DME presentation i got from the internet to be able to download another DME presentation

1. Diabetic Macular Edema
Rova Virgana, Iwan Sovani, Arief S Kartasasmita, Erwin Iskandar,
Grimaldi Ihsan, Made Indra
KSM Vitreoretina
Dept IK Mata FK Unpad
PMN RS Mata Cicendo

3. What do we treat?

4. So … what to look for?

5. So what to look for?
Complete history taking
Thorough physical exam
Additional exam
Barrier to treatment plan

6. Diabetic Macular Edema
• DME results from a hyperglycemia-
induced breakdown of the blood–retina
barrier, which leads to fluid
extravasation from retinal vessels into
the surrounding neural retina
• Diabetic macular edema (DME) occurs
in more than 7% of patients with
diabetic retinopathy and represents the
main cause of progressive vision loss
during the course of disease
Retina and Vitreous. Basic and Clinical Science Course 2019-2020.
American Association of Ophthalmology®

7. Classification of DME Based On OCT
CENTER-INVOLVED NON CENTER-INVOLVED
• The central retinal subfield appears thickened on
OCT scans
• Central subfield–involved DME that affects the
fovea is a common cause of vision loss in
diabetic patients
Retina and Vitreous. Basic and Clinical Science Course 2019-2020. American Association of Ophthalmology®

8. Classification Of DME Based On Characteristic
FOCAL MACULAR EDEMA DIFFUSE MACULAR EDEMA
Retina and Vitreous. Basic and Clinical Science Course 2019-2020. American Association of Ophthalmology®
• Characterized by extensive retinal
capillary leakage and widespread
breakdown of the blood–retina barrier.
• Often accumulating in a cystoid
configuration in the perifoveal macula
(cystoid macular edema or CME)
• Characterized by areas of local fluorescein
leakage from specific capillary lesions, such
as microaneurysms

9. Diagnosis
Schmidt-Erfurth U, Garcia-Arumi J, Bandello F, Berg K, Chakravarthy U, Gerendas BS, et al. Guidelines for the management of diabetic macular edema by the European Society of Retina Specialists (EURETINA).
Ophthalmologica. 2017;237(4):185–222.
• The gold standard in diagnosing DME still remains Fluorescein Angiography. It can
detect different hallmarks of DR like MAs, PDR, ischemic areas and especially DME
due to vascular leakage.
• OCT can be used for screening, classification, monitoring, and treatment evaluation of
DME. It has the ability to provide information on CRT as well as distinct morphological
features of the edema.
• Therefore monitoring disease activity on a monthly basis with OCT even if no
treatment is needed or intended in order to identify morphological changes as early as
possible

10. Screening?

12. Clinically Significant Diabetic Macular Edema (CSME)
• ETDRS defined clinically significant diabetic macular edema (CSME) as the indication for focal laser
photocoagulation treatment in the following settings:
• Retinal thickening located at or within 500 μm of the center of the macula
• Hard exudates at or within 500 μm of the center if associated with thickening of adjacent retina
• Zone of thickening larger than 1 disc area, if located within 1 disc diameter of the center of the macula
• CSME is an older term that predates diagnoses made with OCT technology. Now that anti-VEGF treatment
has supplanted macular laser photocoagulation as the first-line therapy for DME, the CSME diagnosis, which is
made clinically, is much less frequently used.
Studies have not demonstrated any difference in treatment response corresponding to the pattern of macular edema,
whether focal, diffuse, or a combination of these.
Retina and Vitreous. Basic and Clinical Science Course 2019-2020. American Association of Ophthalmology®

13. Management Of DME
• Besides medical management and optimizing the health habits, ocular therapies should be considered to
maximize visual function and prevent progressive vision loss
• These therapies include ocular pharmacologic management and laser photocoagulation treatment
• Treatment is typically indicated when the macular edema is center-involved and affects visual acuity.
• For patients with DME who are asymptomatic or have normal visual acuity, the decision-making
process for treatment is more complex
• Factors that should be considered includes :
• The proximity of exudates or thickening to the fovea
• The status and course of the fellow eye
• Any anticipated cataract surgery
• The presence of high-risk PDR
• Treatment risks
• Any systemic conditions or medications (such as thiazolidinediones) that might exacerbate or cause
DME
Retina and Vitreous. Basic and Clinical Science Course 2019-2020. American Association of Ophthalmology®

14. Comprehensive Treatment
Systemic control
Other ocular findings
Structural
Activity daily living
Family support
Multidiscipline approach

15. Treatment options

16. Ocular Pharmacologic Management Of DME
ANTI-VEGF
• First-line therapy for most eyes with center involved
DME
• Available: Aflibercept, bevacizumab, pegaptanib, and
ranibizumab
• Associated adverse events are most commonly due to
the intravitreal injection procedure rather than the
medication
CORTICOSTEROIDS
• Alternative agents for eyes that are not candidates for
anti-VEGF therapy or that were incompletely
responsive to previous anti-VEGF treatment
• Using triamcinolone acetonide
Retina and Vitreous. Basic and Clinical Science Course 2019-2020. American Association of Ophthalmology®

17. Take home message
Comprehensive management
Detailed examination
Individualized treatment
Multidiscipline approach
We treat human not the eye