Professional Documents
Culture Documents
• Historical Background:
– Diabetic Macular Edema (DME) was unrecognized
before invention of the ophthalmoscope (Helmholtz,
1851).
– Jaeger in 1856 was the first to describe a “roundish or
oval yellow spots and extravasations which permeate
part or the whole thickness of the retina” in a patient
with positive urine glucose test for Diabetes Mellitus.
– That same year Von Graefe refuted any relationship of
the eye findings to diabetes.
– Moderate-to-severe non-proliferative
diabetic retinopathy
• Proliferative diabetic
retinopathy
– High risk
• Maculopathy
– Diffuse/focal
– Clinically significant macular oedema (CSME )
– Ischaemic Maculopathy
• At least 1
Microaneurysms (m)
• Microaneurysms
only
• Remainder of fundus
normal
• Microaneurysms (m)
and Dot
hemorrhages (h)
• May also
demonstrate
macular edema and
lipid exudate (e)
Vessel closure
Supply of oxygen and nutrients are decreased
New fragile growth occurs (secondary to ischemia)
Microaneurysms
• focal dilatations of retinal capillaries,
• 10 to 100 microns in diameter, and.
• appear as red dots especially temporal to the fovea.
• first ophthalmoscopically detectable change in diabetic
retinopathy.
• Despite multiple layers of basement membrane, they are
permeable to water and large molecules, allowing the
accumulation of water and lipid in the retina.
• Since fluorescein passes easily through them, many more
microaneurysms are usually seen on fluorescein angiography
than are apparent on ophthalmoscopy
• Accumulations of
lipids leak from
surrounding
capillaries and
micro aneurysms
• they may form a
circinate pattern.
– ARMD, Exudative
– Branch Retinal Vein Occlusion
– Central Retinal Vein Occlusion
– Hypertension Macular Edema
– Irvine-Gass
– Uveitis
– Other Problems to Be Considered
• Cystoid macular edema
• Hypotonic retinopathy
• Macular pucker
• Epinephrine use in aphakia
Chew EY, Klein ML, Ferris FL 3rd, et al. Association of elevated serum
lipid levels with retinal hard exudate in diabetic retinopathy. Early
Treatment Diabetic Retinopathy Study (ETDRS) Report 22. Arch
Ophthalmol. Sep 1996;114(9):1079-84. 33 Dr. Mazhry frcs,fcps
Ocular Treatment
• Available Tools
– LASERs
– AntiVEGF Therapy
– Steroids
• Focal:
– 50-100 spots to Area(s) of leakage can be identified by
areas of discrete examination (areas of retinal thickening) or by
leakage fluorescein angiography.
• Grid:
– 100-200 spots in
areas of diffuse
leakage
• “Focal-Grid”:
– combination of the Important to avoid foveal avascular zone
above Avoid confluent burns
Exam Findings
• VA OD 20/30+ OS 20/30
• Sensorimotor exam normal
• No distortion with Amsler grid
• Early NSC, PSC OU; early CC, vacuoles OS
• IOP 14mmHg OU
Notes
• HTN, renal disease and dyslipidemia can affect onset
and progression of retinopathy
• Co-management with other health care providers
• Lesions that may indicate nondiabetic etiology
– Venous caliber abnormalities
– Parapapillary cotton wool spots of similar onset
– Flame-shaped hemorrhages
– Diffuse retinal edema
– White centered hemorrhages (Roth’s spots)
• New Indication:
– Persistent Diabetic Cystoid Macular Edema
– Vitrectomy surgery is often helpful in cases
withdetectable posterior hyaloid traction, epiretinal,
membrane, or macular striae.
– May also be beneficial in other cases of persistent or
worsening cystoid macular edema
– Considered for diffuse leakage or exudate in foveal
center with vision 20/70 or worse.
• Objective:
– The development of a collaborative network to
facilitate multicenter clinical research on diabetic
retinopathy, diabetic macular edema and
associated conditions.
Diabetic Retinopathy Clinical Research Network. A randomized trial comparing intravitreal triamcinolone acetonide and focal/grid photocoagulation for
diabetic macular edema. Ophthalmology. Sep 2008;115(9):1447-9, 1449.e1-10.
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