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Risque de décollement de rétine après injection intravitréenne d'anti-VEGF dans la rétinopathie diabétique proliférante sévère

Anti-vascular endothelial growth factor (anti-VEGF) crunch syndrome is characterized by the development of tractional retinal detachment (TRD) following intravitreal injection (IVI) in eyes with proliferative diabetic retinopathy (PDR). It typically occurs within 10 days after the injection. Risk factors include the use of a higher anti-VEGF dose and severe RDP with fibrosis. The existing literature is limited by heterogeneity in the way crunch is documented and the presence of panretinal photocoagulation as a confounding factor. This retrospective study aims to assess the risk of TRD in patients with severe PDR treated with intravitreal anti-VEGF injections combined with panphotocoagulation (PRP), in comparison to those treated with PRP alone.

Clinical records of consecutive patients diagnosed with PDR at the ophthalmology department of Avicenne Hospital, Bobigny, were retrospectively reviewed. The study involved a comparative analysis of two groups: one group receiving IVIs of anti-VEGF associated with PRP, and another group treated with PRP alone. Exclusion criteria included cases where anti-VEGF were prescribed for diabetic macular edema, the presence of intravitreal hemorrhage impeding posterior pole analysis, and injections performed as a preoperative procedure for vitrectomy.

A total of 81 eyes from 57 patients were analyzed, with 42 eyes receiving anti-VEGF injections and 39 eyes undergoing PRP alone. The mean glycated hemoglobin level was 8.6 ± 2.6%, and the mean duration of diabetes was 15.6 ± 9.3 years, with no differences between the two groups. At baseline, fibrosis was noted in 15 out of 42 eyes (35,7%) in the IVI group compared to 8 out of 39 eyes (20.5%) in the PRP group (p=0.17). During the follow-up period, a total of 8 cases of TRD (9.8 %) were observed, evenly distributed with 4 cases in each group. Vitreoretinal surgery was required for 6 out of 8 eyes. All TRD cases were associated with fibrosis (8/23, 34.7%), whereas no cases were observed in the absence of fibrosis (0/58, p<0.001). The fibrovascular proliferation extended along the temporal vascular arcades in those 8 eyes. 

In our cohort, we observed a substantial incidence of TRD, occurring in 9.8% of eyes (8/81). Our results do not suggest a direct triggering effect of anti-VEGF injections on the onset of TRD. Instead, TRD appears to be inherent in the natural progression of severe PDR. However, the presence of fibrovascular proliferation, especially when extending along the temporal vascular arcades seem to increase the risk of TRD.

Patients with severe diabetic retinopathy and concurrent fibrovascular proliferation should be closely monitored, regardless of the initiated treatment.