Transcript Diabets mellitus - Isfahan University of Medical Sciences

July 21, 2015
1
H.Razmjuo MD
Type 1= immune – mediated diabetes – insulin –
dependent diabetes mellitus
Type 2 = non insuline – dependent
Causes of decreased vision
1) Macular edema ( capillary leakage)
2) Macular ischemia ( capillary occlusion)
3) Sequelae from ischemia – induced
neovascularization.
Types
1) Non proliferative diabetic retinopathy = (NPDR)
background diabetic retinopathy
a) mild
b) moderate
c) severe
d) very severe
2) Proliferative diabetic
retinopathy ( PDR)
a) Early
b) high risk or advanced
NPDR can affect visual function
by:
1) Increased intraretinal vascular permeability resulting
in macular edema
2) Variable degrees of intraretinal capillary closure
resulting in macular ischemia
Macular edema
a) Focal
b)Diffuse
CSME
Eyes with CSME benefited from focal argon laser
photocoagulation .
Laser
The mainstay of treatment for PDR involves the use of
thermal laser photocoagulation in panretinal pattern
to induce regression.
1200 or more 500-um burns. Treatment may be divided
in to 2 or more sessions.
Focal laser side effects
1) Paracentral scotoma
2) Transient increased edema= decreased vision
3) Choroidal revascularization
4) Subretinal fibrosis
5) Photo coagulation scar expansion
6) Inadvertent foveolar burns
PRP
1200 or more 500-um burns separated by one – half burn
width. Surrounding ring of edema making many of the
burns appear confluent
Drug therapy
Intravitreal drug therapy was first used over 30 years ago,
when antibiotics were injected into the eye to treat
vision threatening eye infections.
These injections were shown to be safe and effective. More
recently, steroid, antiviral and antibodies (Avastin)
which block abnormal blood vessel growth have been
developed for intraocular use.
Medical management of DME
1)Long acting steroids(Triamcinolon 4mg)
2)Antiv ascular endothelial growth factor
(AVEG 1.5 mg)
Medical manement of DME
1) Sub- Tenon injection of long
acting steroid
In patients with refractory DME a posterior sub– Tenon
injection of triamcinolone acetonide improved visual
acuity at 1 month and stabilized vision up to 1 year in a
retrospective interventional case series.
Arise in IOP was rare, as was ptosis.
2)Intravitreal steroid
Similarly in patients with refractory CSME, intravitreal
injection of corticosteroids was shown to modesty
improve vision in the shout term and reduce macular
thickness for up to 2 years of follow up. Post op cat and
increased IOP were common but were manageable.
Anti VEGF
Vascular Endothelial Growth Factor (VEGF) is a
substance which occurs naturally in the body.
VEGF promotes blood vessel growth and makes retinal
blood vessels leaky. Avastin is a drug which blocks
VEGF, and was initially used systemically to stop new
blood vessels from growing in patients with metastatic
bowel cancer.
Avastin
mechanism of action:
Patients with diabetic retinopathy have abnormally high
levels of VEGF in their eyes. Blocking VEGF with
Avastin can reduce vascular leakage and lessen
macular edema.
Reducing macular edema can stabilize or improve vision.
Anti VEGF used for
1. Persistent macular edema unresponsive to retinal laser
2.
3.
4.
5.
6.
7.
8.
therapy
Rubeosis iridis
ROP
PDR
After cataract operation in patients with diabetic
retinopathy
After deep vitrectomy operation in diabetic patients
In combination with ,laser and steroid]
Subfoveal neovascularization
Intravitreal bevacizumab 1.5mg resulted in
marked regression of neovascularization
and
rapid
resolution
of
vitreous
hemorrhage.
Complications
 Injections to the eye are relatively safe. Hemorrhage,
infection, cataract, and retinal detachment may occur,
but are uncommon. Systemic risks include elevated
blood pressure, stroke, and heart attack.
Patient 1
Pre-Evastin
Patient 1
Post-Evastin
5 days later
patient2
Pre-Evastin
Patient 2
Post-Evastin
2 weeks later
Patient 3
Pre-evastin
Patient 3
Post-Evastin
16 days later
Patient 4
Pre-evastin
Patient 4
Post-Evastin
16 days later
Thanks for your attention