Diagnosis & Management of Diabetic Eye Disease
Download
Report
Transcript Diagnosis & Management of Diabetic Eye Disease
Diagnosis &
Management of
Diabetic Eye Disease
Part 7
A. Paul Chous, M.A., O.D., F.A.A.O.
Tacoma, WA
Specializing in Diabetes Eye Care & Education
Newest Therapies for DR
VEGF Inhibitors: MacugenTM, LucentisTM,
AvastinTM in trials
Macugen & Lucentis both improved VA and
reduced OCT thickness in DME
Macugen & Avastin caused regression of
PDR; Avastin reduced iris
neovascularization
Avastin caused rapid resolution of VH (n=2)
DRCR.net now links multiple researchers &
centers
VEGF in Diabetic Retinopathy
Retinal VEGF levels elevated
in experimental diabetes
VEGF165 injected in primates
induces vascular leakage
within 30 minutes
Increased VEGF levels found
in vitreous of eyes with
proliferative DR & DME
DR patients have higher
VEGF levels in the aqueous
Quam et al. IOVS. 2001; Tolentino et al. Ophthalmology. 1996; Funatsu et al. AJO. 2002;
Adamis et al. AJO. 1994; Aiello et al. NEJM. 1994.
Courtesy of Jeffry Gerson, O.D., F.A.A.O.
Newest Therapies for DR
PKC Inhibitors:
Ruboxistaurin (ArxxantTM, Lilly/Alcon)
showed modest benefit for DME
FDA approval in question
Inflammatory Modulators:
Steroids reduce VEGF production (IV/subtenon’s)
Sustained release steroids: RetisertTM,
AlimeraTM, PosurdexTM
Infliximab: a monoclonal antibody against
TNF-a that inhibits breakdown of the bloodretinal barrier (in trials)
Newest Therapies for DR
Micro-pulsed laser: lower duration &
energy causes less retinal damage,
possibly less severe scotomata and
improved scotopic visual function
Nutraceuticals
Benfotiamine: fat-soluble form of thiamine
that blocks all 4 biochemical pathways of
hyperglycemic insult in vivo & totally
prevented DR in rats
Pycnogenol: patented pine bark extract
reduces capillary leakage and reduced
retinal thickening in one RCCT of DME
Newest Therapies for DR
Low energy laser:
Reduces visual field
Defects, improves
Night vision, lower
Risk of pain during
procedure
SDM
Laser
Sub-threshold Diode Micropulse Laser
By dramatically increasing levels
of intracellular thiamine, benfotiamine
reduces F-6-P and G-3-P via
the pentose phosphate shunt
Glucose
Glucose Metabolism
Polyol Pathway
Glucose-6-phosphate
Fructose-6-phosphate
G-3-P
Glyceraldehyde-3-phosphate
GAPDH
1,3 Diphosphoglycerate
(harmless metabolite)
Hexosamine Flux
Protein Kinase C
Advanced Glycation
Endproducts
Benfotiamine Update
A recent trial of 600 mg
benfotiamine daily for 3 weeks in
patients with longstanding T1DM
Normalized
elevated activity in:
Polyol
Pathway
Hexosamine Pathway
AGE Pathway
PKC not assessed (too much blood
required)
Brownlee M. Diabetologia Sept 2008
Effective Communication
Clear explanation of the patient’s ocular
conditions
treatment
options
Use &positive
language
Information about the link between
diabetesAvoid
& eye disease
(& vice versa)
scare tactics
Realistic appraisal of the individual risk
of vision
Build loss
a Relationship through
risk of blindness < risk of CV disease
Knowledge & Compassion
risk of blindness ranges from 0.5%-19%
Key Points
Diabetes
and diabetic eye
disease are epidemic
Ocular complications are myriad
and associated with large blood
vessel disease
State-of-the-art care is evolving
rapidly
“The only thing to do
with good advice is to
pass it on to others…
It is of absolutely no
use to oneself.”
- Oscar Wilde
Thank You!!
A. Paul Chous, O.D.
[email protected]