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Update on Prevention, Diagnosis & Treatment of Diabetic Macular Edema ( DME) Part 1

Update on Prevention, Diagnosis & Treatment of Diabetic Macular Edema ( DME) Part 1. A. Paul Chous, MA, OD, FAAO Specializing in Diabetes Eye Care & Education Tacoma, WA Adjunct Instructor, Nova Southeastern University College of Optometry

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Update on Prevention, Diagnosis & Treatment of Diabetic Macular Edema ( DME) Part 1

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  1. Update on Prevention, Diagnosis & Treatment of Diabetic Macular Edema (DME) Part 1 A. Paul Chous, MA, OD, FAAO Specializing in Diabetes Eye Care & Education Tacoma, WA Adjunct Instructor, Nova Southeastern University College of Optometry Principal Investigator for the Diabetes Visual Function Supplement Study (DiVFuSS)

  2. What IS DME? • Fluid accumulation and retinal thickening within the macula as a result of diabetes mellitus Cross-sectional view via OCT Ophthalmoscopic view of DME

  3. What Are The Symptoms? • Often asymptomatic in the earliest stages that are most amenable to treatment • More severe disease results in visual distortion, loss of color perception & loss of detail vision • May result in ‘legal blindness’ but not total blindness, unless concomitant proliferative retinopathy with tractional retinal detachment

  4. What Are the Risk Factors? • Established risk factors for diabetic macular edema include disease duration, HbA1c, BP, obstructive sleep apnea and cigarette smoking • T1DM, Latino or Black race, HTN, diabetic nephropathy and neuropathy significantly increase risk per recent retrospective analysis of 440,000 patients Ophthalmology. 2009 Mar;116(3):497-503 Retina. 2012 Oct;32(9):1791-8. Diabetes Res Clin Pract. 2013 Jun;100(3):298-305 Association for Research in Vision & Ophthalmology 2013, Seattle

  5. DME & A1c • 27% of pts in the DCCT had DME by 9 years Diabetes 2010;59:1244–1253 • Each 1 point increase in HbA1c (e.g. from 7.5% to 8.5%) raised the odds of DME by 37% in WESDR over 25 years of follow-up . WESDR = Wisconsin Epidemiologic Study of Diabetic Retinopathy Ophthalmol 2009; 116(3):497-503

  6. Risk for DME w TZDs (thiazolidinediones) • Hi-dose TZDs may increase risk • T2DM Tx w pioglitazone (ActosTM) increased odds of DME by 5x • Risk increased 21x with concomitant insulin • Analysis not controlled for BMI, and pioglitazone pts were generally “sicker” • If Rx’d, lower doses may reduce risk of DME Arch Intern Med. 2012 Jul 9;172(13):1005 EASD Sept 2013 Abstract #67

  7. CSME and Center-Involved DME • CSME (clinically significant macular edema) established treatment criteria per ETDRS (Early Treatment Diabetic Retinopathy) findings • Diagnosis dependent on retinal thickening & proximity to the fovea • Based on stereoscopic, clinical examination • Center Involved DME means foveal involvement requiring therapy

  8. Optical Coherence Tomography (OCT): THE Most Sensitive Tool to Detect DME (98.6% sensitivity) • 1-1.7 um wavelength, non-ionizing light • Resolution to 1 micron • 17,000 scans/sec • Can detect DME long before clinical exam BUT, not all detected DME requires treatment • 30% of patients with DME detected by OCT are not detected by clinical examination • These patients are 4x more likely to develop CSME Ophthalmology.2004 Apr;111(4):712-5. Ophthalmologica.2013;230(4):201-6.

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