Rationale for the Diabetic Retinopathy Clinical Research Network Treatment Protocol for Center-Involved Diabetic Macular Edema

Objective: Describe the underlying principles used to develop a web-based algorithm that incorporated intravitreal anti-vascular endothelial growth factor (anti-VEGF) treatment for diabetic macular edema (DME) in a Diabetic Retinopathy Clinical Research Network (DRCR.net) randomized clinical trial. Design: Discussion of treatment protocol for DME. Participants: Subjects with vision loss from DME involving the center of the macula. Methods: The DRCR.net created an algorithm incorporating anti-VEGF injections in a comparative effectiveness randomized clinical trial evaluating intravitreal ranibizumab with prompt or deferred (≥24 weeks) focal/grid laser in eyes with vision loss from center-involved DME. Results confirmed that intravitreal ranibizumab with prompt or deferred laser provides superior visual acuity outcomes, compared with prompt laser alone through at least 2 years. Duplication of this algorithm may not be practical for clinical practice. In order to share their opinion on how ophthalmologists might emulate the study protocol, participating DRCR.net investigators developed guidelines based on the algorithm's underlying rationale. Main Outcome Measures: Clinical guidelines based on a DRCR.net protocol. Results: The treatment protocol required real time feedback from a web-based data entry system for intravitreal injections, focal/grid laser, and follow-up intervals. Guidance from this system indicated whether treatment was required or given at investigator discretion and when follow-up should be scheduled. Clinical treatment guidelines, based on the underlying clinical rationale of the DRCR.net protocol, include repeating treatment monthly as long as there is improvement in edema compared with the previous month, or until the retina is no longer thickened. If thickening recurs or worsens after discontinuing treatment, treatment is resumed. Conclusions: Duplication of the approach used in the DRCR.net randomized clinical trial to treat DME involving the center of the macula with intravitreal ranibizumab may not be practical in clinical practice, but likely can be emulated based on an understanding of the underlying rationale for the study protocol. Inherent differences between a web-based treatment algorithm and a clinical approach may lead to differences in outcomes that are impossible to predict. The closer the clinical approach is to the algorithm used in the study, the more likely the outcomes will be similar to those published

Erlotinib-associated severe bilateral recalcitrant keratouveitis after corneal EDTA chelation

Purpose: We report a case of erlotinib-associated severe recalcitrant bilateral keratouveitis after uneventful corneal ethylenediaminetetraacetic acid (EDTA) chelation in a patient with non-small cell lung cancer (NSCLC); discontinuation of erlotinib led to complete resolution. Observations: An elderly person presented with band keratopathy (BSK) of undetermined etiology in the both eyes, associated with foreign body sensation and constant tearing. The patient was on oral erlotinib treatment 150 mg PO daily for 1 year for NSCLC status post radiation therapy. Corneal EDTA chelation was performed in both eyes under topical anesthesia for BSK. Four days after surgery, the patient presented with severe pain in both eyes. Slit lamp evaluation revealed 5 mm × 7 mm epithelial defect with clear margins in the right eye and 6 × 7 mm epithelial defect with thick central corneal infiltrate in the left eye. Hypopyon was noticed in both eyes and intense inflammation obscured the details of anterior segment. Intense antibiotic treatment was initiated. After discussion with the oncology services, oral erlotinib was temporarily discontinued. This resulted in resolution of keratitis and hypopyon in both eyes, within one week. Conclusions: and importance: Systemic use of erlotinib suppresses local immunity, facilitates infection and enhances inflammatory reaction in the eye. Clinicians should be cautious and plan any ocular interventional treatment in collaboration with oncology team to prevent adverse outcomes

Clinical applications of spectral domain optical coherence tomography in retinal diseases

AbstractOptical coherence tomography (OCT) was introduced about two decades ago and has revolutionized ophthalmic practice in recent years. It is a noninvasive noncontact imaging modality that provides a high-resolution cross-sectional image of the cornea, retina, choroid and optic nerve head, analogous to that of the histological section. Advances in OCT technology in signal detection technique from time-domain (TD) to spectral-domain (SD) detection have given us the potential to study various retinal layers more precisely and in less time. SD-OCT better delineates structural changes and fine lesions in the individual retinal layers. Thus, we have gained substantial information about the pathologic and structural changes in ocular conditions with primary or secondary retinal involvement. This review we discuss the clinical application of currently available SD-OCT in various retinal pathologies. Furthermore, highlights the benefits of SD-OCT over TD. With the introduction of enhanced depth imaging and swept – source OCT visualization of the choroid and choriocapillaris has become possible. Therefore, OCT has become an indispensable ancillary test in the diagnosis and management of diseases involving the retina and/or the choroid. As OCT technology continues to develop further it will provide new insights into the retinal and choroidal structure and the pathogenesis of posterior segment of the eye