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04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
Diabetic Maculopathy Diabetic Maculopathy Dr. Anand SudhalkarDr. Anand Sudhalkar
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
How is the vision lost?How is the vision lost?
Macular oedema, Macular oedema, ischemia. Foveal ischemia. Foveal exudatesexudates
Vitreous Vitreous Haemorrhage, Haemorrhage,
Tractional Retinal Tractional Retinal DetachmentDetachment
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
Classification of D.R.Classification of D.R.
NPDRNPDR : : MildMild ( few dot haem. microanuery.) ( few dot haem. microanuery.) ModerateateModerateate : Blot Haem, Soft exud. : Blot Haem, Soft exud. SevereSevere : Preproliferative stage : Blot : Preproliferative stage : Blot Haem Haem 44 Quadr. , Venous Beading Quadr. , Venous Beading 22 quadrants, IRMA quadrants, IRMA 11 quadrant. ( 45% go to quadrant. ( 45% go to PDR in one yr.)PDR in one yr.)
PDRPDR : Neovascularisation : Neovascularisation High Risk : NVD > 2/3 rd, NVE 2 High Risk : NVD > 2/3 rd, NVE 2 places, V.H.places, V.H.
Macular oedema can occur at any stage.Macular oedema can occur at any stage.
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
Types of Macular OedemaTypes of Macular Oedema
FocalFocal : M.A., High MW lipoproteins, : M.A., High MW lipoproteins, Hard exudates, Circinate patterns.Hard exudates, Circinate patterns.
DiffuseDiffuse : Capillary bed leakage, Low : Capillary bed leakage, Low MW watery fluid, cystoid spaces, MW watery fluid, cystoid spaces, Bilaterality - Systemic causes, HT, Bilaterality - Systemic causes, HT, Renal Failure, Hypoprotein. Renal Failure, Hypoprotein.
UntreatedUntreated, 50%, 50% loose loose > 2> 2 lines in lines in two yearstwo years
7
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
What is CSME?
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
PREVALENCEPREVALENCE 10% AMONGST ALL DM10% AMONGST ALL DM 40% Of these have CSME40% Of these have CSME Out of all BDR 3% have CSMEOut of all BDR 3% have CSME Out of all PPDR 38% have CSMEOut of all PPDR 38% have CSME out of all PDR 71% have CSMEout of all PDR 71% have CSME 5% of maturity-onset, IDDM at diag.5% of maturity-onset, IDDM at diag. Prevalence Prevalence Duration of Hyperglycemia Duration of Hyperglycemia After 20 yr. 99% of IDDM and 60% of NIDDM After 20 yr. 99% of IDDM and 60% of NIDDM
have retinopathyhave retinopathy 2
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
Treatment OptionsTreatment Options
Medical Management : Control of Medical Management : Control of Diabetes, HT, Renal failure, anaemia, Diabetes, HT, Renal failure, anaemia, hypoprotemia, pregnancy, carotid hypoprotemia, pregnancy, carotid artery diseasesartery diseases
Laser Photocoagulation : Patz 1973, Laser Photocoagulation : Patz 1973, British Multicenter Trial 1975, British Multicenter Trial 1975, Blankenship 1979, Olk 1986, Blankenship 1979, Olk 1986, ETDRS ETDRS 1985 (ongoing)1985 (ongoing)
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
ETDRS Multicentric TrialETDRS Multicentric Trial
Treated 754, Deferred 1490Treated 754, Deferred 1490 After 3 yr. visual loss 12% in treated, After 3 yr. visual loss 12% in treated,
24% in untreated.24% in untreated. When centre of macula was When centre of macula was
involved, treatment effect was more involved, treatment effect was more significant at 3 yr.. Visual loss 13% significant at 3 yr.. Visual loss 13% against 33%against 33%
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
Treatment ProtocolTreatment Protocol
FFA to identify microaneurysms FFA to identify microaneurysms /capillary leakage & dropouts/capillary leakage & dropouts
Focal / grid laser Focal / grid laser Follow-ups 3 to 6 weekly, for Follow-ups 3 to 6 weekly, for
minimum 6 months and maximum minimum 6 months and maximum 3 years3 years
Repeat FFA & Additional laser if Repeat FFA & Additional laser if requiredrequired
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
Role of FFA:Role of FFA:
Identify M.A.Identify M.A.
Map area of cap. dropMap area of cap. drop
Study FAZStudy FAZ
Identify IRMA & NVIdentify IRMA & NV
5
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
FFA taken 4 years Apart
F.A.Z. enlargement
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
Principles of Management : Principles of Management : Laser deliveryLaser delivery
Slit-Lamp Magnification Enlarged & Steady View
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
Focal Oedema : Focal LaserFocal Oedema : Focal Laser
Identify Culprit Identify Culprit M.A. by FFAM.A. by FFA
Identify Centre of Identify Centre of FoveaFovea
Green Wave, Green Wave, Mainster lens, Mainster lens, Short duration, Short duration, 100um size, 100um size, minimum treatmentminimum treatment
Be On Target
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
Pre-laser FFA
microaneurisms
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
Post Laser Treatment
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
Diabetic Macular Diabetic Macular Oedema : Oedema : DiffuseDiffuse
GRIDGRID Laser Photocoagulatiopn Laser Photocoagulatiopn C-Shaped, 100um, Green Laser C-Shaped, 100um, Green Laser Followup 3 months Followup 3 months
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
Clinical Study : Goals and Clinical Study : Goals and ObjectiveObjective
Review the cases of Review the cases of BDRBDR treated treated for for CSMECSME
Study the efficacy ofStudy the efficacy of focalfocal and and gridgrid P.CP.C
Find the difference in the results in Find the difference in the results in ‘ ‘earlyearly’ and ‘’ and ‘delayeddelayed’ treated ’ treated casescases
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
Study of Study of CSME + BDRCSME + BDR
90 eyes90 eyes of of 6666 patients reviewed. patients reviewed. ExcludingExcluding cases with other ocular cases with other ocular pathologies, H.T. , Impaired cardiac pathologies, H.T. , Impaired cardiac & renal status& renal status
Age group Age group 43 to 7543 to 75 years years Diabetic age Diabetic age 1 to 30 years1 to 30 years Duration of visual loss Duration of visual loss 15 days to 1 15 days to 1
yearyear
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
Sub-classificationSub-classification Focal Focal and and DiffuseDiffuse Pre-treatment Visual AcuityPre-treatment Visual Acuity
Snellen Acuity >6/36 <6/36
Focal (68eyes)
53 15
Diffuse (22) 00 22
Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
04/12/23
Assessment of ResultsAssessment of Results
VisionGain/loss
>1 line > 2lines
Stable Worse
Focal68eyes
61 eyes89.71%
32eyes47.06%
5eyes7.35%
2eyes2.95%
Grid22eyes
14 eyes63.63%
5eyes22.72%
6eyes27.27%
2eyes9.10%
Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
04/12/23
Vision at the Time of Vision at the Time of Treatment Treatment
Initial vision > 6/36 Initial vision > 6/36 out of out of 5353 eyes:-eyes:-
51 51 ( 96.22%) ( 96.22%) improved by > one improved by > one lineline
2727(50.94%) (50.94%) improved by > two improved by > two lineslines
Initial vision <6/36 Initial vision <6/36 out of out of 1515 eyes:-eyes:-
10 10 (73.34%) (73.34%) improved by > improved by > one lineone line
5 5 ( 33.33%) ( 33.33%) improved by > improved by > two linestwo lines
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
Duration of Visual Loss at Duration of Visual Loss at the Time of Presentationthe Time of Presentation
Presented within one month : Presented within one month : ……………………………………………………………………………………………..90% improved…..90% improved
Presented after one year : Presented after one year : …………………………………………………………………………………………………62.5% improved………62.5% improved
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
Delay in ReferenceDelay in Reference
‘ ‘ BenignBenign ‘ looking retinopathy ‘ looking retinopathy Waiting for ‘Waiting for ‘betterbetter’ control ’ control
diabetesdiabetes Starting antioxidantsStarting antioxidants, aspirin, , aspirin,
steroid dropssteroid drops Non-availability of Non-availability of laser facilitylaser facility
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
Conclusions :Conclusions :
Early recognition of fovea Early recognition of fovea threatening threatening CSME
Fluorescein angiography & slit-lamp biomicroscopy to identify M.A
Prompt photocoagulation with slit-lamp delivery system
Regular follow-ups and repeat treatments
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
Message : Message : ETDRS REPORT ETDRS REPORT 1919
Recommends Recommends photocoagulation before the photocoagulation before the foveal vision loss occursfoveal vision loss occurs
In In clinically significant clinically significant diabetic macular oedemadiabetic macular oedema
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
Exacerbation Exacerbation afterafter Cataract SurgeryCataract Surgery
Diabetes and CataractDiabetes and Cataract
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre
Special Considerations :Special Considerations :
NPDRNPDR requiring requiring PRP PRP 4, 2, 1 criteria 4, 2, 1 criteria PDR in other eye PDR in other eye PregnancyPregnancy
04/12/23 Dr. Anand Sudhalkar, Eye Clinic & Retinal Laser Centre