1. Diagnosis & Management of Diabetic Eye Disease A. Paul Chous, M.A., O.D., F.A.A.O. Tacoma, WA Specializing in Diabetes Eye Care & Education Part 6

2. Staging of Diabetic Macular Edema DME Absent no retinal thickening or hard exudates in the posterior pole DME Presentsome retinal thickening or hard exudates in the posterior pole Mild DME RT or HE in the posterior pole but distant from the macula Moderate DME RT or HE approaching but not involving the macular center Severe DME RT or HE involving the center of the macula

3. Definition of CSME Clinically Significant Macular Edema Per Early Treatment of Diabetic Retinopathy (ETDRS) protocol Per Early Treatment of Diabetic Retinopathy (ETDRS) protocol Important quantitative criteria that determine the need for focal or grid macular laser photocoagulation Important quantitative criteria that determine the need for focal or grid macular laser photocoagulation 1.Retinal thickening within 500 microns (<1/3 DD) of the foveal center and/or 2. Hard exudates within 500 microns of the fovea with adjacent retinal thickening and/or 3. Retinal thickening > 1DD in size any part of which is within 1DD of the fovea

4. Diabetic Retinopathy/Maculopathy Optical Coherence Tomography Tissue thickening Tissue thickening Cystic changes Cystic changes Disruption of NFL Disruption of NFL Monitor efficacy of Tx. Monitor efficacy of Tx.

5. Referral & Follow-up for DR AOA Clinical Practice Guidelines (2002) recommend referral to a retinal specialist when: AOA Clinical Practice Guidelines (2002) recommend referral to a retinal specialist when: 1. Any DME 2. Severe NPDR 3. Iris neovascularization 4. Unexplained vision loss 5. PDR (stat referral if NVD > 1/4DD, or NVD/NVE with fresh vitreous hemorrhage

6. Recommended Follow-up Mild NPDR every year Mild NPDR every year Moderate NPDR Q 6-12 months Moderate NPDR Q 6-12 months Severe NPDR (T1DM only) Q 3-4 months Severe NPDR (T1DM only) Q 3-4 months DME < CSME Q 3-12 months DME < CSME Q 3-12 months Adequately treated PDR: every year Adequately treated PDR: every year

7. Treatment of DR - PRP Pan-retinal Photocoagulation (PRP) is the ‘gold standard’ treatment for PDR Pan-retinal Photocoagulation (PRP) is the ‘gold standard’ treatment for PDR causes regression of neovascularization (11% lose 1 line of VA) causes regression of neovascularization (11% lose 1 line of VA) Meta-analysis of ETDRS data shows that treating severe NPDR with PRP benefits patients with T2DM only Meta-analysis of ETDRS data shows that treating severe NPDR with PRP benefits patients with T2DM only New NV, fresh VH or failed regression of NV are indications for additional PRP New NV, fresh VH or failed regression of NV are indications for additional PRP PRP reduced the risk of severe vision loss (<20/800) by 50-75% in the DRS PRP reduced the risk of severe vision loss (<20/800) by 50-75% in the DRS

8. Treatment of DR - PRP

9. Treatment of DR - Vitrectomy Vitrectomy indicated for: Vitrectomy indicated for: Non-clearing VH precluding PRP Non-clearing VH precluding PRP Significant vitreo-retinal traction Significant vitreo-retinal traction Severe PDR in younger patients with T1DM Severe PDR in younger patients with T1DM 25 gauge instrumentation has revolutionized vitrectomy 25 gauge instrumentation has revolutionized vitrectomy Faster visual recovery & less inflammation Faster visual recovery & less inflammation 17g versus 25g

10. Treatment of CSME Focal or grid laser reduces the risk of substantial worsening of vision (doubling of the visual angle) by 50% (ETDRS) Focal or grid laser reduces the risk of substantial worsening of vision (doubling of the visual angle) by 50% (ETDRS) Intravitreal triamcilnolone/Kenalog (IVTA/IVK) now commonly used alone or in tandem with laser to treat recalcitrant DME Intravitreal triamcilnolone/Kenalog (IVTA/IVK) now commonly used alone or in tandem with laser to treat recalcitrant DME Patients with PDR and DME typically treated for the DME first and/or receive IVK with PRP Patients with PDR and DME typically treated for the DME first and/or receive IVK with PRP