Diabetic Maculopathy1 Gos2

04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre

Diabetic Maculopathy Diabetic Maculopathy Dr. Anand SudhalkarDr. Anand Sudhalkar


How is the vision lost?How is the vision lost?

Macular oedema, Macular oedema, ischemia. Foveal ischemia. Foveal exudatesexudates

Vitreous Vitreous Haemorrhage, Haemorrhage,

Tractional Retinal Tractional Retinal DetachmentDetachment


Classification of D.R.Classification of D.R.

NPDRNPDR : : MildMild ( few dot haem. microanuery.) ( few dot haem. microanuery.) ModerateateModerateate : Blot Haem, Soft exud. : Blot Haem, Soft exud. SevereSevere : Preproliferative stage : Blot : Preproliferative stage : Blot Haem Haem 44 Quadr. , Venous Beading Quadr. , Venous Beading 22 quadrants, IRMA quadrants, IRMA 11 quadrant. ( 45% go to quadrant. ( 45% go to PDR in one yr.)PDR in one yr.)

PDRPDR : Neovascularisation : Neovascularisation High Risk : NVD > 2/3 rd, NVE 2 High Risk : NVD > 2/3 rd, NVE 2 places, V.H.places, V.H.

Macular oedema can occur at any stage.Macular oedema can occur at any stage.


Types of Macular OedemaTypes of Macular Oedema

FocalFocal : M.A., High MW lipoproteins, : M.A., High MW lipoproteins, Hard exudates, Circinate patterns.Hard exudates, Circinate patterns.

DiffuseDiffuse : Capillary bed leakage, Low : Capillary bed leakage, Low MW watery fluid, cystoid spaces, MW watery fluid, cystoid spaces, Bilaterality - Systemic causes, HT, Bilaterality - Systemic causes, HT, Renal Failure, Hypoprotein. Renal Failure, Hypoprotein.

UntreatedUntreated, 50%, 50% loose loose > 2> 2 lines in lines in two yearstwo years

7


What is CSME?


PREVALENCEPREVALENCE 10% AMONGST ALL DM10% AMONGST ALL DM 40% Of these have CSME40% Of these have CSME Out of all BDR 3% have CSMEOut of all BDR 3% have CSME Out of all PPDR 38% have CSMEOut of all PPDR 38% have CSME out of all PDR 71% have CSMEout of all PDR 71% have CSME 5% of maturity-onset, IDDM at diag.5% of maturity-onset, IDDM at diag. Prevalence Prevalence Duration of Hyperglycemia Duration of Hyperglycemia After 20 yr. 99% of IDDM and 60% of NIDDM After 20 yr. 99% of IDDM and 60% of NIDDM

have retinopathyhave retinopathy 2


Treatment OptionsTreatment Options

Medical Management : Control of Medical Management : Control of Diabetes, HT, Renal failure, anaemia, Diabetes, HT, Renal failure, anaemia, hypoprotemia, pregnancy, carotid hypoprotemia, pregnancy, carotid artery diseasesartery diseases

Laser Photocoagulation : Patz 1973, Laser Photocoagulation : Patz 1973, British Multicenter Trial 1975, British Multicenter Trial 1975, Blankenship 1979, Olk 1986, Blankenship 1979, Olk 1986, ETDRS ETDRS 1985 (ongoing)1985 (ongoing)


ETDRS Multicentric TrialETDRS Multicentric Trial

Treated 754, Deferred 1490Treated 754, Deferred 1490 After 3 yr. visual loss 12% in treated, After 3 yr. visual loss 12% in treated,

24% in untreated.24% in untreated. When centre of macula was When centre of macula was

involved, treatment effect was more involved, treatment effect was more significant at 3 yr.. Visual loss 13% significant at 3 yr.. Visual loss 13% against 33%against 33%


Treatment ProtocolTreatment Protocol

FFA to identify microaneurysms FFA to identify microaneurysms /capillary leakage & dropouts/capillary leakage & dropouts

Focal / grid laser Focal / grid laser Follow-ups 3 to 6 weekly, for Follow-ups 3 to 6 weekly, for

minimum 6 months and maximum minimum 6 months and maximum 3 years3 years

Repeat FFA & Additional laser if Repeat FFA & Additional laser if requiredrequired


Role of FFA:Role of FFA:

Identify M.A.Identify M.A.

Map area of cap. dropMap area of cap. drop

Study FAZStudy FAZ

Identify IRMA & NVIdentify IRMA & NV

5


FFA taken 4 years Apart

F.A.Z. enlargement


Principles of Management : Principles of Management : Laser deliveryLaser delivery

Slit-Lamp Magnification Enlarged & Steady View


Focal Oedema : Focal LaserFocal Oedema : Focal Laser

Identify Culprit Identify Culprit M.A. by FFAM.A. by FFA

Identify Centre of Identify Centre of FoveaFovea

Green Wave, Green Wave, Mainster lens, Mainster lens, Short duration, Short duration, 100um size, 100um size, minimum treatmentminimum treatment

Be On Target


Pre-laser FFA

microaneurisms


Post Laser Treatment


Diabetic Macular Diabetic Macular Oedema : Oedema : DiffuseDiffuse

GRIDGRID Laser Photocoagulatiopn Laser Photocoagulatiopn C-Shaped, 100um, Green Laser C-Shaped, 100um, Green Laser Followup 3 months Followup 3 months


Clinical Study : Goals and Clinical Study : Goals and ObjectiveObjective

Review the cases of Review the cases of BDRBDR treated treated for for CSMECSME

Study the efficacy ofStudy the efficacy of focalfocal and and gridgrid P.CP.C

Find the difference in the results in Find the difference in the results in ‘ ‘earlyearly’ and ‘’ and ‘delayeddelayed’ treated ’ treated casescases


Study of Study of CSME + BDRCSME + BDR

90 eyes90 eyes of of 6666 patients reviewed. patients reviewed. ExcludingExcluding cases with other ocular cases with other ocular pathologies, H.T. , Impaired cardiac pathologies, H.T. , Impaired cardiac & renal status& renal status

Age group Age group 43 to 7543 to 75 years years Diabetic age Diabetic age 1 to 30 years1 to 30 years Duration of visual loss Duration of visual loss 15 days to 1 15 days to 1

yearyear


Sub-classificationSub-classification Focal Focal and and DiffuseDiffuse Pre-treatment Visual AcuityPre-treatment Visual Acuity

Snellen Acuity >6/36 <6/36

Focal (68eyes)

53 15

Diffuse (22) 00 22

Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre

04/12/23

Assessment of ResultsAssessment of Results

VisionGain/loss

>1 line > 2lines

Stable Worse

Focal68eyes

61 eyes89.71%

32eyes47.06%

5eyes7.35%

2eyes2.95%

Grid22eyes

14 eyes63.63%

5eyes22.72%

6eyes27.27%

2eyes9.10%

Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre

04/12/23

Vision at the Time of Vision at the Time of Treatment Treatment

Initial vision > 6/36 Initial vision > 6/36 out of out of 5353 eyes:-eyes:-

51 51 ( 96.22%) ( 96.22%) improved by > one improved by > one lineline

2727(50.94%) (50.94%) improved by > two improved by > two lineslines

Initial vision <6/36 Initial vision <6/36 out of out of 1515 eyes:-eyes:-

10 10 (73.34%) (73.34%) improved by > improved by > one lineone line

5 5 ( 33.33%) ( 33.33%) improved by > improved by > two linestwo lines


Duration of Visual Loss at Duration of Visual Loss at the Time of Presentationthe Time of Presentation

Presented within one month : Presented within one month : ……………………………………………………………………………………………..90% improved…..90% improved

Presented after one year : Presented after one year : …………………………………………………………………………………………………62.5% improved………62.5% improved


Delay in ReferenceDelay in Reference

‘ ‘ BenignBenign ‘ looking retinopathy ‘ looking retinopathy Waiting for ‘Waiting for ‘betterbetter’ control ’ control

diabetesdiabetes Starting antioxidantsStarting antioxidants, aspirin, , aspirin,

steroid dropssteroid drops Non-availability of Non-availability of laser facilitylaser facility


Conclusions :Conclusions :

Early recognition of fovea Early recognition of fovea threatening threatening CSME

Fluorescein angiography & slit-lamp biomicroscopy to identify M.A

Prompt photocoagulation with slit-lamp delivery system

Regular follow-ups and repeat treatments


Message : Message : ETDRS REPORT ETDRS REPORT 1919

Recommends Recommends photocoagulation before the photocoagulation before the foveal vision loss occursfoveal vision loss occurs

In In clinically significant clinically significant diabetic macular oedemadiabetic macular oedema


Exacerbation Exacerbation afterafter Cataract SurgeryCataract Surgery

Diabetes and CataractDiabetes and Cataract


Special Considerations :Special Considerations :

NPDRNPDR requiring requiring PRP PRP 4, 2, 1 criteria 4, 2, 1 criteria PDR in other eye PDR in other eye PregnancyPregnancy

Diabetic Maculopathy1 Gos2

Documents

Transcript of Diabetic Maculopathy1 Gos2