Year : 2019 | Volume
: 31 | Issue : 3 | Page : 249--250
Nethra Eye Care Centre, Thrissur, Kerala, India
Nethra Eye Care Centre, Thrissur, Kerala
|How to cite this article:|
Nanu D. Journal review.Kerala J Ophthalmol 2019;31:249-250
|How to cite this URL:|
Nanu D. Journal review. Kerala J Ophthalmol [serial online] 2019 [cited 2020 May 24 ];31:249-250
Available from: http://www.kjophthal.com/text.asp?2019/31/3/249/274619
Salt Trial: Steroids After Laser Trabeculoplasty: Impact of Short-Term Anti-Inflammatory Treatment on Selective Laser Trabeculoplasty Efficacy
Groth SL, Albeiruti E, Nunez M, Fajardo R, Sharpsten L, Loewen N, et al. SALT Trial: Steroids after laser trabeculoplasty: Impact of short-term anti-inflammatory treatment on selective laser trabeculoplasty efficacy. Ophthalmology 2019;126:1511-6.
Laser trabeculoplasty is a commonly used treatment for lowering intraocular pressure (IOP) in glaucoma. Initially, argon laser trabeculoplasty was used, but it has been largely superseded by selective laser trabeculoplasty (SLT), which results in lesser damage to trabecular meshwork architecture and less adverse events and has better repeatability. SLT uses neodymium: yttrium-aluminum-garnet laser that selectively targets pigmented trabecular meshwork cells and uses very short pulses of low energy to stimulate them. There is typically a short-term anterior-chamber inflammatory response after SLT, and it was routine to prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) or steroids to ameliorate it. However, it has been hypothesized that such an inflammatory response may promote SLT efficacy and suppressing it may actually inhibit SLT's IOP-lowering effect. The SALT Trial was a double-masked, randomized, placebo-controlled, dual-center, multi-surgeon trial designed to examine whether short-term use of steroid or NSAID affects the efficacy of SLT at 12 weeks. The study included patients older than 18 years with IOP of more than 18 mmHg, diagnosed as ocular hypertension, for whom a clinician decided SLT was the appropriate therapy. Patients excluded were those with traumatic, congenital, juvenile-onset, or combined-mechanism glaucoma, those undergone previous glaucoma surgeries, those with corneal edema, those on systemic or ocular steroids and known steroid responders, those with a history of uveitis, pregnant patients, or those within 3 months of giving birth. Ninety-six eyes of 85 patients were included in the study. They were randomized into one of three groups, and either ketorolac 0.5%, prednisolone 1%, or saline tears was given four times daily for 5 days starting on the day of SLT in unmarked bottles. Before SLT, one drop of apraclonidine was instilled, if not contraindicated to avoid postoperative IOP spike. 180-360 degrees of the angle of the anterior chamber were treated with SLT according to surgeon's discretion. 50-100 non overlapping applications, centred on trabecular meshwork with spot size 400um and pulse duration 3ns were performed. The energy was titrated to champagne bubble formation. The baseline IOP in the NSAID, steroid, and placebo groups was similar. Although, in the first 6 weeks, there was not any statistically significant decrease in IOP among the three groups, by week 12, statistically significant lower IOP was noted in the NSAID and steroid groups. The Anterior Chamber (AC) reaction was similar and not significantly different among three groups. Although not statistically significant, the steroid group showed more than 2 mmHg IOP reduction and NSAID group more than 3 mmHg IOP reduction. The limitations of this study are its small sample size, patients could have been grouped based on the type of glaucoma, efficacy of SLT in them could have been assessed, no check of compliance of eye drop use other than patient report, and short-term follow-up of up to 12 weeks only. Furthermore, it has been noted that higher baseline IOP is associated with greater absolute decrease in IOP. The baseline IOP of patients included in this study was higher when compared to patients in other similar studies that have not detected any effect of topical NSAID on efficacy of SLT. The study concluded that short-term postoperative use of NSAID or steroid drops may improve efficacy of IOP reduction after SLT. However, additional studies for assessing long-term outcomes are required to consider if this clinical practice needs to be changed or not.
Neurodevelopmental Outcomes After Intravitreal Bevacizumab Therapy for Retinopathy of Prematurity: A prospective Case-Control Study
Fan YY, Huang YS, Huang CY, Hsu JF, Shih CP, Hwang YS, et al. Neurodevelopmental outcomes after intravitreal bevacizumab therapy for retinopathy of prematurity: A prospective case-control study. Ophthalmology 2019;126:1567-77.
Retinopathy of prematurity (ROP) is a disorder of development of retinal blood vessels in premature babies. This can lead to retinal hypoxia in its early stage and neovascularization in its late stage complicated by retinal traction and retinal detachment. The treatment of ROP is aimed at halting the neovascularization process. This can be done by either laser photoablation of the peripheral avascular retina, which is the current standard treatment or more recently by intravitreal injection of anti-vascular endothelial growth factor (VEGF). Elevated intraocular VEGF is one of the key drivers of retinal neovascularization. The Bevacizumab Eliminates the Angiogenic Threat of ROP Study showed a significant benefit for intravitreal injection of bevacizumab (IVB) for Zone 1, Stage 3 plus ROP compared with conventional laser treatment. However, because of its small sample size, the safety of IVB could not be addressed in this study. One of the key concerns of intraocular VEGF agents was a potential for systemic action of the drug. Multiple studies have shown that following intravitreal injection of anti-VEGF in preterm infants, there is significant reduction in systemic VEGF levels for up to 2–12 weeks. VEGF is a critical agent for neurodevelopment, especially in preterm infants. Two studies examining this have arrived at different conclusions with one study finding a significant neurodevelopmental delay in patients treated with IVB compared with laser treatment, while another one reporting no difference. These two studies were retrospective studies, and to provide a better assessment, the present study was designed as a prospective case–control study. This study evaluated the neurodevelopmental and ocular developmental outcomes in premature children who have undergone IVB for the treatment of Type I ROP. A total of 148 patients (85 boys and 63 girls) were enrolled in three groups: Group 0 (79 patients) included premature infants without retinopathy, Group 1 (31 patients) included ROP without need for treatment, and Group 2 (31 patients) included preterm infants with ROP who had received a single IVB injection. Ocular developmental assessment using standard techniques and neurodevelopmental assessment via Bayley III scores were performed at 1 to 3 years of age and were compared between groups. The study excluded patients who received laser treatment before or after IVB and patients who progressed to Stage 4 or 5 after IVB as well as those who could not complete the neurological assessment and those with cerebral palsy.
There were statistically significant differences between the three groups. Birth weight, 1- and 5-min APGAR score, and gestational age (GA) were significantly lower in Group 1 and 2 compared to Group 0. Overall, there were no significant differences in the demographic of patients or associated systemic risk factors between Groups 1 and 2, except for lower GA in Group 2. Regarding ROP condition, the patients in Group 2 were significantly more likely to show Stage 3, Zone 1 ROP and were more likely to show plus disease compared to Group 1. The cylindrical power was significantly larger in Groups 1 and 2 compared with Group 0. The spherical equivalent was significantly more myopic in Group 2 compared to Group 0. There were no significant differences between Groups 1 and 2 in refractive status, axial length, or Cardiff acuity. Neurodevelopmental assessment using Bailey III showed no significant differences among three groups in any aspect after adjusting for GA and other systemic risk factors. The study found neurodevelopmental outcomes and the risk for poor neurodevelopmental outcomes similar between ROP patients who did not require treatment and ROP patients who underwent IVB.
Limitation of this study is its nonrandomized design, lack of long-term follow-up, and statistically significant differences among the three groups. The study could have assessed children beyond 3 years of age to get long-term neurodevelopmental and ocular developmental outcomes in patients who have undergone IVB. Including an additional group receiving laser ablation for ROP would have been more informative.
The strength of this study is that the patients were enrolled and outcomes evaluated prospectively. They had clear definitions of patient enrolment, exclusion criteria, treatment indication, and designated tests performed for patients.
The study concluded that no significant difference was noted in neurodevelopmental or refractive or visual outcomes between ROP patients treated with IVB and ROP patients without treatment.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.