Pan-retinal photocoagulation and other forms of laser treatment and drug therapies for non-proliferative diabetic retinopathy: systematic review and economic evaluation

医学 糖尿病性视网膜病变 激光凝固 眼科 临床试验 糖尿病 外科 视力 内科学 内分泌学
作者
Pamela Royle,Hema Mistry,Peter Auguste,D Shyangdan,Karoline Freeman,Noemi Lois,Norman Waugh
出处
期刊:Health Technology Assessment [NIHR Journals Library]
卷期号:19 (51): 1-248 被引量:77
标识
DOI:10.3310/hta19510
摘要

Background Diabetic retinopathy is an important cause of visual loss. Laser photocoagulation preserves vision in diabetic retinopathy but is currently used at the stage of proliferative diabetic retinopathy (PDR). Objectives The primary aim was to assess the clinical effectiveness and cost-effectiveness of pan-retinal photocoagulation (PRP) given at the non-proliferative stage of diabetic retinopathy (NPDR) compared with waiting until the high-risk PDR (HR-PDR) stage was reached. There have been recent advances in laser photocoagulation techniques, and in the use of laser treatments combined with anti-vascular endothelial growth factor (VEGF) drugs or injected steroids. Our secondary questions were: (1) If PRP were to be used in NPDR, which form of laser treatment should be used? and (2) Is adjuvant therapy with intravitreal drugs clinically effective and cost-effective in PRP? Eligibility criteria Randomised controlled trials (RCTs) for efficacy but other designs also used. Data sources MEDLINE and EMBASE to February 2014, Web of Science. Review methods Systematic review and economic modelling. Results The Early Treatment Diabetic Retinopathy Study (ETDRS), published in 1991, was the only trial designed to determine the best time to initiate PRP. It randomised one eye of 3711 patients with mild-to-severe NPDR or early PDR to early photocoagulation, and the other to deferral of PRP until HR-PDR developed. The risk of severe visual loss after 5 years for eyes assigned to PRP for NPDR or early PDR compared with deferral of PRP was reduced by 23% (relative risk 0.77, 99% confidence interval 0.56 to 1.06). However, the ETDRS did not provide results separately for NPDR and early PDR. In economic modelling, the base case found that early PRP could be more effective and less costly than deferred PRP. Sensitivity analyses gave similar results, with early PRP continuing to dominate or having low incremental cost-effectiveness ratio. However, there are substantial uncertainties. For our secondary aims we found 12 trials of lasers in DR, with 982 patients in total, ranging from 40 to 150. Most were in PDR but five included some patients with severe NPDR. Three compared multi-spot pattern lasers against argon laser. RCTs comparing laser applied in a lighter manner (less-intensive burns) with conventional methods (more intense burns) reported little difference in efficacy but fewer adverse effects. One RCT suggested that selective laser treatment targeting only ischaemic areas was effective. Observational studies showed that the most important adverse effect of PRP was macular oedema (MO), which can cause visual impairment, usually temporary. Ten trials of laser and anti-VEGF or steroid drug combinations were consistent in reporting a reduction in risk of PRP-induced MO. Limitation The current evidence is insufficient to recommend PRP for severe NPDR. Conclusions There is, as yet, no convincing evidence that modern laser systems are more effective than the argon laser used in ETDRS, but they appear to have fewer adverse effects. We recommend a trial of PRP for severe NPDR and early PDR compared with deferring PRP till the HR-PDR stage. The trial would use modern laser technologies, and investigate the value adjuvant prophylactic anti-VEGF or steroid drugs. Study registration This study is registered as PROSPERO CRD42013005408. Funding The National Institute for Health Research Health Technology Assessment programme.
最长约 10秒,即可获得该文献文件

科研通智能强力驱动
Strongly Powered by AbleSci AI
更新
PDF的下载单位、IP信息已删除 (2025-6-4)

科研通是完全免费的文献互助平台,具备全网最快的应助速度,最高的求助完成率。 对每一个文献求助,科研通都将尽心尽力,给求助人一个满意的交代。
实时播报
刚刚
我是老大应助淡淡的新之采纳,获得10
1秒前
慕青应助CX采纳,获得10
1秒前
1秒前
1秒前
2秒前
2秒前
hanchangcun发布了新的文献求助10
3秒前
Xianhe完成签到,获得积分10
3秒前
summer发布了新的文献求助10
3秒前
可可发布了新的文献求助10
4秒前
4秒前
今后应助kiwiii采纳,获得10
4秒前
假唱卡带完成签到,获得积分10
4秒前
李青秀发布了新的文献求助20
4秒前
garey发布了新的文献求助10
5秒前
5秒前
Leeyee发布了新的文献求助10
5秒前
段红琼发布了新的文献求助30
5秒前
卷儿发布了新的文献求助10
5秒前
6秒前
Cici发布了新的文献求助10
6秒前
7秒前
7秒前
hlc完成签到,获得积分10
7秒前
7秒前
jack发布了新的文献求助10
7秒前
dida完成签到,获得积分10
7秒前
gy发布了新的文献求助10
8秒前
卡卡西应助乐观寻绿采纳,获得20
9秒前
小波发布了新的文献求助10
10秒前
Joyce发布了新的文献求助10
10秒前
wang完成签到,获得积分20
10秒前
明亮的冷雪完成签到,获得积分10
10秒前
wang完成签到,获得积分10
10秒前
11秒前
幻梦境完成签到,获得积分10
12秒前
13秒前
冷冷发布了新的文献求助10
13秒前
13秒前
高分求助中
A new approach to the extrapolation of accelerated life test data 1000
Cognitive Neuroscience: The Biology of the Mind 1000
Technical Brochure TB 814: LPIT applications in HV gas insulated switchgear 1000
Toward a Combinatorial Approach for the Prediction of IgG Half-Life and Clearance 500
ACSM’s Guidelines for Exercise Testing and Prescription, 12th edition 500
Picture Books with Same-sex Parented Families: Unintentional Censorship 500
Nucleophilic substitution in azasydnone-modified dinitroanisoles 500
热门求助领域 (近24小时)
化学 材料科学 医学 生物 工程类 有机化学 生物化学 物理 内科学 纳米技术 计算机科学 化学工程 复合材料 遗传学 基因 物理化学 催化作用 冶金 细胞生物学 免疫学
热门帖子
关注 科研通微信公众号,转发送积分 3970120
求助须知:如何正确求助?哪些是违规求助? 3514810
关于积分的说明 11176124
捐赠科研通 3250136
什么是DOI,文献DOI怎么找? 1795198
邀请新用户注册赠送积分活动 875647
科研通“疑难数据库(出版商)”最低求助积分说明 804964