Diabetic eye disease Macular degeneration Sam S. Dahr, M.D. Retina Center of Oklahoma www.RCOklahoma.com [email protected]

Downloaded from: The Retina (on 28 May 2007 12:48 AM) © 2007 Elsevier

Diabetic retinopathy

“Sick capillaries” Downloaded from: The Retina (on 28 May 2007 12:48 AM) © 2007 Elsevier

Symptoms—fairly nonspecific Diminished central vision Scotomas—islands of vision loss Fog in peripheral vision Floaters

Diabetic retinopathy

Downloaded from: The Retina (on 28 May 2007 12:48 AM) © 2007 Elsevier

Global Diabetic retinopathy project group Ophthalmology 2003; 110: 1677

Retinopathy Grade Mild-> follow q 6-12 months Moderate->follow q 4-6 months Severe->follow q 3-4 months Proliferative-> treat with PRP, then follow q 2-4 months.

Macular edema grade • Present or absent • If present, is it • Clinically significant-> recommend focal laser • Not clinically significant • ->observe every 2-4 months

How does diabetes reduce vision? Macular edema Macular ischemia Macular atrophy Vitreous hemorrhage Tractional retinal detachment

Macular edema options: depends on pattern • Focal island-> focal laser. • Cystoid edema -> consider injection. • Diffuse edema -> consider injection followed by grid laser. • Edema may be aggravated by PRP.

Macular edema considerations • Timing • Relationship to retinopathy grade • Relationship to systemic blood sugar, blood pressure, cholesterol, and extracellular fluid status • Epiretinal membrane/taut hyaloid

Macular ischemia

Thinning/Atrophy in macula

Scatter laser

Vitrectomy surgery • Vitreous hemorrhage • Tractional retinal detachment from scar tissue buildup on retina

Tractional detachments Causes: diabetes, sickle cell, trauma, von Hippel Lindau disease. Key principles Remove the posterior hyaloid. Minimize iatrogenic breaks.

Evolving non-laser therapies for diabetic retinopathy • Subtenons steroid injection • Intravitreal steroid injection • Intravitreal Avastin injection

Diabetic retinopathy • Laser is still a mainstay of therapy. • With good compliance, very few patients go blind upon long term followup (Ophthalmology 2003; 110: 1683). • Intravitreal anti-VEGF therapy and/or steroid may be useful in special situations.

Take care of yourself Blood sugar Blood pressure Cholesterol Extracellular fluid status Weight

Age-related macular degeneration AMD ARMD

Presenting symptons • Diminished central vision • Distortion or “wavy lines”

Downloaded from: The Retina (on 28 May 2007 12:48 AM) © 2007 Elsevier

Risk factors for Advanced AMD Age Family history Complement factor H mutation Smoking Elevated CRP UV exposure?

Age-Related Eye Disease Study (AREDS) Randomized Participants N=4757

Placebo N=1,483

Antioxidant N=1,482

Zinc N=904

Antioxidant & Zinc N=888

Results published 2001

Category 3 – Extensive Intermediate or Large Drusen (>125 microns)

Category 4: Neovascular AMD or Central Geographic Atrophy in 1 eye

Rate to Advanced AMD AMD Categories 3 and 4 by Treatment Group

Estimated Probability

Placebo Antioxidants Zinc Antioxidants + Zinc

40%

28%

30% 20%

20% 10%

P vs. A+Z – p