This document discusses diabetic maculopathy and macular edema. It covers the causes of vision loss, classifications of diabetic retinopathy, types of macular edema, clinically significant macular edema (CSME), treatment options including laser photocoagulation, a clinical study on treating CSME with focal and grid laser, and conclusions about the importance of early recognition and treatment.
Novel Development in treatment of Diabetic Macular Edema, by Dr. Fritz Allen, presented at VO, Lecture Series 11, Feb 20, 2011
COPE Course ID: 30657-PS
Diabetic maculopathy is a form of damage to the eye causing by diabetic macular oedema where fluids build up on the macula. It can be cured by laser surgeries.
Novel Development in treatment of Diabetic Macular Edema, by Dr. Fritz Allen, presented at VO, Lecture Series 11, Feb 20, 2011
COPE Course ID: 30657-PS
Diabetic maculopathy is a form of damage to the eye causing by diabetic macular oedema where fluids build up on the macula. It can be cured by laser surgeries.
updating in diabetic macular edema including old and new approach era, including DRCR protocol
how to approach, how to treat, when to surgery
plus knownledge about anti-VEGF therapy up to date
Title:
Choosing amongst current modalities to manage Diabetic Retinopathy
At Medical Retina Clinic, Eye Department WAPDA Teaching Hospital Complex Lahore
Objective:
1. To review the current management options for DR
2. To share author’s four years follow up from Jan 2008 to Nov 2011 at Medical Retina Clinic, Eye Department WAPDA Teaching Hospital Complex Lahore.
3. Discussion on future Trends in management of DR.
Synopsis:
Diabetic retinopathy is the leading cause of new blindness in the world,
Argon LASER treatment has established itself as a gold standard in the management of DR. Intravitreal therapies in the form anti VEGF agents and steroids are also being widely used nationally and internationally. These therapies do not replace but complement each other.
Author will share his four years experience at Medical Retina clinic WAPDA hospital complex Lahore. 125 patients with DR were enrolled during this period. Treatment modalities used, included Argon Green Laser, Intravitreal Anti VEGF (Bevacizumab), Intravitreal Triamcinolone and subtenon Triamcinolone. Staging and severity of the disease as well as response to the offered therapy were the parameters used to tailor the treatment options.
Dr. Zia ul Mazhry
FRCS (Edin), FRCS (Glasgow), FCPS, CICOphth (UK)
Asstt Professor Central Park Medical College Lahore.
Consultant Eye Surgeon and Head of Eye Department
Wapda Teaching Hospital Complex
210 Feroz Pur Road Lahore.
Website: www.EyeAcuity.com
mazhry@yahoo.com
03004401151
HISTORY
History regarding duration of diabetes, pastglycemic control (hemoglobin A1c), Medications used (especially insulin, oral hypoglycemics, antihypertensives, and lipid-lowering drugs), systemic history (e.g., renal disease, cardiovascular events, systemic hypertension, serum lipid levels, pregnancy)(Konno et al.,2001).
History related to drugs causing macularedema (Thiazolidinediones, fingolimod (used inMS), tamoxifen, taxanes, niacin, interferons and prostaglandin analogs).Ocular examination
Detailed patient assessment and diagnosis should include a complete ophthalmic examination, including visual acuity (preferably by a ETDRS/Log MARchart) INVESTIGATIONS OCT
All patients with DME should undergo OCT (Both Raster and radial scans). Retinal thickening (Central subfield and inner ETDRS ring thickness measurement), presence of vitreomacular adhesion or traction and morphological characteristics like presence of neurosensory detachment, cystic spaces, foveal contour should be noted(Massin et al.,2001).
The features suggestive of prognosis-like horizontal and vertical extent of IS-OS disruption, ELM disruption and hyper reflective foci (HFs)within the neurosensory retina should be noted. In the presence of gross cystoids macular edema, often it is difficult to assess these features.
Reduction in visual acuity in association with diabetic retinopathy commonly occurs from diabetic macular edema. Traditional methods of assessing DME include contact and non-contact slit-lamp biomicroscopy, indirect funduscopy, fluoresce in angiography and fundus streo-photography. However, given the relative deprival of ability of these methods to detect and to quantify DME, alternative objective methods have been applied. The introduction of OCT allows an objective evaluation of DME with effectiveness in both qualitative and quantitative description of this pathology. That is why it becomes a standard tool in the management of patients with DME .More than ten years after ETDRS, OCT greatly enhanced our ability to detect and analyse macular thickening and has brought new insights on the morphology of DME and on the presence of vitreo-retinal interface abnormalities.
GENERAL INFORMATION ABOUT DIABETIC MACULAR EDEMA WITH 2 PATIENT CASES, TREATED WITH 2 DIFFERENT TREATMENT TECHNIQUES.
CLASSIFICATION (CSME)
RISK FACTORS
CAUSES
SIGNS AND SYMPTOMS
MANAGEMENT AND TREATMENT OPTIONS
DIAGNISTIC TESTS, BLOOD AND URINE TEST
SCORING SYSTEM
PATHOLOGY
DIFFERENTIAL DIAGNOSIS
PROGNOSIS
EPIDEMIOLOGY
DESCRIPTION OF 2 CASES, THEIR DIAGNOSTIC RESULT AND DETAILS ABOUT TREATMENTS PERFORMED.
Lecture on Management of Cataract Surgery and Diabetes Mellitus. 2010 World Congress, American Society of Cataract & Refractive Surgery. Boston, MA 2010
updating in diabetic macular edema including old and new approach era, including DRCR protocol
how to approach, how to treat, when to surgery
plus knownledge about anti-VEGF therapy up to date
Title:
Choosing amongst current modalities to manage Diabetic Retinopathy
At Medical Retina Clinic, Eye Department WAPDA Teaching Hospital Complex Lahore
Objective:
1. To review the current management options for DR
2. To share author’s four years follow up from Jan 2008 to Nov 2011 at Medical Retina Clinic, Eye Department WAPDA Teaching Hospital Complex Lahore.
3. Discussion on future Trends in management of DR.
Synopsis:
Diabetic retinopathy is the leading cause of new blindness in the world,
Argon LASER treatment has established itself as a gold standard in the management of DR. Intravitreal therapies in the form anti VEGF agents and steroids are also being widely used nationally and internationally. These therapies do not replace but complement each other.
Author will share his four years experience at Medical Retina clinic WAPDA hospital complex Lahore. 125 patients with DR were enrolled during this period. Treatment modalities used, included Argon Green Laser, Intravitreal Anti VEGF (Bevacizumab), Intravitreal Triamcinolone and subtenon Triamcinolone. Staging and severity of the disease as well as response to the offered therapy were the parameters used to tailor the treatment options.
Dr. Zia ul Mazhry
FRCS (Edin), FRCS (Glasgow), FCPS, CICOphth (UK)
Asstt Professor Central Park Medical College Lahore.
Consultant Eye Surgeon and Head of Eye Department
Wapda Teaching Hospital Complex
210 Feroz Pur Road Lahore.
Website: www.EyeAcuity.com
mazhry@yahoo.com
03004401151
HISTORY
History regarding duration of diabetes, pastglycemic control (hemoglobin A1c), Medications used (especially insulin, oral hypoglycemics, antihypertensives, and lipid-lowering drugs), systemic history (e.g., renal disease, cardiovascular events, systemic hypertension, serum lipid levels, pregnancy)(Konno et al.,2001).
History related to drugs causing macularedema (Thiazolidinediones, fingolimod (used inMS), tamoxifen, taxanes, niacin, interferons and prostaglandin analogs).Ocular examination
Detailed patient assessment and diagnosis should include a complete ophthalmic examination, including visual acuity (preferably by a ETDRS/Log MARchart) INVESTIGATIONS OCT
All patients with DME should undergo OCT (Both Raster and radial scans). Retinal thickening (Central subfield and inner ETDRS ring thickness measurement), presence of vitreomacular adhesion or traction and morphological characteristics like presence of neurosensory detachment, cystic spaces, foveal contour should be noted(Massin et al.,2001).
The features suggestive of prognosis-like horizontal and vertical extent of IS-OS disruption, ELM disruption and hyper reflective foci (HFs)within the neurosensory retina should be noted. In the presence of gross cystoids macular edema, often it is difficult to assess these features.
Reduction in visual acuity in association with diabetic retinopathy commonly occurs from diabetic macular edema. Traditional methods of assessing DME include contact and non-contact slit-lamp biomicroscopy, indirect funduscopy, fluoresce in angiography and fundus streo-photography. However, given the relative deprival of ability of these methods to detect and to quantify DME, alternative objective methods have been applied. The introduction of OCT allows an objective evaluation of DME with effectiveness in both qualitative and quantitative description of this pathology. That is why it becomes a standard tool in the management of patients with DME .More than ten years after ETDRS, OCT greatly enhanced our ability to detect and analyse macular thickening and has brought new insights on the morphology of DME and on the presence of vitreo-retinal interface abnormalities.
GENERAL INFORMATION ABOUT DIABETIC MACULAR EDEMA WITH 2 PATIENT CASES, TREATED WITH 2 DIFFERENT TREATMENT TECHNIQUES.
CLASSIFICATION (CSME)
RISK FACTORS
CAUSES
SIGNS AND SYMPTOMS
MANAGEMENT AND TREATMENT OPTIONS
DIAGNISTIC TESTS, BLOOD AND URINE TEST
SCORING SYSTEM
PATHOLOGY
DIFFERENTIAL DIAGNOSIS
PROGNOSIS
EPIDEMIOLOGY
DESCRIPTION OF 2 CASES, THEIR DIAGNOSTIC RESULT AND DETAILS ABOUT TREATMENTS PERFORMED.
Lecture on Management of Cataract Surgery and Diabetes Mellitus. 2010 World Congress, American Society of Cataract & Refractive Surgery. Boston, MA 2010
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
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Age-Related Macular Degeneration by\ Eman Salman
It was used for student presentation in ophthalmology course rotation
I Hope you find what is helpful for your knowledge ♥
Welcome and introduction to the 2nd innovation camp in Network of Nordic Public Libraries, 19 September 2011 in Stockholm. 55 participants from the libraries in Oslo, Helsinki, Stockholm, Reykjavik, Akureyri and Aarhus co-create ideas and concept for the future of public libraries in the Nordic Societies
Robotic Radiosurgery Treatment for Eye Tumours duttaradio
Robotic radiosurgery treatment is an excellent treatment option for eye tumours. This presentation explains in detail the application of CyberKinfe as a treatment option.
Dr. Torres gives great information on age related macular degeneration. This is a great update not only on the disease but on emerging treatments for this devastating problem.
Apart from its established role in Age related maculopathy, Ani-Vegf have other usage too. Presently clinical study reports are coming in showing encouraging results.
oECCE with posterior chamber intraocula lens implantation achieves results equal to phacemulsification in expert hands and has been an accepted method of cataract surgery.
Blindness due to diabetic retinopathy affects the adult population20 to 64 yr. age and is as common a complication of diabetes as end stage renal disease and nontraumatic lower limb amputations. Long standing hyperglycaemia causes loss of endothelial pericytes and thickening of basement membrane of capillaries resulting in breaking down of endothelial barrier and narrowing of lumen, causing retinal oedema and capillary closures.
Vision can be diminished due to macular oedema, ischaemia or exudates Vitreous haemorrhage, or TRD. Vitreous haemorrhage occurs in PDR and causes sudden drop in vision.Tractional retinal detachment is the end stage complication along with neovascularization.
Two broad classifications NPDR-previous BDR and PDR. NPDR is further subclassified from treatment point of view into mild moderate and severe depending upon occurrences of dot haemorrhages, microeneurysms and exudates. The severe form needs special mention due to it's importance in decision making for PRP and guidelines laid are Blot haemo. in 4 qdrs., venous beading in 2 qdrs. and IRMA in 1 qdr. If two or more of these are present, 45% can go into PDR in a years time.
We will be discussing macular oedema as a cause for visual loss. There are two basic types but clinically some overlapping does occur. The focal type is due to a leaking microaneurysm, the exudate is a high molecular weight lipoprotein clinically constituting hard exudates and spreading around the culprit microaneurysm in a circinate pattern. The diffuse oedema is due to capillary leakage oozing out low molecular weight watery fluid creating cystoid spaces. Usually the condition is bilateral and associated with systemic conditions like H.T., renal failure, anemia and hypoprotenemia.
When would this condition cause visual disturbances? It is when the foveal region is threatened. Early identification of this situation is done by slit-lamp biomicroscopy using fundus contact or non contact lenses. The central 500mu circle of foveal avascular area is scrutinised for the retinal thickening. Even if the centre of fovea is not involved, the danger to visual acuity exists if the pathology is touching the boundary. A large area of retinal oedema even a disc diameter away from centre of macula is clinically significant from treatment point of view.
How common is the condition ? Is the trouble of considering this worth it's while? The answer lies here. Ten percent of all diabetics will have some kind of retinopathy. Of those who have retinopathy, 40% will have CSME i.e 2.5% of all diabetics need some laser treatment. If you consider only BDR cases 3% need attention for CSME. The prevalence increases with advancing retinopathy to 38% for PPDR and 71% in PDR group. 5% of maturity onset insulin dependent diabetics have retinopathy at the time diagnoses and not uncommon to have ophthalmologist diagnose it from fundus examination for the first time. The prevalence of the disease is directly proportionate with duration of hyperglycaemia.
Diabetis control and complications trial was a prospective and randomised clinical trial designed to study the connection between glycacaemic control and retinal, renal and neurologic complications. Control of hyperglycaemia is shown to help in delaying the onset and slowing the progression of retinopathy in type 1 IDDM. On the other hand in cases of mild to moderate NPDR in NIDDM who were put under strict control later on, showed worsening of retinopathy. Hence in clinically significant cases photocoagulation should not be delayed in waiting for blood sugar to be normal. Control of HT, renal failure, anaemia, hypoprotemia are helpful adjuvants to photocoagulation. Laser photocoagulation is the treatment for macular oedema and has been supported by many clinical trials out of which early treatment diabetic retinopathy study needs special mention. It is one of the best scientifically conducted multicentric prospective trials in the field of medicine as a whole and not only ophthalmology.
It was aimed to judge the efficacy of laser treatment for macular oedema, to decide about optimal timing to initiate PRP in cases of severe NPDR and to evaluate the role of aspirin in management of diabetic retinopathy.
Fluorescein angiography helped in differentiating focal and diffuse oedema and identified the culprit microaneurysms in focal oedema group. This made laser treatment with slit-lamp delivery and Mainster lens more precise. The cases were followed up at regular intervals and repeat FFA & additional laser treatment give as required.
FFA though not essential for diagnosis of CSME, is useful in locating the leaking MA in focal edema, understanding capillary drop-outs and dilatations in diffuse edema, mapping out FAZ and diagnosis of macular ischemia. It can also help in locating IRMA and early NV.
Progressive enlargement of FAZ is seen with advancing retinopathy. This can greatly worsen the prognosis and laser will not help.
Steady and variable magnification, choice of spot size, safeguarding foveola, pricision of laser delivery are possible only with good slitlamp delivery system. Choice for various contact lenses lies with the surgeon, I prefer mainster lens for it’s wide field. This keeps the disc, macula and arcades in view and prevents foveal burns. The picture is inverted but with practice it does not bother us.
The focal macular oedema is treated by coagulating the culprit microaneurysm identified by FFA or one present in the centre of circinate exudate. Excessive burns should be avoided in other areas.
Slide on left shows exudates close to fovea and FFA picture on right shows MA
On left are the fresh laser burns and on right the photograph after three months.
Grid pattern photocoagulation for defuse macular edema. 500 mu from centre of foveola and lateral margin of disc are spared.
We reviewed our cases of BDR with CSME to analyse the results of focal and grid laser photocoagulation and to compare the visual gain in early and late treated cases
Total of 90 eyes from 66 patients were reviewed. Excluding the other possible ocular causes of vision loss, associated systemic conditions like Hypertension and impaired cardiac and renal status which may contribute to the loss of visual acuity.
Out of 68 eyes with focal oedema, 53 had visual acuity > or = 6/36. 15 had vision <6/36 at the time of treatment. Out of the diffuse oedema group, all presented with vision < 6/36.
The results were analysed as per the improvement in vision on Snellen's chart by more than one or two lines. In the focal oedema group the improvement was noted in 61 of 68 eyes by one line and 32 of 68 eyes by two lines. Out of 22 eyes in the diffuse oedema group treated with grid laser, improvement was noted 14 eyes for more than one line and 5 eyes gained more than two lines.
The cases which presented with initial visual acuity better than or - 6/36, had better gain in post laser vision than those which presented with vision < 6/36.
Early treatment for CSME has shown better results as the foveal function is not yet compromised.
Inability to judge CSME early, leads a physician and sometimes an ophthalmologist to avoid reference for laser even in symptomatic patients. They advise better control of diabetes and delay laser treatment. Some ophthalmologists are known to start antioxidents, asperin and even steroids and worsen the prognosis by avoiding early laser treatment. Non avaibility of laser machines is one of the causes.
This means advising photocoagulation even with 6/6 vision if clinically the fundus picture shows CSME
Missing diabetic retinopathy before cataract surgery can ruin the results of good phaco as there is sudden worsening of retinopathy within a month post-op.
Regular followup is necessary even after successful treatment for CSME to recognise the signs of early PDR. Early initiation of PRP is advocated by ETDRS if the other eye has PDR, if cataract surgery is due, if patient is pregnant, if follow up is irregular. Once vitreous haemorrhage occrs, laser treatment becomes difficult.