidity; Female; Humans; Incidence; Male; Middle Aged; Prognosis; Prospective Studies; Retrospective Studies; Subarachnoid Hemorrhage; Syndrome; Vitreous Hemorrhage
PubMed: 14966173
DOI: 10.1136/jnnp.2003.016816