الفهرس 
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Abstract
Diabetic retinopathy (DR) is the most common cause of visual loss in the 20–74 age-group in developed countries. Diabetic macular edema is the most common cause of visual loss in patients diagnosed with diabetic retinopathy (Williams, 2012). The risk of blindness is 29 times higher in diabetic patients compared to non-diabetic ones (IDF, 2013). Clinical trials have tested anti-VEGF treatments and demonstrated that the inhibitors of vascular endothelial growth factor (VEGF) have been shown to have significant efficacy in the DME treatment. Therefore, anti-VEGF has become the gold standard for the treatment of DME. However, the majority of the eyes responded well to anti-VEGF therapy with signs of disappearing edema and visual enhancement, no optimal edema control can be ensured in some eyes, and this group was called as refractory or persistent macular edema (Wells et al, 2015). The refractory-persistent- DME causes permanent disturbance for the retinal architecture that can led to permanent loss of vision due to chronic tissue stress and photoreceptor cell loss (Uji et al, 2012). Therefore, its treatment is extremely important and various combination therapies have been tried for this purpose. In this study, we tried to assess the efficacy of the combined therapy with sub-tenon steroid and anti-VEGF injection in the treatment of resistant diabetic macular edema (DME) because there is lack of studies that has investigated the efficacy and safety of combined treatment (sub-tenon triamcinolone with anti-VEGF) in the early treatment course for patients with resistant DME. This study included 100 eyes of patients with resistant DME who were divided into 2 groups; group 1 (50 eyes) received combined therapy with posterior subtenon TA and anti-VEGF injections (0.5 mg ranibizumab) and group 2 (50 eyes) which received anti-VEGF injections (0.5 mg ranibizumab) only. The 2 groups were followed up for the period of 6 months and BCVA, CMT, number of injections needed, and occurrence of complications were assessed. There was significant improvement in BCVA and CMT in both groups at the end of follow up period. However, patients in group 1 needed a smaller number of injections with more recurrence in group 2 than group 1. There were no serious complications in any of the patients that shared in this study. Only a transient rise in IOP was observed just following the injections. To conclude, combined therapy with STTA and Anti-VEGF is efficient and safe management modality for resistant DME over Anti-VEGF solely. It helps to decrease number of injections which improves the economic burden in case of limited financial resources. Limitations in our study included small number of patients, short follow up period, dropouts of some patients due to financial limitations to obtain Anti-VEGF injections and frequent follow up visits. Our recommendations include studies with a greater number of patients, longer follow up periods. Also, we recommend head-to-head comparative studies between different modalities for treatment of resistant DME.