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Daniel M. Schwartz, MD

Professor of Clinical Ophthalmology

Director Retina Division

UCSF

Disclosure

Co-inventor of OCT-Angiography with Scott Fraser and Jeff Fingler from Caltech

Retina Diabetes affects the retina’s small blood vessels in 3 ways: Abnormal leakage

Closure

Growth of fragile, new blood vessels

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Normal Retina- Left Eye Non-Proliferative Diabetic Retinopathy

Leaky Capillaries Cause Macular Edema

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Fluorescein Angiography-Intravenous Injection of Dye

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Old Therapy

Focal laser

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Blood vessel closure in diabetes

Growth of new blood vessels in diabetes (neovascularization)

Proliferative Diabetic Retinopathy: Neovascularization

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Hemorrhage Vitreous Hemorrhage

Treatment of Diabetic Neovascularization: Laser Panretinal Photocoagulation

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Two Big Changes in Management of Diabetic Macular Edema

Optical Coherence Tomography (OCT) Has replaced contact lens exam

Anti-VEGF injections Have replaced focal laser

Cross Section of Normal Retina Through Macula

High Resolution OCT: Optical Biopsy

OCTHISTOLOGY

Macular Edema

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Intravitreal Injections of Anti-VEGF Agents for Diabetic Macular Edema:Stops Leakage from Microaneurysms

and Improves Vision

Anti-VEGF for Diabetic Macular Edema

412 microns

1 month later afterAnti-VEGF 282 microns (normal)

Proliferative Diabetic Retinopathy: Neovascularization: Important Role

of Detection

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Diabetic Retinopathy:Detailed Periodic Clinical Exams

to Prevent Visual Loss

Peripheral neovascularization Diabetic Retinopathy

Fluorescein angiography superior to color photos for characterizing

retinopathy

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Neovascularization Very Easy to See with FA

Fluorescein Angiography: Not a Popular Test Among Patients Pupillary dilation

Yellow skin

Discomfort from bright lights

Multiple sticks to gain venous access

Occasional allergic reaction to dye

30 minute test

For all the above reasons, not used as a screening test for diabetic retinopathy

High Resolution OCT: Has Changed Evaluation and Treatment of Diabetic

Macular Edema

But, doesn’t show retinal microvasculature

Conventional OCT

OCT produces an interference signal between a controlled reference reflection and a sample reflection which depends on the relative positions of the reflections

The amplitude of this signal is the quantity used in conventional OCT images

Lc

OCT Amplitude

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Phase Variance OCTA more precise measure of position can be calculated from the interference oscillation - called phase

The red dots show the phase position for two successive images with small relative motion occurring. While the OCT intensity is constant, the motion can clearly be observed.

While depth resolutions are possible down to 2m, phase change measurements allow for motion to be observed as small as 2nm!

(1000 times better than the imaging resolution)

The mean and variance of the phase changes measured will be the basis of motion contrast

Depth Imaging of Small Retinal Blood Vessels with OCT-A

Software

OCT-Angiography 45 degreewide-field image

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Capillary Nonperfusionin NPDR

Neovascularization by OCT‐A

Implications for Diabetes Screening and Follow up Examinations

45% of patients with diabetes never make it to their annual appointment with ophthalmologist

But, they do see the primary care physician and go to the pharmacy

PCP or Pharmacy

READING CENTER

OCT-Angiography OCT-A is a software tool that renders

angiographic images from OCT scanning data

Multiple potential imaging sites Ophthalmology, Optometry, Primary Care,

Pharmacies

Goal is to make it easy for patients with diabetes to get retinal evaluation

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Diabetic Retinopathy Misconceptions Corrected Throw out the old ideas about inescapable

blindness from diabetes Outdated natural history studies

○ Prior to recognition that control of blood glucose was critical

Power of metabolic control

We’ve got treatments for the outliers to keep them seeing

Examination schedule and its modifications based on any retinal changes

Read any article on diabetic retinopathy, and they’ll quote the Klein’s

Early 1980’s, Wisconsin cohort

Virtually all Type 1 diabetics had some retinopathy 20 years after diagnosis

Mean HbAIC in this often quoted study = 10.1

In1978 textbook, Epidemiology of Diabetes and Its Vascular Lesions, West writes, “The extent to which the level of hyperglycemia determines the risk of retinopathy is not at all clear. This is the most important issue at hand and deserves high priority in epidemiologic research“

Importance of Blood Glucose Control Type 1 DM

DCCT (1993)

1441 pts

6.5 yr average follow up

HbAIC Intensive 7.3 versus Conventional 9.0

Translates to 74% reduction in development of

retinopathy; 54% reduction in progression

Epidemiology of DiabetesInterventions and Complications (EDIC)-10 yr additional follow-up of DCCT Patients

HbAIC 8.0

Extremely low incidence of severe visual loss Of 596 patients (1192 eyes), 4 eyes were

20/200 or less. Of these 4, in only ONE eye was the visual loss due to diabetes!

# of legally blind patients = ZERO!

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Klein R, Klein BE. Are individuals with diabetes seeing better?: a long-term epidemiological perspective.Diabetes. 2010 Aug;59(8):1853-60.

The Klein’s recant: “Data from epidemiological studies have

shown remarkable improvements in the care and management of diabetes associated with significant decreases in the prevalence and incidence of diabetic retinopathy…”

Examine

Type 1: within 5 years diagnosis

Type 2: time of diagnosis

Goals of examination Classify retinopathy follow-up schedule

Determine if treatment required

Recent Article in Leading Ophthalmology Journal on Diabetic Eye Disease

In addition to treating retinopathy, ophthalmologists can play an important role in educating and motivating patients to achieve better metabolic control, which, if successful, potentially could do more to reduce the progression of retinopathy than any of the ocular treatments currently in the armamentarium of theophthalmologist.

Summary Throw out the old pre-conceptions of diabetic

visual loss Outdated natural history studies

○ Prior to recognition that control of blood glucose was critical

Power of metabolic control in reducing development and progression of diabetic retinopathy

We’ve got laser and drug treatments for the minority of patients that require therapy

OCT-A may replace fluorescein angiography Follow up is critical, since often diabetic eye

disease is asymptomatic