1. This document describes a clinical trial that evaluated the safety and efficacy of ranibizumab injections compared to sham injections for treating diabetic macular edema (DME).
2. A total of 151 patients with DME were randomly assigned to receive either 0.3 mg, 0.5 mg ranibizumab injections, or sham injections monthly for 12 months.
3. The results showed that ranibizumab led to significant improvements in best corrected visual acuity and retinal thickness compared to sham injections over the 12-month period, establishing ranibizumab as an effective treatment for DME.
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.
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.
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.
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.
Dear Friends,
This presentation is basically targeted for MD Residents and Ophthalmologists who are tired of going through many presentation to get full practical information regarding Diabetic Retinopathy.You will get mainly full practicle information( rather than long tiring theoretical presentations) needed for your clinical practice.Pls dont forget to give feedback
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.
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
Dear Friends,
This presentation is basically targeted for MD Residents and Ophthalmologists who are tired of going through many presentation to get full practical information regarding Diabetic Retinopathy.You will get mainly full practicle information( rather than long tiring theoretical presentations) needed for your clinical practice.Pls dont forget to give feedback
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.
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
In this case-based presentation, Dr. Lori Myers unscrambles the alphabet soup of Diabetic Retinopathy, providing clear explanations and outstanding images to describe the diagnosis, risk stratification, and treatment of diabetic retinopathy.
This presentation introduces myopia, high myopia, and in more details, pathologic myopia (aka malignant myopia). It is intended for training ophthalmologists, ophthalmology residents, medical students in ophthalmology rotations.
Biological screening of herbal drugs: Introduction and Need for
Phyto-Pharmacological Screening, New Strategies for evaluating
Natural Products, In vitro evaluation techniques for Antioxidants, Antimicrobial and Anticancer drugs. In vivo evaluation techniques
for Anti-inflammatory, Antiulcer, Anticancer, Wound healing, Antidiabetic, Hepatoprotective, Cardio protective, Diuretics and
Antifertility, Toxicity studies as per OECD guidelines
Embracing GenAI - A Strategic ImperativePeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Welcome to TechSoup New Member Orientation and Q&A (May 2024).pdfTechSoup
In this webinar you will learn how your organization can access TechSoup's wide variety of product discount and donation programs. From hardware to software, we'll give you a tour of the tools available to help your nonprofit with productivity, collaboration, financial management, donor tracking, security, and more.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
Macroeconomics- Movie Location
This will be used as part of your Personal Professional Portfolio once graded.
Objective:
Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
4. RESOLVE trial design
Randomized 1:1:1
Sham (n = 49)
Baseline fundus photograph, FA, and OCT (reading center)
Investigator identifies potential patients with
DME with center involvement
Photocoagulation after
3 injections if needed
Assessment if
“increase” is needed
Increase to
0.6 mg if needed
Ranibizumab
0.3 mg (n = 51)
Ranibizumab
0.5 mg (n = 51)
Increase to
1.0 mg if needed
After
1 month
Months 3–12
treatment on demand based
on success,
futility, and safety criteria
Monthly
injections
DME, diabetic macular edema; FA, fluorescein angiography
OCT, optical coherence tomography
Phase II, double-blind, multicenter study
5. Study objectives and endpoints
Objective:
-- Safety and efficacy of Ranibizumab in DME
involving the foveal center.
Primary endpoints
– Group A:
Demonstrate superiority of Ranibizumab to sham in
reducing macular edema from baseline to Month 6
in DME
– Group B:
Confirm the efficacy of Ranibizumab on VA as mean
average change from baseline through to Month 12
6. Study objectives and endpoints
Secondary endpoints
– Explore the treatment effect on VA, retinal
structure, and need for laser photocoagulation
– Explore the superiority of Ranibizumab in reducing
macular edema compared with sham
7. Key inclusion criteria
• Male / female patients >18 years of age
• Diabetes mellitus type 1 or type 2
• HbA1C ≤ 12.0%
• DME with center involvement in at least one eye
(focal or diffuse)
• Eligibility criteria for the study eye at Visit 1
– central macular thickness must be ≥300 µm in the center
subfield, as assessed by OCT and confirmed by the central
reading center
– best-corrected visual acuity letter score between
73 and 39
8.
9.
10. Baseline demographics and
ocular disease characteristics
Age, years
Mean (range)
Gender, n (%)
Female
Male
Race, n (%)
Caucasian
Black
Asian
Other
DME type (RC), n (%)
Focal
Diffuse
Questionable
Cannot grade
Missing
Time since first DME diagnosis, years
Mean (range)
Ranibizumab 6 mg/mL
(n = 51)
Ranibizumab 10 mg/mL
(n = 51)
Sham
(n = 49)
63.2 (37-85)
22 (43.1)
29 (56.9)
47 (92.2)
0
4 (7.8)
0
21 (41.2)
27 (52.9)
1 (2.0)
2 (3.9)
0
1.2 (0-7.2)
62.8 (32-84)
24 (47.1)
27 (52.9)
44 (86.3)
0
4 (7.8)
3 (5.9)
25 (49.0)
25 (49.0)
0
0
1 (2.0)
1.14 (0-7.2)
65.0 (41-82)
24 (49.0)
25 (51.0)
41 (83.7)
1 (2.0)
5 (10.2)
2 (4.0)
25 (51.0)
24 (49.0)
0
0
0
1.40 (0-19.8)
All patients, groups A+B randomized set; RC, reading center
11. Exclusion criteria
• Unstable medical status
• Pan retinal photocoagulation performed within 6
months before study.
• Grid/central laser photocoagulation
Except for patients with only mild laser burns at least
1,000 µm from the center of the fovea performed >
6 months preceding day 1
12. Treatment adjustments:
Dose-doubling was performed under the following
conditions:
• Retinal thickness in the study eye remains >300 µm at
the Month-1 visit following baseline injection
or
• Retinal thickness in the study eye is >225 µm and a
reduction in retinal edema from the previous assessment
is <50 µm, at any monthly visit after Month 1 following
the baseline injection
1Kvanta et al. Invest Ophthalmol Vis Sci 1996; 37: 1929-1934
2Jonas & Neumaier. Ophthalmic Res 2007; 39: 139-142
13. Treatment adjustments (cont)
• Once the injection volume was increased to 0.6 ml,
subsequent administrations remained at 0.6 ml (0.6
or 1.0 mg ranibizumab)
• If treatment had been withheld for 45 days,
subsequent injections restarted with the initial
injection volume of 0.3 ml or 0.5 ml.
14. Treatment adjustments:
success and re-initiation criteria
Discontinuation because of success if
• Retinal thickness in the study eye is ≤225 µm
and
• BCVA is ≥79 letters (≥20/25) at any visit following the
third injection
Re-initiation of treatment if
• Retinal thickness increases by ≥50 μm
or
• VA decreases by ≥5 letters and is <74 letters
15. At the investigator’s discretion:
Discontinue treatment if no borderline
improvement after 3 consecutive injections
Borderline improvement defined as:-
•Retinal thickness in study eye decrease ≥50 µm
and represents at least a 20% reduction
or
•Increase in BCVA of ≥ 5 letters
Treatment adjustments:
futility criteria
16. Treatment adjustments
laser rescue
Criteria for laser rescue treatment after 3 consecutive
monthly Ranibizumab / sham treatments
>10 letter decrease in BCVA at 2 consecutive visits
≥1 month apart
and
The investigator does not consider the macula flat
as assessed by OCT (defined as ≤225 µm).
24. Conclusions - Efficacy
• The mean average change in BCVA from baseline to
month 1 through 12 was statistically superior with
ranibizumab (7.8 letters) compared with sham (-1.4
letters)
• The mean change in CRT from baseline to month 12
was significantly higher in the ranibizumab arm than
in the sham arm (194.2 vs. 48.4 um).
25. Conclusions - safety
• The ocular SAEs in the study eye was comparable
between the treatment arms ranibizumab: 3.9%
• Most of the SAEs were nonocular in origin in
ranibizumab 13.7%.
• AEs was comparable between the ranibizumab
62.7%.
26. Author’s interpretation
• Ranibizumab led to significant and continuous
improvements in both BCVA and CRT over 12
months compared with sham treatment in
patients with VI due to DME.
• Future clinical trials are required to confirm its
long-term efficacy and safety
27. My interpretation
• Well designed study
• Sample size, randomization and base line
distribution were perfect
• Financial biasness
28.
29. Diabetic macular edema
Definition / Classification
ETDRS:
– Thickening of the retina and/or hard exudates
within 1 disc diameter of the center of the macula
Retinal Edema = Increased thickening of the retina
Intracelullar
Extracelullar
30. Epidemiology
1. Wild S et al. Diabetes Care 2004;27:1047–1053. 2. King H et al. Diabetes Care 1998;21:1414–1431. 3. Chen E et al. CMRO
2010;26:1587–1597. 4. RNIB and EpiVision. 2009; Future sight loss UK (2): An epidemiological and
Leading cause of visual impairment
Prevalence of diabetes expected to approximately double
globally between 2000 and 2030
Number of diabetes cases estimated to reach 300 million
world wide by 2025
˃50% of patients lose ˃2 lines of visual acuity within 2
years
In the UK, prevalence of DME
– Estimated to be 187,842 in 2010
– Expected to increase to 235,602 in 2020
31. Pathogenesis of macular oedema
• Vascular Endothelial Growth Factor ( VEGF) is
released from ischemic retina
• Aqueous VEGF level remains elevated
• VEGF 165 binds with VEGFR-1 & VEGFR-2 causes-
Loss of tight junction between endothelial cells
Formation of fenestration within endothelial cells
Calcium mediated permeability channel resulting in
loss of inner and outer blood-retinal barriers
32. • Thick Henles layer allows for more fluid to
collect
• Avascularity of central area limits fluid
absorption
• Thin basal lamina provides easy access to
inflammatory products and toxins
33. OCT classification of DME
The first OCT-classification of DME (Otani et al.1999)is based on
retinal morphological changes:
• Sponge-like swelling
• Cystoid oedema
• Serous retinal detachment
• Diffuse macular oedema
Classifications are presented by several authors
• Kang et al., 2004;
• Panozzo et al., 2004;
• Kim et al., 2006;
40. Ischaemic Diabetic
macular oedema
• Dot and blot
heamorrhage
• Cottonwool spot
• FA showis capillary drop
out or non perfusion at
the macular area and
elsewhere.
41. Clinically Significant Macular Edema
(ETDRS)
Retinal thickening
within 500 μm of
the center of the
macula
Hard exudates at or
within 500 μm of
the center of the
macula (if associate
with retinal
thickening of the
adjacent retina
.
Retinal thickening
one disc area (1500
μm) or larger, any
part which is within
one disc diameter of
the center of the
macula.
42.
43. • Desislava Koleva-Georgieva (University Eye Clinic,
University Hospital”St. George”, Bulgaria) proposed in
2012
• Summarizes from several quantitative and qualitative
OCT data
• Classified based on:
Retinal thickness
Retinal morphology
Macular traction and
Foveal photoreceptor status
44. A. Retinal thickness:
1. No macular edema
2. Early subclinical macular
edema –
3. Established macular edema
C. Presence and severity of
macular traction (incomplete
PVD and/or ERM):
1. No macular traction
2. Questionable macular
traction
3. Definite macular tractionB. Retinal morphology:
1. Simple non-cystoid macular
edema
2. Cystoid macular edema
2.a. Mild cystoid macular
edema
2.b. Intermediate cystoid
macular edema
2.c. Severe cystoid macular
edema
3. Serous macular detachment
D. Retinal outer layers
integrity (IS/OS and ELM):
1. IS/OS and ELM intact
2. IS/OS and ELM with
disrupted integrity
45. I. Retinal thickness:
1. No macular edema – normal macular morphology
and thickness.
2. Early subclinical macular edema – no clinically
detected retinal thickening on ophthalmoscopy, OCT
measured retinal thickness.
3. Established macular edema – retinal thickening and
evident morphological characteristics of oedema.
46. Simple non-cystoid macular edema
Increased retinal thickness
Reduced intraretinal reflectivity
Irregularity of the layered structure
Flattening of the foveal depression, without
presence of cystoid spaces
47. Cystoid macular edema
Criteria of non-cystoid macular edema
+
intraretinal cystoid spaces
a. Mild cystoid macular edema –
cystoid spaces with horizontal diameter < 300μm
48. b. Intermediate cystoid
macular edema –
cystoid spaces with
horizontal diameter ≥
300μm < 600μm
c. severe cystoid macular
edema –
cystoid spaces with
horizontal diameter ≥
600μm,or large confluent
cavities with retinoschisis
appearance
49. 3. Serous macular detachment –
• Any of the above, associated with
• Serous macular detachment hyper-reflective line of
the pigment epithelium
50. IV. Presence and severity of macular traction (incomplete
PVD and/or ERM):
1. No macular traction – Presence of complete PVD or no
PVD and no ERM
51. 2. Questionable macular traction –
Incomplete PVD with perifoveal or peripapillary
adhesion and/or globally adherent ERM without
detectable distortion of retinal surface contour at the
points of adhesion
52. 3. Definite macular traction –
Incomplete PVD with perifoveal adhesion and/or
focal ERM with detectable distortion of retinal
contour at the points of adhesion
53. V. Retinal outer layers integrity (IS/OS and ELM):
IS/OS and ELM intact (fig. A);
IS/OS and ELM with disrupted integrity (fig. B).
54. Treatment of DME
Systemic control
• Metabolic control
• Blood pressure control
• DM control
• Lipid lowering
Local control
• Focal /Grid laser
• IVTA /Ozudex
• Ing Anti VEGF
• Combination with
Vitrectomy.
55. Standard therapy
• Focal and/or grid laser
• Recent trials: gain 0.9 letters to 3 letters
Mitchell P, Bandello F, Schmidt-Erfurth U, Lang GE, Massin P, Schlingemann RO et al. The RESTORE study: ranibizumab
monotherapy or combined with laser versus lasermonotherapy for diabetic macular edema. Ophthalmology 2011; 118: 615–
625
Elman MJ, Aiello LP, Beck RW, Bressler NM, Bressler SB, Edwards AR et al. Randomized trial evaluating ranibizumab plus prompt
or deferred laser or triamcinolone plus prompt laser for diabetic macular edema Ophthalmology 2010; 117: 1064–1077
63. RESTORE study
Total patient
345 > 18 years
Ranibizumab
+
Sham laser
n - 116
Ranibizumab
+
laser
n-118
Sham injection
+
laser
n -111
Mean
average change in
BCVA letter score
from baseline to
month 1 through 12
6.1 5.9 0.8
The mean central
retinal thickness
was
significantly
reduced from
baseline
- 118.7 - 128.3 - 61.3
Conclusion: Ranibizumab alone or combined with laser
were superior to laser monotherapy
69. BOLT
• Inj. Bevacizumab vs macular laser
• Mean VA 20/50 vs 20/80 at 2 years
• Gain of 9 letters vs 2.5 letters
• Conclusions: provides evidence supporting
longer term use of Inj. Bevacizumab
72. • IVB, Laser and 2 mg IVTA
• 50 patients in each group
• Conclusions: Intravitreal bevacizumab injection in
patients with DME yielded a better visual
outcome at 24 weeks compared with macular
photocoagulation.
• No adjunctive effect of IVT was demonstrated
73.
74.
75. Conclusions
• The safety profile of Ranibizumab in patients with
DME was similar to that reported in patients with
AMD
• Ranibizumab is effective in improving BCVA ,
reducing CRT and well tolerated in DME.