AIM:-To determine the association of risk factors in type 2 diabetic patients with diabeticmacular ischemia. Materials and methods:-A cross sectional study was performed on 100 diabetic patients attending the out patient department of ophthalmology, govt Stanley medical college,Chennai, during the period November 2012 to October 2013. Patients who filled the inclusion criteria were included in the study. Detailed history about systemic medical illness and ophthalmic history were elicited. Ophthalmic examination included V/A,refraction, slit lamp examination of the anterior segment, IOP and fundus examination. Diabetic retinopathy graded according to the abbreviated ETDRS severity scale. Fundus fluorescein angiography done and diabeticmacular ischemia graded according to the criteria followed by bresnick et al. Systemic examination included BP recording, lab investigations FBS, PPBS, HbA1c, lipid profile,urine routine,ECG done. Significance of associations are analysed using chi square test and all the significant variables in univariate analysis were included in the multivariate analysis to calculate adjusted odds ratio for the individual factors. Results:- The association of diabeticmacular ischemia with nephropathy and uncontrolled DM were found to be statistically significant (OR 4.5, 95% CI 1.8-11.0, P value .001); (OR 2.9, 95% CI 1.2-7.4, P value .02) respectively,the association of other variables age,gender,duration of DM, HTN, IHD, hyperlipidaemia were p value 0.912,0.500, 0.539, 0.554, 0.476, 0.201 respectively not found to be significant. 9/13 eyes (69.23%) in severe;13/22eyes (59.1%) in moderate; 1/6 eyes(16.7%) in mild diabeticmacular ischemia showed decreased visual acuity. Conclusion:- In our study the most significant associated factor was nephropathy followed by uncontrolled diabetes and the other factors like duration of DM, HTN, IHD, hyperlipidaemia were not as significantly associated as nephropathy. Also we found that visual acuity is more affected in severe grades of diabeticmacular ischemia and preserved in milder grades of diabeticmacular ischemia.
Diabetic retinopathy occurs because the retinal vessels are abnormal, either because they proliferate (proliferative retinopathy) or because the vessels are func- tionally incompetent and leak ﬂ uid and lipid into the retina. Visual impairment occurs when edema affects the central retina or macula (diabeticmacular edema, or DME). Macular edema is reversible in the early stages but chronic edema may lead to irreversible changes in the retina. In a large cohort study, diabetics with macular edema had a 50% prevalence of visual impairment and a 20% prevalence of blind- ness, compared to 16% and 4% respectively in diabetic patients without macular edema. 5 Figures 1 and 2 contrast the ophthalmic features of macular edema with a
for these patients. In a study from Wallick et al., patients with diabeticmacular edema were found to have, on aver- age, 25.5 annual days with a health care related visit . In a Canadian study published in 2014 by Gonder et al., the mean 6-month DME-related cost was $2092 per patient . The present day cost is likely higher since the study considered that 70% of patients were injected with bevavi- zumab and the rest with ranibizumab. Thus, there is a constant need for a therapy with long term efficacy for this visually debilitating disease.
Patients were properly positioned on a stable chair with the chin rested on the slit lamp that was mounted with a laser wavelength, Carl Zeiss Visulas 532S laser system. Patients were given grid or focal laser depending on the type of the macular oedema. Topical anaesthetic, 5% pro- paracaine hydrochloride was instilled in the eye which needed to be lasered. The laser settings were 50 micron spot size, duration of 0.1 seconds and appropriate power started from 50 mW and stepped up till it burned the retina with light gray burn. The number of laser burn given was based on the severity of diabeticmacular oedema (range: 20 - 200 laser burns and 500 μm away from the centre of the fovea). Only one session of laser (either focal or grid laser) was given to each patient in LASER group. The procedure was done by Investigator A (ophthalmologist). Patient was follow-up at 3 months post laser and no other treatment was given during that period. 2.2 Intravitreal triamcinolone acetonide
Our findings show that triglycerides and LDL choles- terol play important roles in the onset and severity of dia- betic macular edema. Lipid lowering therapy with statins targets LDL cholesterol [7, 24, 25], but our findings indi- cate that the triglyceride level must also be controlled to prevent diabeticmacular edema in patients with DR. Current treatment guidelines for dyslipidemia focus on LDL cholesterol and use of statin therapy [24, 25]. New guidelines released by the ACC/AHA in November 2013 recommend statin therapy for all patients with diabetes who are 40–75 years-old, have LDL cholesterol levels of 70 mg/dL or more, and have a 10-year risk of cardiovas- cular disease risk that is 7.5% or more, based on pooled cohort equations [7, 25]. These guidelines also suggest use of other therapies for patients with type 2 diabetes, such as fibrates, niacin, and/or fish oil, when the serum triglyceride level is moderately high despite statin use. Statin therapy can reduce triglycerides level by 10–20%, depending on the specific statins [35–39]. More specifi- cally, rosuvastatin, atorvastatin, and especially pitavasta- tin are more effective in reducing triglyceride levels than the older statins [35–42]. The greatest benefit was seen in patients with high baseline triglyceride levels [35–42]. Furthermore, the combined use of statin and a fibrate (e.g. fenofibrate and bezafibrate) more effectively lowers serum triglycerides than statin therapy alone [43–45]. The ACCORD trial reported that fenofibrate provided no overall benefit for patients with type 2 diabetes when added to a statin, but it did improve outcomes in a sub- set of patients with elevated triglycerides (>204 mg/dL [2.30 mmol/L]) and low HDL cholesterol levels (<34 mg/ dL [0.88 mmol/L]) [17, 46]. Based on these consid- erations, we suggest use of a statin with a supplemental therapy for patients with hypertriglyceridemia and DR to protect against diabeticmacular edema.
Abstract: Here we reported a rare case of the implantation of a dexamethasone intravitreal implant (DEX) in which decreased retinal vessel density (VD) was found by optical coherence tomography angiography (OCTA). A 74-year-old male with diabetes mellitus presented with bilateral macular edema. The best-corrected visual acuity (BCVA) was 0.6 in the right eye. Diabeticmacular edema (DME) was diagnosed. A DEX for the right eye was planned, and the preoperative evaluation showed a super ﬁ cial VD of 48.74 percent, a deep VD of 53.12 percent, and a foveal avascular zone (FAZ) 0.165 mm 2 in size by OCTA. The BCVA in the right eye recovered to 0.8, and a notably lower super ﬁ cial VD of 45.97 percent and a deep VD of 45.40 percent were observed with an enlarged FAZ of 0.294 mm 2 one month postoperatively. Moreover, BCVA in the right eye was maintained at 0.8, while further reductions in both super ﬁ cial (40.07 percent) and deep (40.91 percent) VD were noted with a FAZ measured at 0.305 mm 2 two months postoperatively. In conclusion, retinal super ﬁ cial and deep VD decreased, while the FAZ increased, after the implantation of the DEX in a patient with DME.
Abstract Aims: this study assesses the effectiveness of anti-VEGF therapy for preserving or improving vision in people with diabeticmacular oedema (DME). Settings and Design: none randomized controlled trial. It was carried out between March, 2009–2011. Material and Methods: intravitreal Bevacizumab injection 0.05ml / 1.25mg on 90 patients with 106 eyes with diabeticmacular oedema. Results: the age ranged from 40 to 85 years with a mean age of 55.61 (54.59 for females and 56.95 for males). Patient received from 1–2 injections of Bevacizumab with a mean of 1.04 + 0.19 according to the FFA and OCT follow up. Eighteen eyes (17%) received the intravitreal injection alone, 31 eyes (29%) had macular grid in conjunction with the intravitreal injection and the rest 57 eyes (54%) had PRP with the injection according to the presence of associated nonproliferative of proliferative changes in the fundus. Conclusions: anti-VEGF therapy is effective in the treatment of DME. Several short-term prospective studies have shown visual improvement and reduced retinal thickness with treatment. DME not as responsive as PDR and further long-term study is needed.
Abstract: Diabeticmacular edema (DME) represents one of the leading causes of visual impairment in working-age adults. Although there are several proven treatments available for this condition, pharmacotherapy through the use of intravitreal antivascular endothelial growth factor agents has revolutionized the management of DME over the past decade with superior outcomes compared to laser therapy. This review summarizes the pathophysiology and available treatment options for the management of DME, with an emphasis on the efficacy and safety profile of a single particular intravitreal antivascular endothelial growth factor agent, aflibercept.
Diabeticmacular edema (DME), is one of the most common causes of visual impairment in the diabetic patients . The worldwide prevalence of diabetes is estimated to rise to 366 million by 2030 . The 10-year incidence of macular edema in patients with type 2 diabetes was up to 14%, and 29% of type 1 progressed into DME over a 25-year period [3,4]. Hence, finding a safe and effective treatment of DME becomes urgent. Despite the high prevalence of DME, there is no definite treatment because of its complicated pathophysiologic mechanism, which is still not fully understood. However, there is no single modality that has been shown to be superior. The Early Treatment Diabetic Retinopathy Study (EDTRS) showed that macular laser photocoagulation (MPC) is effective in reducing the risk of visual loss by approximately 50% in eyes with clinically significant macular edema . However, unsatisfactory outcomes are frequent, and 12% treated eyes developed moderate visual loss. Moreover, about 15% patients fall into the category of refractory DME and do not respond to repeated laser treatments. This shows that in spite of laser being the gold standard treatment of DME, some patients do not respond to laser . Various modalities of treatment are currently being tried in the management of persistent; laser refractory DME such as supplemental laser, intravitreal steroid injection, and anti-vascular endothelial growth factor (anti-VEGF) injection .
Mean best-corrected visual acuity showed stabilization at 4 months (P,0.017, Table 2) and was maintained throughout the study in 159 eyes (85%). There was an improvement in best-corrected visual acuity in 24 (15%) of the 159 eyes over 14 months of follow-up, with corresponding improvement in foveal thickness and exudates (Figure 4). During follow-up, additional SDM treatment was necessary in 43 eyes (23%). The median number of SDM treatments was two (range one to three). Twenty-eight eyes showed persistent macular edema and worsening of visual acuity on follow-up (14.96%). These eyes were retreated with SDM at the 4-month follow-up. Further management included intravitreal injection of tri- amcinolone acetonide 4 mg/0.1 mL in 22 eyes (11.76%) and pars plana vitrectomy in six eyes (3.2%). For group 2 patients, the mean foveal thickness was 428.89 ± 68.94 µ m. Mild to moderate nonproliferative retinopathy was seen in ten cases and severe nonproliferative retinopathy in 22 cases. These patients were managed by SDM with a median of three sessions (range one to five) 4 months apart. At 4 months, central foveal thickness improved significantly to 356 ± 63.76 µ m (P,0.001, Table 1) and showed gradual stabilization to 262.73 ± 58.5 µ m at the 12-month follow-up in 22 cases (65%). Visual acuity was stable in 20 eyes at 4 months (P = 0.441, Table 2), and one Snellen’s line of acuity improvement was documented in two eyes at the 12-month follow-up. Eleven eyes (33%) showed a poor response to SDM and were injected with triamcinolone. SDM could improve CSDME without inducing further noticeable damage to the macular area after maximum argon laser photocoagula- tion (Figure 5). The results were maintained at 12 months in 65% of cases. Eleven eyes needed intravitreal triamcinolone injection for diabeticmacular edema that did not respond to
Abstract: Diabeticmacular edema (DME) remains an important cause of visual loss. Although anti-vascular endothelial growth factor (VEGF) agents are generally used as first-line treat- ments for patients with center-involving DME, there is an important role for corticosteroids as well. Corticosteroids may be especially useful in pseudophakic patients poorly responsive to anti-VEGF therapies, in patients wishing to reduce the number of required injections, and in pregnant patients. Intravitreal triamcinolone acetonide has been used for many years but is not approved for this indication. An extended-release bioerodable dexamethasone delivery system and an extended-release nonbioerodable fluocinolone acetonide insert have both achieved regulatory approval for the treatment of DME. All intravitreal corticosteroids are associated with risks of cataract progression, elevation of intraocular pressure, and endophthalmitis. There is no current consensus regarding the use of corticosteroids, but they are valuable for selected patients with center-involving DME.
Macular sensitivity is an important predictor of visual function. Visual acuity is just one aspect of macular func- tion, although numerous studies have presented visual acuity as the only functional parameter outcome. To our knowledge, the present report was the first to evaluate the efficacy of anti-VEGF treatment in patients with DME and DMI using microperimetry, SD-OCT and OCTA. Our findings suggest that treatment with anti-VEGF antibodies can improve light sensitivity and can provide better fixation stability to patients with DME and DMI. Notably, all patients achieved visual improvement at the final visit, which was associated with significant improve- ment in retinal sensitivity, but this was not necessarily accompanied by significant visual acuity improvement. Moreover, areas of lower sensitivity matched areas of cap- illary dropout on FA and OCTA. However, the improve- ment in mean threshold was not correlated with ischemia severity; rather it correlated with the reduction of retinal thickness on SD-OCT. Other authors have suggested that microperimetry can be used to evaluate visual outcome after intervention in eyes affected by DME and that this modality offers the possibility of a direct comparison of retinal pathology with psychophysical measurements as well as an objective evaluation of fixation patterns . Cennamo et al. demonstrated that patients with DMI and had a significant reduction in light sensitivity compared with the control group. They also observed a correlation between areas of lower light sensitivity and structural damage on SD-OCT, particularly in the ganglion cell complex (GCC) .
Methods: In this prospective, interventional pilot study, 46 eyes from 46 consecutive patients with DME were allocated to receive macular laser photocoagulation using navigated laser. Best corrected visual acuity and retreatment rate were evaluated for up to 12 months after treatment. The control group was drawn based on chart review of 119 patients treated by conventional laser at the same institutions during the same time period. Propensity score matching was performed with Stata, based on the nearest-neighbor method.
drug treatment for macular edema has received much atten- tion in recent years, particularly the intravitreal injection of triamcinolone acetonide. Triamcinolone acetonide action on eye tissue relieves the immune inflammatory reaction by reduc- ing the immune reaction of cells, lowering the permeability of inflammatory vessels, and eliminating particle antigens or amebocytes. However, the intravitreal injection of triam- cinolone acetonide is an invasive treatment method, and the technical operation and toxic and side effects of the drug can induce various complications, including an increase in IOP, eye infection, vitreous hemorrhage, and phacoscotasmus. Hence, a more effective and safe treatment method is needed.
Patients and methods: The medical records of 138 eyes of 138 patients with DME treated by either STTA or STTA + MAPC were reviewed. The degree of DME was determined by the optical coherence tomographic features: patients with serous retinal detachment (SRD+; 38 eyes) and patients without SRD (non-SRD; 100 eyes). The central macular thickness (CMT) and the best-corrected visual acuity (BCVA) were measured periodically for 6 months after the treatments.
The introduction of OCT in DME evaluation has unques- tionably provided accurate and better measurements, 10,23 with a sensitive and noninvasive technique 16 that produced high- resolution images capable of determining subtle macular thickness in vivo measurements. 15 OCT has widely been applied in measurements of central macular thickness (CMT) in healthy eyes. 11,14,23 In addition, OCT proved vital in the diagnosis, and monitoring the response and/or the progression of diabetic retinopathy. 24 The role of OCT has substantially been investigated for classi ﬁ cation of the morphological pat- tern of DME. 3,4,7,8,10,13,17,25,26 Consequently, it facilitated the identi ﬁ cation and description of several OCT-based DME patterns including; sponge-like diffuse retinal thickness (SLDRT), cystoid macular edema (CME), and the presence of subretinal ﬂ uid (SRF). Several studies have shown SLDRT to be the most common pattern while the SRF pattern has been associated with the worst visual acuity. 3,4,12,15,27 Recently, an innovative technique in OCT was introduced for imaging of the retinal microvasculatures known as OCT angiography (OCT-A). OCT-A is noninvasive procedure that is able to identify foveal capillary nonperfusion early in the course of the disease. 28 Even OCT-A has an advantage over fundus ﬂ uorescein angiography of visualizing the different layers of
(bevacizumab; Genentech Inc, San Francisco, CA, USA). Two weeks after Avastin injection, the patient underwent focal laser for a leaking microaneurysm and grid laser for capillary dropout. During follow-up visits, the patient received another session of panretinal photocoagulation for active proliferative diabetic retinopathy, additional grid laser treatment for ischemic macular edema, three additional intravitreal Avastin injections bilaterally, and two intravitreal injections of triamcinolone acetonide 4 mg/0.1 mL. Despite the aggressive treatment, macular edema and subretinal fluid persisted during all follow-up visits in the following 2.5 years (Figure 1B).
DOI: 10.4236/ojoph.2019.94021 199 Open Journal of Ophthalmology including their ability to watch television, read, face recognition and doing ma- nual work that requires near central vision . The deterioration of vision in AMD has also been associated with emotional status, falls and mobility  . As for estimating the impact of AMD on QoL, Slakter and Stur  suggested that it is more important to consider a patient’s ability to adapt and cope other than considering the degree of vision loss in isolation which highlights the im- portance of measuring the VRQoL in patients with low vision with reliable tests. Diabeticmacular edema is a vision threatening complication of diabetes mel- litus (DM) in working-age adults  . DME can occur at any stage of di- abetic retinopathy and is responsible for severe central vision loss . Diabetic ocular complications are also known to have impacts on QoL from preliminary symptoms to severe vision loss . Assesment of patients’ QoL has been im- plemented to determine the outcomes of clinical therapeutic decisions. The 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) has been used in various phase 3 trials to evaluate the efficacy and safety of intravitreal anti-VEGF therapy in patients with DME and visual acuity im- provement in patients with DME treated with anti-VEGF agents has been found to be correlated with enhanced patient-reported visual function measured with NEI VFQ-25   .
Edematous diabetic Maculopathy is the leading cause of blindness in people under 60 in industrialized countries   . The prevalence of this serious complication of diabetes also varies according to the studies, regions, and race. In fact, it is around 3% among Caucasian diabetics in the United States, Europe and Australia, while among Afro-Americans it varies between 8% and 11%. That is a frequency of 2.5 to 4 times higher than in white persons   . In di- abetics of Latin American origin, the prevalence of macular edema ranges be- tween 5% and 10%  . In this study, diabeticmacular edema was more common in type I diabetics, as previously reported by Yau . It is important to educate diabetic patients to reduce the prevalence of diabetic retinopathy and maculopathy in our country.