Marcus Gonzales, OD, FAAO Cedar Springs Eye Clinic

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Lester Hensley
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1 Marcus Gonzales, OD, FAAO Cedar Springs Eye Clinic

2 25.6 million adults 11.3% of the adult population 10.9 million adults 65 years and older 26.9% of this age population 79 million people are Pre-diabetic!! By 2020, projected to be 35 million people

3 1.7 million adults 9.8% of the adult population yrs old

4 40-45% have some form of retinopathy Virtually 100% of type 1 diabetics of 20 years duration have retinopathy 80% of type 2 diabetics of 15-year duration have some level of retinopathy Leading cause of new blindness among U.S. adults

5 Most common cause for reduced vision Affects nearly 30% of patients with diabetes 3x more likely to occur in patients with poorly controlled concomitant hypertension Can happen at any stage of retinopathy

7 14 million

9 Signs of DR Stages and Management of DR Treatments Audience Based Cases

10 Duration of the disease Poor glycemic control Pregnancy Systemic hypertension Kidney disease Anemic Elevated Cholesterol

11 None Subtle Blur Floaters Hand-motion vision Painful blind eye

abnormality NVD = neovascularization of the disc NVE =

12 H/Ma = hemorrhages and/or microaneurysms CWS = cotton wool spots VB = venous beading IRMA = intraretinal microvascular abnormality NVD = neovascularization of the disc NVE = neovascularization elsewhere PrH = preretinal hemorrhage VH = vitreous hemorrhage

17 Most Predictive of Progressing to Proliferative Stages

18 Most Predictive of Progessing to Proliferative Stages

26 We stage retinopathy to determine f/u schedule and treatment options Remember macular edema can occur at any stage of retinopathy and may supersede other f/u schedules If retinopathy level is progressing, closer follow-up is advised

27 Non-Proliferative Stages Mild Moderate Severe Very Severe Proliferative Stages Early High-Risk Clinically Significant Macular Edema

28 Document in the Exam Findings and in the Impressions/Assessment Presence/absence of Retinopathy and Presence/absence of Macular edema

29 At least 1 microaneursym H/Ma < Standard Photograph 2a

30 Management Photodocument Follow up in 12mo depending on extent and location of lesions Communicate with PCP Things to Consider Earlier f/u based on current control of diabetes or progression of stage

31 H/Ma > Standard Photograph 2a And/or CWS, VB, mild IRMA

32 Management Photodocument Follow up in 6-12mo depending on extent and location of lesions Communicate with PCP Things to Consider Earlier f/u based on current control of diabetes or progression of stage

33 4/2/1 Rule H/MA s > Standard photo 2A in 4+ quadrants OR VB in 2+ quadrants (Standard Photo 6B) OR IRMA present in 1+ quadrant > Standard Photo 8A

34 Management Photodocument Follow up in 2-3mo Communicate with PCP Things to Consider Strong risk for progression to proliferative stage

35 Two or more of the 4/2/1 criteria Venous Beading Standard Photo 6B

36 Management Photodocument Refer to retina OMD in 2-4wks Communicate with PCP Things to Consider Probably need NaFl to help differentiate this stage of retinopathy

37 Mild NVD < 1/3 disc area Mild NVE (-) VH Standard Photo 10A

38 Management Photodocument Refer to retina OMD in 2-4wks Communicate with PCP Things to Consider Panretinal photocoagulation probably indicated Anti-VEGF injections may also be considered

OR Moderate/severe NVD on or within 1 DD

39 OR Moderate/severe NVD on or within 1 DD of disc > 1/4 to 1/3 disc area (Standard photo 10A) Mild NVD on or within 1 DD of disc AND fresh vitreous heme/preretinal heme OR Moderate/severe NVE AND fresh vitreous heme/preretinal heme (Standard photo 7)

40 Management Photodocument Refer to retina OMD within 24-48hrs Communicate with PCP Things to Consider Panretinal photocoagulation indicated Anti-VEGF injections may also be considered

41 Tractional retinal detachments Neovascularization of the iris Neovascularization of the angle

46 Clinically Significant Macular Edema (CSME) Retinal thickening at/within 500um of fovea Hard exudates at/within 500um of fovea with adjacent retinal thickening Retinal thickening 1DD in size within 1DD of fovea Management: Refer to OMD within 2wk

47 Macular Edema Edema < CSME definition Management Monitor in 1mo for conversion to CSME Remember: Vision may still be 20/20!?!

52 Argon Laser Treatment Focal Grid Panretinal Intravitreal Treatment Anti-VEGF Steroid Vitrectomy

59 Anti-VEGF Improve VA in more patients than laser Decrease level of retinopathy Continued injections Doesn t work well s/p vitrectomy Steroid Similar benefits to anti-vegf IOP elevations and cataract development Can still work s/p vitrectomy

62 Over 619 studies listed with the clinicaltrials.gov

63 Volunteers

DIABETIC RETINOPATHY

DIABETIC RETINOPATHY C. L. B. Canny, MD FRCSC Diabetic retinopathy is the most serious eye manifestation of diabetes and is responsible for most of the blindness caused by diabetes. Diabetic retinopathy