We prefer to let the coricosteroids carry out a

reduction of the macular volume in order to

selectively photocogulate the fundus

achieving a more local effect with less energy

diffusion and photoreceptor destruction

Selective multifocal laser

over the exudative spotsguided by OCT and angiography

WHAT ABOUT DME? We choose a different way combined medical approachJosé Juan Escobar Barranco, Begoña Pina Marín, Manel Fernández Bonet

•Conclusions

•Methods

•Purpose

•Results

•Take Home

•The main cause of blindness in type II diabetic patients is

macular edema.•The diabetic macular edema (DME) has a complex

multifactorial pathogenesis involving the alteration of the

blood-retinal barrier, hipoxia which initiates the cascade of

angiogenesis (upregulation of vascular endothelial growth

factor-VEGF-) and inflamation (increase in the leukocytes

density and leukocytes adhered to endothelium)

•Why do we need a combination therapy?

•Only one pathway of the angiogenic cascade or

vasopermeability cascade is blocked by antiVEGF

treatment and other pathways need to be blocked.

• After antiVEGF appears a compensatory upregulation of

VEGF and other growth factors

•We suggest a combined medical approach from the very beginning, which yields a visual acuity (VA) gain

and a stabilization of the symptomatology with a good profile of safety.

•We show 31 eyes from 18 diabetic II patients with very poor metabolic control, all of them with the

diagnosis of diabetic macular edema.

• Therapeutic Guideline

•Follow-up•Monthly:VA (ETDRS),

OCT, biomicroscopy and

funduscopy

•Quarterly:angiography

Day 0

Pathogenesis of de DMEAdvanced glycation end products (AGE), Reactive oxygen species (ROS)

AGE

ROS

Hypoxia

Alteration Blood-retinal Barrier

Increase Vasopermeability

MACULAR EDEMA

Breakdown cell junction

Thickening of basement membrane

Pericytes loss

Upregulation VEGF

Inflamation(leukostasis)

DIABETES

After 1 month

•A total of 31 eyes from 18 diabetic with the diagnosis of DME have been follow-up.

•The mean follow-up period is 18.7 months.

•After the initial approach a cease of exudation at an agiographical level is found, as well as a

reestablishment of the foveal profile (mean diminishment of 280 microns) along with an improvement of

VA of 12/14 ETDRS letters (mean).

•After a mean of 5.5 months an increase of OCT thickness is found in 17/31 cases with a mild worsening

of VA. We reached stabilization and improvement of VA after a retreatment with ranibizumab and

triamcinolone intravitreously.

•The combined treatment from the beginning seems to improve the VA prognosis in multifocal DME.

0.5mg ranibizumab + 2mg triamcinolone

control the VEGF, responsible of

the breakdown in the blood retinal

barrier and neovascularization

to modify the misbalance of

inflammatory factors and

diminish macular thickness

644µmBaseline: 67years ♀. VA: 35 letters (20/200)

644 µm

Month 1 (before laser): VA: 74 letters (20/32)

240 µm

470µm

Month 5: VA: 61 letters (20/63)

•Combination therapy offer a sinergetic effect of multiple targets involved in the process of DME.

•Laser still remains to be the gold standard treatment in stabilization of DME.

•In cases with better initial VA our medical approach seems to improve the VA prognosis.

•Combination therapies offer a reduced risk associated with fewer injections.

283µm

Month 18 : VA: 70 letters (20/40)

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