Document 16234

Evolving Therapy and Management of Diabe7c Re7nopathy Jaime H. Membreno, MD , FACS Re7na and Macula Specialists, PLLC Assistant Clinical Professor of Ophthalmology University of Central Florida, College of Medicine University of South Florida, School of Medicine Significant End Organ Disease l 
Affects Nearly 26 million Americans l 
Leading Cause of of new blindness ages 25-­‐74 l 
Fueled by mul7ple social and lifestyle factors l 
Various popula7ons at risk l 
Improved systemic care can stave off progression l 
Blue Mountain , Farmingham , ETDRS, DRS, NIH, DCCT, DRCR Silver Linings l 
Improved mul7disciplinary collabora7on l 
Public Educa7on and Programs l 
Improved tools and strategies l 
Intraocular advances for managing re7nal complica7ons l 
Intraocular advances for monitoring re7na complica7ons l 
Intraocular advances for trea7ng re7na complica7ons Public Educa7on and Programs l 
Decades of Epidemiological and pathophysiological data l 
Brief Review of landmark studies l 
Current emphasis by public organiza7ons on lifestyle, obesity, preven7on l 
Current health care and health delivery incen7ves l 
Governmental and non-­‐governmental campaigns Improved Tools and Strategies l 
Glycemic and Glycosylated Hemoglobin management l 
Comorbidity and systemic risk factor management l 
Cholesterol, Hypertension, Lipids, Weight management l 
Electronic data and inter-­‐disciplinary commmunica7on l 
Early interven7on and screening with improved collabora7on Understanding Ocular Diabe7c Disease l 
Improved understanding of Pathophysiological Mechanism l 
Growth Hormone , Hypoxia and Vasoprolifera7ve factors l 
Cytokines and hematologic factors l 
Vascular Endothelial Growth Factor l 
Cornea, len7cular, re7na and nerve disease Monitoring Re7na Complica7ons l 
Ophthalmologic dilated re7nal evalua7on is cri7cal l 
Type 1 within five years of diagnosis or a[er passing puberty l 
Type 2 shortly a[er diagnosis l 
Follow up will vary based on ocular and systemic comorbity l 
General Preferred Prac7ce Pa\erns by AAO l 
Fluorescein Angiography and Op7cal Coherence Tomography, B-­‐scan Managing Re7na Complica7ons l 
Costs, treatment, side-­‐ effects, complica7ons, Binocular or monocular status l 
Condi7on and treatment status of fellow eye l 
Concomitant condi7ons such pregnancy, cardiovascular disease, stroke l 
Associated ocular disease such as cataract , glaucoma, vascular occlusion l 
Phase and severity of Diabe7c re7nopathy: edema, neovasculariza7on, etc l 
Approach is tailored for specific pa7ent Treatment of Re7na Complica7ons-­‐Edema l 
Foveal or non-­‐ foveal edema l 
An7 VEGF (Vascular Endothelial Growth Factor): Bevacizumab*, Rhanibicizumab, Aflibercept*, Pegaptamib l 
Cor7coscteroids: Dexamethasone*, Triamcinolone (Triessence) l 
Laser: Micropulse , grid and focal laser l 
Pars Plana Vitrectomy Treatment of Re7na Complica7ons-­‐
Neovasculariza7on/Vitreous Hemorrhage l 
Severity of neovasculariza7on and visibility of fundus l 
Laser – DRS: Pan Re7na Photocoagula7on, single or mul7ple treatments l 
An7-­‐VEGF (Vascular Endothelial Growth Factor)-­‐ DRCR: Bevacizumab*, Rhanibicizumab*, Aflibercept*, Pegaptamib* l 
Pars Plana Vitrectomy Treatment of Re7na Complica7ons-­‐ Prolifera7ve / Trac7on Re7na Detachment l 
Examina7on/ diagnos7c imaging/ guarded visual prognosis l 
An7 VEGF (Vascular Endothelial Growth Factor): Bevacizumab*, Rhanibicizumab, Aflibercept*, Pegaptamib l 
Laser: pan re7na photocoagula7on l 
Pars Plana Vitrectomy, Repair of Trac7on Re7na Detachment l 
Neovascular Glaucoma Summary l 
Preven7on and public policy is very relevant l 
Mul7disciplinary approach , communica7on and systemic control l 
Understanding of Pathophysiology l 
Improved diagnos7c and imaging modali7es l 
Improved medical treatment op7ons , an7 VEGF in par7cular l 
Improved surgical vitrectomy modali7es with improved outcomes References l 
Na7onal Diabetes Informa7on Clearinghouse l 
Silva P et al, Nat rev Endocrinology 2010;6(9):494-­‐508 l 
ACCORD study group et al. N Engl J Medicine. 2010;363(3): 233-­‐244 l 
American Academy of Ophthalmology. Preferred Prac7ce Guidelines: Diabe7c Re7nopathy. 2008, 2012 l 
Early Treatment Diabe7c Re7nopathy Study Group. Ophthalmology . 1987; 94(7):761-­‐774 l 
Diabe7c Re7nopathy Clinical Research Network. Opthhalmology 2008;115(9): 1447-­‐1449.