Management of DMO DR LIZ WILKINSON, NDDH
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1 Management of DMO DR LIZ WILKINSON, NDDH VICE CHAIR DIABETIC SCREENING ADVISORY BOARD, CLINICAL LEAD DIABETIC EYE SCREENING PROGRAMME NORTH & EAST DEVON, IMMEDIATE PAST PRESIDENT OPHTHALMOLOGY ROYAL SOCIETY OF MEDICINE
2 What are our options? Improve diabetic control Focal laser Anti Veg F injection (2 options) Steroid injection short term < 6 months Steroid injection long term < 3 years Combination
3 Interventions Option Guidance Benefit Risk -systemic Risk- local Licence/NICE Requirements Improve Control NICE Type 1 and Type 2 Slow progression Protect other organs Increase lifespan None None None Laser RCOphth Local None Macular burns None Intravitreal Anti Veg F (3) TA 274 (2013) TA 346 Local Short term Decrease PDR Thromboembolic Endophthalmitis Retinal hole Inflammation. >400um Central retinal Thickness Patient access scheme Intravitreal Steroid (2) TA 349 (Dexamethasone) TA301 (Fluocinolone Acetonide) Local, longer term from 6 months to 3 years Minimal Glaucoma Endophthalmitis Retinal hole Inflammation Pseudophakic Unresponsive to other treatments or unsuitable Patient access scheme Combination
4 What are our options? Improve diabetic control Focal laser Anti Veg F injection (2 options) Steroid injection short term < 6 months Steroid injection long term < 3 years Combination
5 Diabetic control A Is for HbA1c, which is a measurement of the sugar in your blood. Your HbA1c should be 6.5% (48mmol/mol) to 7.0% (53 mmol/mol) or less. Ask your GP to tell you. Your day to day blood sugar should range from 4 (before meals) to 10 (after meals). NICE guidelines for Type 2 DM Audit of impact of education on HbA1c B C D Is for blood pressure. This should be 130/80 or less. Is for cholesterol. This should be 4 or less. Is for diet. Low Glycaemic Index. Try not to eat processed or white food (eg: bread, rice, pasta) and eat lots of unprocessed food and vegetables. E Is for exercise. Walk as much as possible.
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7 I was a size 18 and have now just bought my first size 10 jeans. I am half the person I was and feel so much better
8 My blood work is the same as a normal person and the new picture of my eyes this week was normal. I am hoping that at my next meeting with my diabetic nurse I will be taken
9 Amputation rates in the South West Diabetic complications are directly related to the control of the systemic disease and the duration.
10 An epidemic of diabetes
11 What are our options? Improve diabetic control Focal laser Anti Veg F injection (2 options) Steroid injection short term < 6 months Steroid injection long term < 3 years Combination
12
13 What are our options? Improve diabetic control Focal laser Anti Veg F injection (2 options) Steroid injection short term < 6 months Steroid injection long term < 3 years Combination
14 Mr M 58 year old Type 2 Diabetic diagnosed aged 41 Moved to area June 2012 Bilateral PDR and DMO VA R 6/36 L 1/60
15 Mr M May 2013 Post loading phase IVI Anti Veg F CRT 826 now down to 282 VA 6/18 January 2016 Switch to 2 nd anti Veg F - 25th IVI 2 monthly VA 6/24 May 2016 Post 2 monthly IVI VA 6/36
16 Mr M August 2016 Post monthly loading 2 nd anti Veg F VA 6/18 December 2016 Return to 2 monthly 2 nd anti Veg F VA 6/18 October 2017 Post R phaco + IOL Stability on 2 monthly IVI planned around surgery VA 6/18 +
17 What are our options? Improve diabetic control Focal laser Anti Veg F injection (2 options) Steroid injection short term < 6 months Steroid injection long term < 3 years Combination
18 Mr A 43 year old Type 1 Diabetic for 39 years Downs Syndrome, epilepsy, anxiety January 2016 R VA 6/12 Bilateral PDR (proliferative diabetic retinopathy) May 2016 VA 6/18 Post PRP Increasing DMO Aug 2016 VA 6/36 Pre IVI Steroid (short term)
19 Mr A Sept /18 Post IVI Steroid No adverse events Jan /24 Pre Long Acting Steroid + Cataract Surgery August /18 Post long acting steroid No adverse events
20 Mrs D Type 2 Diabetic for 19 years R VA 3/60 L VA 2/60 with RAPD + Nov 2012 Pre anti Veg F loading R VA 3/60 Jan 2013 Post loading CRT down from 747 to 273 VA 6/60 May 2013 Severe CVE Active PDR Decision to stop Anti Veg F
21 Mrs D April 2015 R Phaco + IOL PDR under control September 2015 Post op IVI Long Acting Steroid Occasional top up PRP VA 6/60 October years post steroid VA still 6/60
22 What are our options? Improve diabetic control Focal laser Anti Veg F injection (2 options) Steroid injection short term < 6 months Steroid injection long term < 3 years Combination
23 Mrs S 35 year old Type 1 Diabetic for 28 years First seen 2013 Pregnant 2015 OCT scans pre pregnancy 2014 VA 6/6 BE
24 Mrs S May /40 pregnant VA 6/9 Declines laser July /40 pregnant VA 6/12 Declines laser Jan 2016 Post breastfeeding VA 6/18 Accepts IVI Anti Veg F x 5 loading Laser left eye as below criteria for anti Veg F
25 Mrs S July 2016 Post anti Veg F No anatomical/visual improvement Anti Veg F switch Feb 2017 Monthly anti Veg F Now IVI BE Holding the faith! October 2017 VA back to R 6/9 L 6/6 Monthly anti Veg F BE Macular Laser intermittently BE
26 Mr D Aged 75 Type 2 Diabetic for 12 years BP 192/88 BM 17 Chol 7 April 13 R VA 6/6 April 13 L VA 6/18
27
28 Mr D Nov 17 R VA 6/6 Nov 17 L VA 6/9
29 What do we need to think of? Diabetic control (HbA1c) and duration CVE/MI risk Injection under LA? Glaucoma PDR Pregnant/Breastfeeding Travel/Work
30 Standardisation Stratification
31 Standardisation Stratification Optimisation
32 Standardisation Stratification Optimisation
33 Standardisation Stratification Optimisation
34 Thank you
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