Past ocular history. DME Case 1. Patient presents blurred VA. Hemoglobin A1c 11.5% -- patient states sugars have not been in good control

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Clifton Fowler
5 years ago
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1 Past ocular history Patient presents blurred VA DME Case 1 Hemoglobin A1c 11.5% -- patient states sugars have not been in good control PDR with macular edema OU Rishi Singh MD Cleveland Clinic OD OS 1

Steroid VA OD 20/30 VA OS 20/30 1 MONTH Patient receives Avastin OU: Patient received PRP OD 1-week prior:

2 First treatment: Avastin OU PRP OU BASELINE BASELINE VA OD 20/30 VA OS 20/30 Options? 1. Focal Laser 2. Panretinal Laser 3. Anti-VEGF 4. Steroid VA OD 20/30 VA OS 20/30 1 MONTH Patient receives Avastin OU: Patient received PRP OD 1-week prior: Patient receives PRP OS at this visit: VA OD 20/70-2 VA OS 20/30 +3 Response to Avastin & PRP OD 1-week post PRP: 2 nd Avastin injection OD 6 MONTHS FROM BASELINE VISIT VA OD 20/70-2 VA OS 20/25-2 2

edema DME Case Has received Avastin (8/10) (1x) switched to monthly Lucentis 0.

3 7 months since baseline visit OD: 1 month post 2 nd Avastin injection better by OCT: VA OD 20/25-2/+1 7 months since baseline visit OS: VA OD 20/20-1 Past ocular history NPDR with clinically significant macular edema DME Case Has received Avastin (8/10) (1x) switched to monthly Lucentis 0.3 mg since 12/10 (33x) Focal treatment 1x (5/13) OCT still demonstrated continued CME despite multiple injections and focal treatment in right eye 3

4 Transparency: 0 % Overlay: ILM-RPE Difference Transparency: 100 % Response to Lucentis injections Response to focal treatment 15 th injection VA 20/60 +2 Prior to focal VA 20/ th injection VA 20/ month post-focal VA 20/ th injection VA 20/60-2 Response to Lucentis injections post-focal treatment 30 th injection VA 20/60 Options? Switch to another anti-vegf? Steroid? Vitrectomy? 31 st injection VA 20/60 +1 PRP? 32 nd injection VA 20/50-1/+1 4

Decided on intravitreal TA (Triescence) Most recent

IOP 21 Past ocular history OS s/p PPV with improved

5 Decided on intravitreal TA (Triescence) Most recent visit Had mild steroid response 2 nd month post-injection IOP 27 Prior to injection VA 20/50-2 IOP 19 OCT mildly worse VA 20/ month VA 20/50 +2 IOP 21 Past ocular history OS s/p PPV with improved acuity to 20/50 => ischemia eroded vision to 20/400 PDR TRD Case PRP OD 2x 5

6 Right Eye Right Eye Pre-PRP VA OD 20/ month post-prp VA OD 20/30-2 VA OD 20/40 Options: 1. Anti-VEGF 2. Steroids 3. Observation 4. Surgery s/p Avastin OD Pre-op VA OD 20/40 1 month post-injection: VA OD 20/30 VA OD 20/40 6

found Fovea: Not found Fovea: Not found Past ocular history NPDR with

7 3 weeks post-op 2 months post-op OCT and vision improving VA OD 20/500 OCT and vision still improving VA OD 20/500 Fovea: Fovea: Not found Fovea: Not found Fovea: Not found Past ocular history NPDR with clinically significant macular edema OS Hx of focal laser OS DME Case 7

Pre-Navilas treatment Options: FA shows mild ischemic changes within the fovea no evidence of neovascularization elsewhere VA OS 20/40 1. Anti-VEGF 2.

Combination treatment Pre-Navilas treatment Response to Navilas Baseline VA OS 20/40 Navilas treatment & treatment plan: OD OS 1 month VA OS 20/50 +1

8 Pre-Navilas treatment Options: FA shows mild ischemic changes within the fovea no evidence of neovascularization elsewhere VA OS 20/40 1. Anti-VEGF 2. Steroid 3. Focal Laser 4. Combination treatment Pre-Navilas treatment Response to Navilas Baseline VA OS 20/40 Navilas treatment & treatment plan: OD OS 1 month VA OS 20/ May 2013 OS 21 May 2013 OS OS Focal Date:21 May :39:08 AM Delivered spots: 147 Power: mw; average: 100 mw Pulse duration: ms; average: 100 ms Spot size: µm; average: 100 µm Total applied power: 1.47 J 2 months VA OS 20/40 21 May 2013 OS 8

Response to Navilas Case 2: DME Month 2 to Month

with newly diagnosed type 2 diabetes mellitus

2% Poor vision OU 6 months VA OS 20/40-1/+2 Month

9 Response to Navilas Case 2: DME Month 2 to Month 3 3 months VA OS 20/ year-old white man with newly diagnosed type 2 diabetes mellitus HgbA1C 11.2% Poor vision OU 6 months VA OS 20/40-1/+2 Month 3 to Month 6 20/200 OU Approach? 1. Address macular edema first OD 2. Address macular edema first OS 3. Bilateral anti-vegf injections 4. Bilateral steroid injections 5. PRP for severe NPDR 9

2 years Later s/p Best Regimen for this Patient?

injections / year OS: Ranibizumab x 2; focal laser; bevacizumab x 2 Reluctant to treat further given poor vision

to address VEGF drive / ischemia D) Observation only 20/20 20/80 Widefield Angiography 20/20 20/80 Best Regimen

10 2 years Later s/p Best Regimen for this Patient? OD: Ranibizumab x 8; focal laser; bevacizumab x 4; now on exclusively bevacizumab for cost reasons Average 6 injections / year OS: Ranibizumab x 2; focal laser; bevacizumab x 2 Reluctant to treat further given poor vision A) Alternate anti-vegf each eye every 2 months for the foreseeable future B) Switch to steroid agent C) Add PRP to address VEGF drive / ischemia D) Observation only 20/20 20/80 Widefield Angiography 20/20 20/80 Best Regimen for this Patient? A) Alternate anti-vegf each eye every 2 months for the foreseeable future B) Switch to steroid agent C) Add PRP to address VEGF drive / ischemia D) Observation only 10

Case 3: DME 20/30 20/20 64-year-old demanding

vision no complaints 20/30 20/20 Management

A) Observe OU B) Focal laser OU 20/30 20/20

11 Case 3: DME 20/30 20/20 64-year-old demanding Beverly Hills matron with type 2 diabetes mellitus x 10 years last HgbA1C 7.4% presents for screening exam Happy with vision no complaints 20/30 20/20 Management Plan? Pt Declined Any Treatment 1 Year Later A) Observe OU B) Focal laser OU 20/30 20/20 C) Anti-VEGF OU D) Triamcinolone OU E) Anti-VEGF OD Observe OS 11

Now What? Vision Stable Still Asymptomatic A) Bevacizumab OD B) Ranibizumab OD C) Triamcinolone OD D) Continue observation OD Baseline Ranibizumab 0.

12 Now What? Vision Stable Still Asymptomatic A) Bevacizumab OD B) Ranibizumab OD C) Triamcinolone OD D) Continue observation OD Baseline Ranibizumab 0.3 mg OD #1 4 weeks later Observe (pt defers injection) 6 weeks later Ranibizumab 0.3 mg OD #2 20/30 20/30 20/30 4 weeks later Observe (pt defers injection) 20/30 8 weeks later Pt still deferring injections Asks for glasses to help OD 20/30 Next Steps for OD? Next Steps for OS? Still 20/20 1. A) Continue ranibizumab 2. B) Switch to bevacizumab 3. C) Switch to triamcinolone 4. Focal laser 5. Observe 1. A) Begin ranibizumab 2. B) Begin bevacizumab 3. C) Begin triamcinolone 4. Focal laser 5. Observe 12

Diabetic Retinopatathy

Diabetic Retinopatathy Jay M. Haynie, OD, FAAO Financial Disclosure I have received honoraria or am on the advisory board for the following companies: Carl Zeiss Meditec Arctic DX Macula Risk Advanced