RESUMO
Macular edema (ME) is the most common sight-threatening complication in uveitis. The diagnostic and therapeutic management of the uveitic macular edema (UME) might be challenging due to the complex diagnostic workup and the difficulties physicians face to find the underlying cause, and due to its usually recurrent nature and the fact that it can be refractory to conventional treatment. Some of the mild cases can be treated with topical steroids, which can be combined with non-steroid anti-inflammatory drugs. However, immunomodulators such as methotrexate, tacrolimus, azathioprine, cyclosporine and mycophenolate mofetil together with anti-tumor necrosis factor-α (anti-TNF alpha) monoclonal antibodies such as adalimumab and infliximab, may be required to control the inflammation and the associated ME in refractory cases, or when an underlying disease is present. This review of the literature will focus mostly on the non-infectious UME.
RESUMO
INTRODUCTION: Ranibizumab (Lucentis), a humanised antibody fragment that inhibits vascular endothelial growth factor (VEGF)-A, is widely used for the treatment of neovascular age-related macular degeneration (NV-AMD). The objective of this study was to compare the outcomes of two different treatment protocols: loading dose (LD) and pro re nata (PRN (as needed)) dosing schedule from baseline. METHODS: This retrospective chart review was conducted at King's College Hospital, London, UK. Consecutive patients were identified using the 'Ranibizumab in NV-AMD' database. These patients had treatment-naive choroidal neovascularisation (CNV) secondary to AMD, received ranibizumab therapy and had completed 12 months of follow-up. Baseline examination included visual acuity (Early Treatment Diabetic Retinopathy Study (ETDRS) letters), slit-lamp biomicroscopy, fluorescein angiography, and qualitative and quantitative assessment of central macular characteristics on optical coherent tomography (OCT). Intravitreal ranibizumab (0.5mg/0.05ml) was given to all patients at baseline. Patients on LD regimen received two further consecutive monthly intravitreal ranibizumab injections independent of clinical findings. Further injections were determined by the same re-treatment criteria as patients on PRN schedule from baseline. The main outcome variables in the two treatment groups were visual acuity and central macular thickness at different time points. RESULTS: The LD group contained 47 patients and the PRN group contained 31 patients. There were no significant differences between groups in the mean changes in visual acuity or central macular thickness. Visual acuity was similar in both groups at 6 months. However, twice as many patients improved visual acuity by 15 or more letters in the LD group (29.8% in the LD group compared with 12.9% in the PRN group (p=0.01)). CONCLUSION: This study showed that standard protocols used for OCT-guided retreatment achieved smaller mean gains in vision than those obtained with monthly ranibizumab administration. Further, loading doses of ranibizumab resulted in more visual gains than the PRN protocol.
