Combination Injections for Diabetic Retinopathy

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Combination Injections for Diabetic Retinopathy

Diabetic macular edema has usually been treated with laser. Intraocular steroid injections combined with anti-VEGF medications, such as Avastin, more vision is restored.

Injecting both Avastin and a steroid injection can be a useful way to treat stubborn macular edema from diabetic retinopathy.  While both can be used alone to treat macular swelling in diabetic patients, the combination is sometimes considered as an alternative.

Traditional Laser

The gold standard has been to treat diabetic macular edema with laser treatment.  This has been a very effective means of achieving visual stability, that is, preventing further loss of vision.  About 20-25% of patients do improve.

Swelling That Doesn’t Go Away

Many patients do not improve with laser.  Their vision doesn’t improve and the macular edema does not resolve.  Usually additional laser won’t help as the persistent swelling is due to leaky “microaneurysms” located in the center of the macula.  Treating these centrally located areas with laser treatment would create permanent blind spots in the central vision.

“Plan B”:  Steroid or Avastin

Alternatives to the laser treatment include intraocular injections of steroid (e.g. Kenalog/triamcinolone acetonide) or anti-VEGF medications (e.g. Avastin, Lucentis).  Many times a single injection of either can improve both the vision and the macular edema.

“Plan C”: Steroid and Avastin

Once in a while, I have patient that doesn’t respond to either a single injection of steroid or anti-VEGF.  The next alternative is to alternate treatments with the other drug.  For instance, if I start with the steroid and get minimal or no response, I’ll usually recommend that the next injection be Avastin, or something similar.

Occasionally we have to alternate treatments several times before getting a satisfactory response.

What Does This Mean? The use of anti-VEGF and steroids is not new.  These drugs have been used “off-label” for the treatment of diabetic macular edema for several years.  Remember, though “off-label,” it is standard of care.

The recent report of success using a combination of Lucentis and laser treatment for diabetic macular edema underscores the need for an adequate treatment for this common complication of diabetic retinopathy.

In a few years, I predict that laser will be used only sparingly for the treatment of diabetic retinopathy and that the mainstay of treatment for diabetic macular edema will be more drug based.

We have come a long way in successfully treating diabetic retinopathy and preserving vision.

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Comments
  • Aissa D May 13, 2010 at 4:08 pm

    Would you recommend Ozurdex for intravitreal implant versus Kenalog injection then followed by a series of Avastin treatment?

    • Randall V. Wong, M.D. May 13, 2010 at 7:58 pm

      Wow! I think you are asking me if Ozurdex, by itself, is the same as Kenalog plus Avastin?

      I don’t know. For now, I’m going to suggest that Kenalog plus a series of Avastin injections offers the most versatility.

      Ozurdex releases a steroid. Why couldn’t we implant Ozurdex (instead of Kenalog injections) and give periodic Avastin?

      Great question.

      Thanks.

      Randy

  • Aissa D May 19, 2010 at 7:06 pm

    Do you think it would work? Putting aside the politics of cost/profit and health insurance issues.

    • Randall V. Wong, M.D. May 21, 2010 at 6:31 am

      The title is a bit misleading. My bad. I intended to say that both injections sometimes need to be used on an alternate basis. For some reason, this “cycling” has a good effect on some patients that are tough to treat.

      r

  • Neil Hansen September 25, 2012 at 4:29 pm

    Two inquiries: Have had pancraes transplant 15 yeaqrs ago, and for a very long time, I had no eye issues. Then about six years ago, developed cataracts which were operated on, and worked out okay for a number of years before glaucoma set in. Anyway, in the paqst five years, I have gotten regular Retinopathies which have gotten worse each year. I have beeen injected with avastin and that would do the trick for a few months, but became effctive on differnt levels. Sometimes good for three months, sometimes one. Most recently, I have had two avastin injectiomns and they seem to have done nothing or very litle. What might be causing the retinopathies especially since the pancreas transplants have taken care of the insulin issue. Am I developing a resistance to avastin? If you could offer any theories, I’d appreciate them.

    • Randall V. Wong, M.D. September 26, 2012 at 9:44 am

      Dear Neil,

      Not lots of experience with pancreas transplants and retinopathy. I’ve had several patients with pancreas transplants but no retinopathy.

      Most “resistance” to Avastin may be an allergic type of sensitivity. I’ve only read about this and not experienced it in my own practice.

      By “not working” do you mean the neovascularization is present or your vision does not get better?

      Slightly confused,

      r

  • Neil Hansen September 26, 2012 at 4:50 pm

    Hello, again. The last two treatments didn’t improve anything, and if possible, have made them worse. I’ve been suffering headaches since the treatments after June. Newver suffered headaches like this for an extended length of time.

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