Diagnosis and treatment of diabetic retinopathy. Blake Cooper MD Ophthalmologist Vitreoretinal Surgeon Retina Associates Kansas City

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1 Diagnosis and treatment of diabetic retinopathy Blake Cooper MD Ophthalmologist Vitreoretinal Surgeon Retina Associates Kansas City

2 Disclosures Consulted for Novo Nordisk 2017,2018. Will be discussing an off label use Bevacizumab (Avastin). Professional and personal interest in diabetes.

3 Learning Objectives Identify who would benefit from seeing an eye care professional. Describe and identify the levels of diabetic retinopathy. Have a better understanding of the current management of advanced diabetic eye disease.

4 Personal Objectives Recognize the importance of diabetic retinopathy as a public health problem. Realize that diabetic retinopathy is a leading cause of (preventable) blindness. Understand landmark clinical trials and the role of eye care professionals in the treatment of a patient with diabetes.

5 Retina RETINA Light

6 Retinal Diagnostic Tests Fundus Photography Fluorescein Angiography (FA) Optical Coherence Tomography (OCT) Ocular Ultrasonography Electroretinography (ERG)

8 Fundus Photography

9 Normal FA

10 Wide Field Imaging

12 Normal OCT

15 Diabetic retinopathy Progressive dysfunction of the retinal blood vessels caused by chronic hyperglycemia. It can be a complication of type 1 or 2 diabetes. Initially, patients may be asymptomatic, if not treated though they may develop visual loss and possible blindness.

16 Diabetic retinopathy A leading cause of visual loss globally Patients with diabetes are 25 times more likely to go blind Only half of patents receive appropriate eye care 90% of blindness could be prevented

17 Risk Factors Duration of diabetes Poor control of Diabetes Hypertension Nephropathy Obesity and hyperlipidemia Smoking Pregnancy

18 Symptoms Asymptomatic in early stages of the disease As the disease progresses symptoms may include: Blurred vision Floaters Fluctuating vision Distorted vision Dark areas in the vision Poor night vision Impaired color vision Partial or total loss of vision

19 Pathology

20 Disease progression pathways Diabetes Preclinical changes Background DR Preproliferative DR Microvascular leakage Macular edema Clinically significant macular edema Proliferative DR Vitreous hemorrhage and/or Retinal detachment Microvascular occlusion and/or Neovascular glaucoma Vision loss

21 Microvascular Leakage (Diabetic Macular Edema)

22 Microvascular Occlusion (Macular Ischemia)

23 Microvascular occlusion

24 Microvascular occlusion

25 No Background Diabetic Retinopathy

26 Microaneurysms Mild Nonproliferative Diabetic Retinopathy

27 Hard exudates Microaneurysm Moderate nonproliferative diabetic retinopathy Flamed shaped hemorrhage

28 Venous beading Severe nonproliferative diabetic retinopathy

29 Cotton wool spot Hard exudates Proliferative diabetic retinopathy Neovascularizaton Blot hemorrhage

30 Proliferative diabetic retinopathy

31 Proliferative diabetic retinopathy FA, fluorescein angiography.

32 Vitreous hemorrhage

33 Vitreous hemorrhage

34 Traction retinal detachment

35 Traction retinal detachment

Increasing retinal ischemia setting the stage for proliferative changes Background retinopathy Retinal/macular edema (maculopathy) Dot & blot hemorrhages Preproliferative retinopathy Macular edema

36 Increasing retinal ischemia setting the stage for proliferative changes Background retinopathy Retinal/macular edema (maculopathy) Dot & blot hemorrhages Preproliferative retinopathy Macular edema (maculopathy) Intraretinal microvascular abnormalities Proliferative retinopathy Macular edema (maculopathy) Rubeosis iridis neovascular glaucoma Microaneurysms Hard exudates Flame shaped hemorrhages Cotton wool spots Venous changes Traction retinal detachment Vitreous hemorrhage Physical/anatomical effects of diabetes Progression of retinopathy Complications of proliferative change; sight threatening

Screening for diabetic retinopathy is included in standard of care EXAMPLE: RECOMMENDED SCREENING PROGRAM, ADA GUIDELINES Adults with type 1 diabetes Adults with type 2 diabetes No evidence of

of diabetes onset Initial dilated and comprehensive eye examinations at the time of diabetes diagnosis Consider examinations every 1-2 years Subsequent dilated retinal examinations for type 1 or type

37 Screening for diabetic retinopathy is included in standard of care EXAMPLE: RECOMMENDED SCREENING PROGRAM, ADA GUIDELINES Adults with type 1 diabetes Adults with type 2 diabetes No evidence of retinopathy for one or more annual eye examination Any evidence of retinopathy present Retinopathy progressive or sight-threatening Initial dilated and comprehensive eye examinations within 5 years of diabetes onset Initial dilated and comprehensive eye examinations at the time of diabetes diagnosis Consider examinations every 1-2 years Subsequent dilated retinal examinations for type 1 or type 2 repeated at least annually More frequent dilated retinal examinations are recommended Diabetic Retinopathy: A Position Statement by the American Diabetes Association. American Diabetes Association Standards of Medical Care in Diabetes Diabetes Care 2018 Jan; 41(Supplement 1): S105-S118

38 PATIENTS WITH DIABETES

39 Age-Adjusted % U.S. Adults w/ Diagnosed Diabetes Receiving Annual Dilated Eye Exam 60.5 (%) % 63% % Behavioral Risk Surveillance System, CDC Division of Diabetes Translation

40 Reasons why patients do not receive annual eye exams No eye doctor, no transportation, or could not get appointment 6.4 % Cost/lack of insurance Patient* barriers Other 21. 5% 32. 3% 39. 7% No need** Provider barriers Patient doesn t understand importance Assuming patient responsibility to comply with referral/lack of follow-up Primary provider lack of specific referral (e.g., specific eye care specialist or specific request/patient information) *Patients diagnosed with diabetes who are not receiving annual eye exams **Consisted of have not thought of it and no reason to go Chou et al. Diabetes Care 2014;37:180 8;

41 Treatment options NPDR without macular edema 1. Observation 2. Control risk factors Macular edema 1. Intraocular VEGF inhibitor +/- steroid 2. Focal/grid laser photocoagulation 3. Vitrectomy with membrane peeling 4. Control risk factors NPDR, nonproliferative diabetic retinopathy; VEGF, vascular endothelial growth factor.

42 Diabetic Macular Edema Elevated levels of VEGF are not reduced by Focal laser

43 Diabetic Macular Edema Prevalence Mild NPDR Moderate- Severe NPDR PDR

44 Focal laser CLINICAL SCIENCES Early Photocoagulation for Diabetic Retinopathy ETDRS Report Number 9 EARLY TREATMENT DIABETIC RETINOPATHY STUDY RESEARCH GROUP Focal laser reduces risk of visual loss by 50% Ophthalmology 1991; 98;

45 Diabetic macular Edema (DME)

46 Focal laser

47 ** * * * * * * * * Focal laser

48 Focal laser

49 Microvascular leakage Impairment of endothelial tight junctions Loss of pericytes Weakening of capillary walls Elevated levels of vascular endothelial growth factor (VEGF)

50 Vascular endothelial growth factor (VEGF) Promotes vascular growth and permeability Elevated levels of circulating VEGF in conditions with retinal ischemia Levels are not reduced with focal laser

51 Chronic Hyperglycemia Optical Coherence Tomography (OCT) Images Retinal Microvascular Damage and Diabetic Retinopathy Retinal Hypoxia VEGF-A Possibly Other Mediators Normal retina Permeability Neovascularization Vascular Leakage Diabetic Macular Edema Retina with DME

52 The Diabetic Retinopathy Clinical Research Network Protocol T Comparative Effectiveness Study of Aflibercept, Bevacizumab, or Ranibizumab for DME Supported through a cooperative agreement from the National Eye Institute; National Institute of Diabetes and Digestive and Kidney Diseases; National Institutes of Health, Department of Health and Human Services EY14231, EY14229, EY018817

53 Mean change in visual acuity letter score Change in visual acuity over 2 years Full cohort week treatment group comparison*: Aflibercept vs. bevacizumab P = 0.02 Aflibercept vs. ranibizumab P = 0.47 Ranibizumab vs. bevacizumab P = Weeks Aflibercept Bevacizumab Ranibizumab * P-values adjusted for baseline visual acuity and multiple comparisons

54 Intravitreal injections

55 Preparation

56 Injection

57 PDR

58 Pan retinal photocoagulation (PRP) Photocoagulation Treatment of Proliferative Diabetic Retinopathy Clinical Application of Diabetic Retinopathy Study (DRS) Findings, DRS Report Number 8 THE DIABETIC RETINOPATHY STUDY RESEARCH GROUP PRP reduces risk of visual loss by 50% Ophthalmology 1991; 88;

59 Panretinal photocoagulation (PRP)

60 Post pan-retinal photocoagulation

The Diabetic Retinopathy Clinical Research Network Protocol

National Institute of Diabetes and Digestive and Kidney

61 The Diabetic Retinopathy Clinical Research Network Protocol S Prompt PRP vs. Ranibizumab + Deferred PRP for PDR Study Supported through a cooperative agreement from the National Eye Institute; National Institute of Diabetes and Digestive and Kidney Diseases; National Institutes of Health, Department of Health and Human Services EY14231, EY14229, EY018817

62 Intraocular steroids

63 Treatment options Vitreous hemorrhage 1. Pan-retinal photocoagulation 2. Vitrectomy with laser photocoagulation 3. Intraocular vascular endothelial growth factor (VEGF) inhibitor Traction retinal detachment 1. Observation if not involving the macula 2. Vitrectomy with membrane dissection

64 Pars plana vitrectomy Early Vitrectomy for Severe Vitreous Hemorrhage in Diabetic Retinopathy Two-Year Results of a Randomized Trial Diabetic Retinopathy Virectomy Report 2 CLINICAL SCIENCES THE DIABETIC RETINOPATHY VITRECTOMY STUDY RESEARCH GROUP Vitrectomy results in improved vision in patients with persistent vitreous hemorrhage Arch Ophthalmol. 1985;

65 Pars plana vitrectomy

66 Severe NPDR PM 53yo WF - Vision 20/20 NPDR, nonproliferative diabetic retinopathy.

67 PDR/VH PM 53yo WF Vision PDR, proliferative diabetic retinopathy; VH, Vitreous hemorrhage.

71 s/p PPV/MP/EL 1 Month Post Op Vision 20/25 EL, endolaser; MP, membrane peel; PPV, pars plana vitrectomy.

72 PDR/VH CM 46yo AAM Vision PDR, proliferative diabetic retinopathy; VH, vitreous hemorrhage.

73 PDR/VH CM 46yo AAM Vision PDR, proliferative diabetic retinopathy; VH, vitreous hemorrhage.

74 PDR/VH CM 46yo AAM Vision PDR, proliferative diabetic retinopathy; VH, vitreous hemorrhage.

75 PDR, proliferative diabetic retinopathy; VH, Vitreous hemorrhage; TRD, tractional retinal detachment. PDR/TRD/VH 5 months later Vision 20/200

76 PDR/TRD 5 months later Vision LP PDR, proliferative diabetic retinopathy; TRD, tractional retinal detachment.

77 s/p PPV/MP/EL 2 months Post Op Vision 20/70 EL, endolaser; MP, membrane peel; PPV, pars plana vitrectomy.

78 s/p PPV/MP/EL/SO Post Op - Under SO Vision HM EL, endolaser; MP, membrane peel; PPV, pars plana vitrectomy; SO, silicone oil.

79 Pre Op Post Op

80 Treatments work best before vision is lost Many patients are diagnosed only after vision is lost Vision loss is a late symptom of diabetic eye disease Bottom line

81 How you can prevent visual loss Control risk factors Bottom line Have yearly dilated eye exams

82 QUESTIONS?

Eyes on Diabetics: How to Avoid Blindness in Diabetic Patient

Eyes on Diabetics: How to Avoid Blindness in Diabetic Patient Rova Virgana FK Unpad Pusat Mata Nasional RS Mata Cicendo Bandung Eye Center (Hospital and Clinic) PIT IDI Jabar 2018 Keys Facts from WHO