Discussion
diabetic retinopathy, corneal ulcer, corneal sensation, keratitis, CMT
DIABETIC RETINOPATHY, VASODILATION, INFLAMMATION, CORNEAL ULCER, EXUDATIVE AGE-RELATED MACULAR DEGENERATION, SECONDARY, KERATITIS, CAVITY, DIABETIC MACULAR EDEMA, MACULAR EDEMA, CORNEAL MELTING, INFLAMMATORY DISEASE, COMPLICATIONS
Anti-vascular endothelial growth factor (Anti-VEGF) drugs have resulted in improved visual outcomes, while treating diabetic macular edema. To maintain the initial gains in VA, repeated intravitreal injections are needed with subsequent increase of economic burden as well as possible occurrence of serious complications [Although VEGF upregulation plays an essential role in DME, several studies have demonstrated elevated inflammatory factors in the vitreous cavity of patients with diabetic retinopathy [Bromfenac is indicated for the treatment of ocular inflammatory diseases and postoperative inflammation. It is more lipophilic than other NSAIDs, facilitating corneal penetration, increasing duration of action and enhancing COX II inhibitory activity, thereby reducing production of prostaglandins and inflammatory cytokines [Due to the paucity of studies reported about using of topical bromfenac after intravitreal ranibizumab for the treatment of DME, our results will be compared with studies reported about using this combination in the treatment of other causes of macular edema or about using other NSAIDs such as topical nepafenac or ketorolac after intravitreal ranibizumab in treatment of DME.Both bromfenac and nepafenac may be more beneficial in the treatment of DME compared to ketorolac due to their higher levels of posterior segment penetration [The present randomized clinical trial showed that adding topical bromfenac to intravitreal ranibizumab produces additive effects on DME treatment. Both study groups revealed improvement of visual acuity after sixth month follow-up compared to the baseline. Although statistically not significant, the beneficial effect of visual acuity was more evident in patients who received ranibizumab plus topical bromfenac. This was found also to be correlated with the decrease in CMT and AMT at the sixth months of follow-up.Nikkhah et al. [On the other hand, Shimura et al. [In a case series, Pinna et al. [Both study arms showed macular thickness reduction after sixth month of follow-up compared to the baseline. Furthermore, patients who received ranibizumab plus topical bromfenac demonstrated a more statistically significant reduction of central and average macular thickness compared to patients treated by ranibizumab alone.Gomi concluded that reduction in CMT in exudative age-related macular degeneration between baseline and month 6 tended to be greater in eyes treated with topical bromfenac. Thus, combined bromfenac may strengthen and extend the effect of an anti-VEGF drug [Nikkhah et al. [Garcia-Gonzalez et al. [Intraocular pressure was found to be reduced in the ranibizumab plus bromfenac group (although not significant) compared to group treated with ranibizumab only. This finding could be due to the effect of bromfenac on prostaglandin (PG) production particularly prostaglandin E2 (PGE2), which increases the IOP by local vasodilation and increased permeability of blood–aqueous barrier [In the present study, the need for reinjection was significantly less among patients in ranibizumab plus bromfenac group compared to those treated with ranibizumab alone. Grant also noticed significant decrease in the number of ranibizumab injections after using of topical bromfenac with anti-VEGF for inhibiting CNV secondary to AMD [Both study groups revealed no serious side effects and adding of topical bromfenac to intravitreal ranibizumab did not alternate this finding. On the contrary, decrease corneal sensation as well as corneal melting were reported after using topical bromfenac. Cumulative application of topical bromfenac may cause a neurolytic keratitis like situation, which may trigger the formation of corneal ulcer [The major limitation of this study was the small sample size and shorter study period. Follow-up for longer period and inclusion of larger number of patients is recommended.