http://www.tvrs.gr/

1. Diabetic Retinopathy
Laser Treatment
ANTI VEGF
Diabetic RetinopathyDiabetic Retinopathy
Laser TreatmentLaser Treatment
ANTI VEGFANTI VEGF
Dr. Tunç OvalıDr. TunDr. Tunçç OvalOvalıı

2. Dr. Tunç Ovalı
Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF
No financial interestNo financial interest

3. Dr. Tunç Ovalı
Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF
Diabetic RetinopathyDiabetic Retinopathy Laser TreatmentLaser Treatment
 Peripheric retinal ischemiaPeripheric retinal ischemia …… panretinal laser photocoagulationpanretinal laser photocoagulation
 Macular edemaMacular edema …… focal / grid laser photocoagulationfocal / grid laser photocoagulation

4. Dr. Tunç Ovalı
Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF
Diabetic RetinopathyDiabetic Retinopathy Laser TreatmentLaser Treatment
 Peripheric retinal ischemiaPeripheric retinal ischemia …… panretinal laser photocoagulationpanretinal laser photocoagulation
The laser treatment recomendations for diabetic retinopathy areThe laser treatment recomendations for diabetic retinopathy are based onbased on
the results of two randomized clinical trials :the results of two randomized clinical trials :
1. Diabetic Retinopathy Study Research Group, report no 14, Int. Ophthalmol. Clin 19871987
2. Early Treatment Diabetic Retinopathy Study Research Group,ETDRS report no 2, Ophthalmology
19871987
% 50 reduction in severe visual loss in eyes with severe NPDR or% 50 reduction in severe visual loss in eyes with severe NPDR or PDR in two yearsPDR in two years

5. Dr. Tunç Ovalı
Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF
Panretinal photocoagulationPanretinal photocoagulation
 spot size : 500spot size : 500 –– 800800 µµm at the retinam at the retina
( magnification of the wide field lenses ! )( magnification of the wide field lenses ! )
 one burn apartone burn apart
 1.2001.200 –– 1.600 burns ( in 31.600 burns ( in 3 –– 5 sessions )5 sessions )
 exposure : 0.1exposure : 0.1 –– 0.2 sec.0.2 sec.
 burns : nasaly 500burns : nasaly 500 µµm apart from the discm apart from the disc
temporally 2 disc diameter from the center of the maculatemporally 2 disc diameter from the center of the macula

6. Dr. Tunç Ovalı
Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF
Complications of panretinal photocoaculation :Complications of panretinal photocoaculation :
⇨⇨ damage of the cornea / iris / lensdamage of the cornea / iris / lens
⇨⇨ rise of intraocular pressure ( ciliochoroidal effusion )rise of intraocular pressure ( ciliochoroidal effusion )
⇨⇨ macular edemamacular edema
⇨⇨ choroidal detachmentchoroidal detachment
⇨⇨ optic disc damageoptic disc damage

7. Dr. Tunç Ovalı
Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF
Complications of panretinal photocoaculation :Complications of panretinal photocoaculation :
⇨⇨ pretinal fibrosis macular tractionpretinal fibrosis macular traction
⇨⇨ vitreus hemorrhagevitreus hemorrhage
⇨⇨ scotomascotoma
⇨⇨ subretinal fibrosissubretinal fibrosis

8. Diagnostic toolsDiagnostic tools
⇨⇨ Biomicroscopic fundoscopyBiomicroscopic fundoscopy
⇨⇨ Fundus Florescein AngiographyFundus Florescein Angiography
⇨⇨ Optic Cohorens TomographyOptic Cohorens Tomography
Dr. Tunç Ovalı
Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

9. Dr. Tunç Ovalı
Diabetic macular edema and interpretation with OCTDiabetic macular edema and interpretation with OCT
1.1.Diffuse microcycstsDiffuse microcycsts
2.2.Big cycstic edemaBig cycstic edema
3.3.Subfoveal serous elavationSubfoveal serous elavation
Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

10. Dr. Tunç Ovalı
NAK

11. Diabetic MaculopathyDiabetic Maculopathy
⇨⇨ Diffuse / focal leakageDiffuse / focal leakage
⇨⇨ Ischemic maculopathyIschemic maculopathy
⇨⇨ Vitreomaculer tractionVitreomaculer traction
Dr. Tunç Ovalı

12. Dr. Tunç Ovalı
Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF
Diabetic RetinopathyDiabetic Retinopathy Laser TreatmentLaser Treatment
 Macular edemaMacular edema …… focal / grid laser photocoagulationfocal / grid laser photocoagulation

13. Dr. Tunç Ovalı
Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF
Diabetic RetinopathyDiabetic Retinopathy Laser TreatmentLaser Treatment
 Macular edemaMacular edema …… focal / grid laser photocoagulationfocal / grid laser photocoagulation

14. Dr. Tunç Ovalı
Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF
Diabetic RetinopathyDiabetic Retinopathy Laser TreatmentLaser Treatment
 Macular edemaMacular edema …… focal / grid laser photocoagulationfocal / grid laser photocoagulation

15. Dr. Tunç Ovalı
Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF
Diabetic RetinopathyDiabetic Retinopathy Laser TreatmentLaser Treatment
 Macular edemaMacular edema …… focal / grid laser photocoagulationfocal / grid laser photocoagulation
Parameters for focal photocoagulation :
 spot size : 100 – 200 µm ( at the retina )
 exposure time : focalfocal 0.1 – 0.3 sec. gridgrid 0.1 sec
 power increase : 10 – 20 mW
 focalfocal : gray – white burns gridgrid : barely visible burns

16. Dr. Tunç Ovalı
Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF
Intravitreal administration of drugsIntravitreal administration of drugs
-- Pathogenesis of DME is complex and multifactorialPathogenesis of DME is complex and multifactorial
-- VEGF and inflamation have both a central roleVEGF and inflamation have both a central role
ANTI VEGFANTI VEGF BevacizumabBevacizumab AvastinAvastin ®®
RanibizumabRanibizumab LucentisLucentis ®®
Aflibercept Eylea ®®
SteroidsSteroids TriamcinolonTriamcinolon
Dexamethasone implantDexamethasone implant OzurdexOzurdex ®®

17. Dr. Tunç Ovalı
Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF
Two-Year Outcomes of the Ranibizumab for Edema of the mAcula in Diabetes - READ 2 Study
Nguyen QD, Shah SM, Khwaja AA, et al. Ophthalmology 2010 117: 2146-2151

18. Dr. Tunç Ovalı
Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF
Randomized Trial Evaluating Ranibizumab Plus Prompt or Deferred Laser or Triamcinolone Plus Prompt
Laser for Diabetic Macular Edema
The Diabetic Retinopathy Clinical Reseach NetworkThe Diabetic Retinopathy Clinical Reseach Network Ophthalmology 2010 117: 1064-1077

19. Dr. Tunç Ovalı
Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF
Safety and Efficacy of Ranibizumab in Diabetic Macular Edema - RESOLVE StudyRESOLVE Study
Massin P, Bandello F, Garweg JG, et al. Diabetes Care 33:2399–2405, 2010

20. Dr. Tunç Ovalı
Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF
Ranibizumab Monotherapy or Combined with Laser versus Laser Monotherapy for Diabetic Macular
Edema - The RESTORE StudyThe RESTORE Study
Mitchell P, Bandello F, Schmidt-Erfurth U, et al. Ophthalmology 2011 118: 615-625

21. Dr. Tunç Ovalı
i.vit. Ranibizumabi.vit. Ranibizumab
ACACÖÖ type II diabetestype II diabetes
After 2. inj.
After 1. inj.
0.4
0.9
0.6

22. Dr. Tunç Ovalı
i.vit. Ranibizumabi.vit. Ranibizumab
FCFC type II diabetestype II diabetes
After 1. inj.
After 2. inj.
0.05
0.05
0.1

23. Dr. Tunç Ovalı
i.vit. Ranibizumabi.vit. Ranibizumab
BBÇÇ type II diabetestype II diabetes
After 2. inj.
After 1. inj.
After 3. inj.
0.4
0.1
0.8
0.5

24. Dr. Tunç Ovalı0.2 2 months later - 0.5
Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF
i.vit. Triamcinoloni.vit. Triamcinolon

25. Dr. Tunç Ovalı
Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF
i.vit. Triamcinoloni.vit. Triamcinolon
i.vit. Triami.vit. Triam. GGöözz Antiglaucoma therapy
Lens sclerosisLens sclerosis
Cataract surgeryCataract surgery
1.injec.1.injec. n : 103n : 103
n : 11n : 11
% 10.7% 10.7
n : 8n : 8
% 7.8% 7.8
n : 3n : 3
% 2.9% 2.9
2. injec.2. injec. n : 38n : 38
n : 6n : 6
% 15.8% 15.8
n : 8n : 8
% 21.1% 21.1
n : 3n : 3
% 7.9% 7.9
>> 3. injec.3. injec. n : 21n : 21
n : 3n : 3
% 14.3% 14.3
n : 9n : 9
% 42.9% 42.9
n : 2n : 2
% 9.5% 9.5

26. Dr. Tunç Ovalı
Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF
Dexamethazone implant

27. Dr. Tunç Ovalı
Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF
Dexamethazone implant

28. Dr. Tunç Ovalı
Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF
AA
Dexamethazone implant

29. Dr. Tunç Ovalı
Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

30. Dr. Tunç Ovalı
Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF
How I do itHow I do it ……
-- Systemic control is every thing !!!Systemic control is every thing !!!
-- Fundus florescein angiography ( wide field ?? ) + OCTFundus florescein angiography ( wide field ?? ) + OCT  Laser / Surgery ?Laser / Surgery ?
- ANTI VEGF ( prevents bleading / macular edema )
- Focal laser / modified grid laser phocoagulation
- Panretinal photocoagulation ( until extrem far periphery )
- Steroidal implant
- … and waiting for the next big thing !!!

31. Thank youThank you
tuncovali @ fulyaretina.com
GSM : + 90 532 737 00 17

32. Dr. Tunç Ovalı
Diabetic Retinopathy – Laser Treatment and ANTI VGFDiabetic RetinopathyDiabetic Retinopathy –– Laser Treatment and ANTI VGFLaser Treatment and ANTI VGF