JKOS Journal of the Korean Ophthalmological Society J Korean Ophthalmol Soc 0378-6471 2092-9374 Korean Ophthalmological Society 10.3341/jkos.2016.57.12.1903 jkos-57-1903 Original Article Intravitreal Bevacizumab versus Intravitreal Bevacizumab Combined with Posterior Subtenon Triamcinolone Acetonide for Diabetic Macular Edema LeeJung Hyun MD ChungHee Young MD LeeKyung Min MD ParkYoung Sook MD SohnJoon Hong MD HwangDuck Jin MD Hangil Eye Hospital, Incheon, Korea Address reprint requests to Duck Jin Hwang, MD Hangil Eye Hospital, #35 Bupyeong-daero, Bupyeong-gu, Incheon 21388, Korea Tel: 82-32-503-3322, Fax: 82-32-503-0801 E-mail: halleu7@naver.com 09 2016 25 09 2016 5712 1903 1909 04052016 05082016 18092016 Copyright © 2016 Korean Ophthalmological Society 2016 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Purpose

To investigate the outcome of intravitreal bevacizumab (IVB) combined with posterior subtenon triamcinolone acetonide injections compared to IVB injection alone in patients with diabetic macular edema (DME).

 Methods

IVB injection (IVB group) and combination therapy injection (combination group) were administered to 35 eyes and 31 eyes, respectively, diagnosed with proliferative diabetic retinopathy combined with DME. Changes in best corrected visual acuity (BCVA), central macular thickness (CMT), total macular volume (TMV), amount of hard exudates and intraocular pressure (IOP) were compared retrospectively between groups prior to injection and 1, 2 and 3 months after injection.

 Results

BCVA changes in both groups were only statistically significant at 4 weeks after injection. Reduction of CMT and TMV was maintained for 1 month after treatment in all groups, but CMT and TMV deteriorated 2 months after treatment. No significant differences in BCVA, CMT or TMV were detected between the IVB and combination groups. The amount of hard exudates were only significantly decreased at month 3 in the combination group whereas the amount of hard exudates was not significantly different at 3 months in the IVB group (at baseline 2,899 ± 2,314 pixels vs. at 3 months 2,536 ± 1,981 pixels, p-value = 0.041). IOP showed no significant difference between the groups. Elevated IOP or endophthalmitis were not observed.

 Conclusions

In terms of BCVA improvement, subtenon triamcinolone provided no additional benefit on CMT and TMV reduction. However, combination therapy was effective in reducing the amount of hard exudates at 3 months.

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Measuring the amount of hard exudates with color fundus photography and the Photoshop program. The selected area by the magic wand tool is expressed in pixels by the histogram option.

Changes in parameters of both groups during the follow-up after injection. (A) Visual acuity. (B) Spectral domain optical coherence tomography (SD-OCT) measurements of central macular thickness. (C) SD-OCT measurements of total macular volume. (D) Intraocular pressure. IVB = intravitreal bevacizumab.

Changes in amount of hard exudates (in pixels) detected by fundus photography and the Photoshop program of both groups during the follow-up after injection. IVB = intravitreal bevacizumab.

Basic characteristics according to treatment group

  IVB group Combination group p-value
Eyes 35 31  
Age (years) 53.9 ± 9.1 51.7 ± 7.9 0.275*
Male:Female 27:8 18:13 0.058†
Right:Left 17:18 14:17 0.807†
Duration of diabetes (years) 9.3 ± 7.2 7.11 ± 6.2 0.316*
Hypertension (yes:no) 18:17 10:21 0.082*
Visual acuity (log MAR) 0.40 ± 0.27 0.37 ± 0.19 0.091*
Intraocular pressure (mm Hg) 17.5 ± 3.6 15.7 ± 3.7 0.124*
Central macular thickness (μ m) 367.0 ± 113.6 415.9 ± 157.8 0.262*
Total macular volume (mm3) 1.06 ± 0.08 1.19 ± 0.04 0.165*
Amount of hard exudates (pixels) 2,394 ± 1,989 2899 ± 2,314 0.235*

Values are presented as mean ± SD unless otherwise indicated. IVB group = intravitreal bevacizumab injections in diabetic macular edema; Combination group = combined therapy with intravitreal bevacizumab and subtenon triamcinolone acetonide injection in diabetic macular edema.

p-value of values et each follow-up period in intravitreal bevacizumab injection group and intravitreal bevacizumab combined with subtenon triamcinolone injection group, Mann-Whitney U-test

p-value of values et each follow-up period in intravitreal bevacizumab injection group and intravitreal bevacizumab combined with subtenon triamcinolone injection group, Pearson's chi-square test.

Treatment effect in each group

    IVB grou
 Combination group
Mean ± SD p-value* Mean ± SD p-value† p-value‡
Visual acuity (log MAR) At baseline 0.40 ± 0.27   0.37 ± 0.19   0.291
  1 month 0.34 ± 0.22 0.030 0.24 ± 0.22 0.024 0.124
  2 months 0.36 ± 0.23 0.916 0.25 ± 0.19 0.306 0.077
  3 months 0.39 ± 0.28 0.854 0.30 ± 0.21 0.285 0.153
Central macular thickness (μm) At baseline 367.0 ± 113   415.9 ± 157   0.262
  1 month 265 ± 104 <0.001 302 ± 144 0.001 0.223
  2 months 337 ± 129 0.196 338 ± 194 0.066 0.982
  3 months 394 ± 130 0.410 454 ± 221 0.953 0.344
Total macular volume (mm3) At baseline 1.06 ± 0.08   1.19 ± 0.04   0.165
  1 month 0.95 ± 0.09 0.003 1.04 ± 0.10 0.010 0.211
  2 months 0.93 ± 0.10 0.059 1.04 ± 0.12 0.068 0.351
  3 months 0.99 ± 0.14 0.790 1.15 ± 0.09 0.590 0.245
Amount of hard exudates (pixels) At baseline 2,394 ± 1,989   2,899 ± 2,314   0.235
  1 month 2,400 ± 1,998 0.871 2,930 ± 2,015 0.865 0.278
  2 months 2,389 ± 1,994 0.899 2,837 ± 2,020 0.217 0.343
  3 months 2,379 ± 2,030 0.968 2,536 ± 1,981 0.041 0.608
Intraocular pressure (mm Hg) At baseline 16.2 ± 3.5   15.3 ± 2.8   0.164
  1 month 16.3 ± 4.1 0.879 15.6 ± 3.2 0.812 0.491
  2 months 15.7 ± 3.9 0.535 15.6 ± 2.9 0.815 0.172
  3 months 16.5 ± 4.4 0.689 15.4 ± 3.3 0.977 0.173

Values are presented as mean ± SD unless otherwise indicated. IVB group = intravitreal bevacizumab injections in diabetic macular edema; Combination group = combined therapy with intravitreal bevacizumab and subtenon triamcinolone acetonide injection in diabetic macular edema.

p-value of values at each follow-up period comparing to baseline values in intravitreal bevacizumab injection group, Wilcoxon matched-pairs signed ranks test

p-value of values at each follow-up period comparing to baseline values in intravitreal bevacizumab combined with subtenon triamcinolone injection group, Wilcoxon matched-pairs signed ranks test

p-value of values et each follow-up period in intravitreal bevacizumab injection group and intravitreal bevacizumab combined with subtenon triamcinolone injection group, Mann-Whitney U-test.