Evolving Therapy and Management of Diabe7c Re7nopathy Jaime H. Membreno, MD , FACS Re7na and Macula Specialists, PLLC Assistant Clinical Professor of Ophthalmology University of Central Florida, College of Medicine University of South Florida, School of Medicine Signiﬁcant End Organ Disease l  Aﬀects Nearly 26 million Americans l  Leading Cause of of new blindness ages 25-‐74 l  Fueled by mul7ple social and lifestyle factors l  Various popula7ons at risk l  Improved systemic care can stave oﬀ progression l  Blue Mountain , Farmingham , ETDRS, DRS, NIH, DCCT, DRCR Silver Linings l  Improved mul7disciplinary collabora7on l  Public Educa7on and Programs l  Improved tools and strategies l  Intraocular advances for managing re7nal complica7ons l  Intraocular advances for monitoring re7na complica7ons l  Intraocular advances for trea7ng re7na complica7ons Public Educa7on and Programs l  Decades of Epidemiological and pathophysiological data l  Brief Review of landmark studies l  Current emphasis by public organiza7ons on lifestyle, obesity, preven7on l  Current health care and health delivery incen7ves l  Governmental and non-‐governmental campaigns Improved Tools and Strategies l  Glycemic and Glycosylated Hemoglobin management l  Comorbidity and systemic risk factor management l  Cholesterol, Hypertension, Lipids, Weight management l  Electronic data and inter-‐disciplinary commmunica7on l  Early interven7on and screening with improved collabora7on Understanding Ocular Diabe7c Disease l  Improved understanding of Pathophysiological Mechanism l  Growth Hormone , Hypoxia and Vasoprolifera7ve factors l  Cytokines and hematologic factors l  Vascular Endothelial Growth Factor l  Cornea, len7cular, re7na and nerve disease Monitoring Re7na Complica7ons l  Ophthalmologic dilated re7nal evalua7on is cri7cal l  Type 1 within ﬁve years of diagnosis or a[er passing puberty l  Type 2 shortly a[er diagnosis l  Follow up will vary based on ocular and systemic comorbity l  General Preferred Prac7ce Pa\erns by AAO l  Fluorescein Angiography and Op7cal Coherence Tomography, B-‐scan Managing Re7na Complica7ons l  Costs, treatment, side-‐ eﬀects, complica7ons, Binocular or monocular status l  Condi7on and treatment status of fellow eye l  Concomitant condi7ons such pregnancy, cardiovascular disease, stroke l  Associated ocular disease such as cataract , glaucoma, vascular occlusion l  Phase and severity of Diabe7c re7nopathy: edema, neovasculariza7on, etc l  Approach is tailored for speciﬁc pa7ent Treatment of Re7na Complica7ons-‐Edema l  Foveal or non-‐ foveal edema l  An7 VEGF (Vascular Endothelial Growth Factor): Bevacizumab*, Rhanibicizumab, Aﬂibercept*, Pegaptamib l  Cor7coscteroids: Dexamethasone*, Triamcinolone (Triessence) l  Laser: Micropulse , grid and focal laser l  Pars Plana Vitrectomy Treatment of Re7na Complica7ons-‐ Neovasculariza7on/Vitreous Hemorrhage l  Severity of neovasculariza7on and visibility of fundus l  Laser – DRS: Pan Re7na Photocoagula7on, single or mul7ple treatments l  An7-‐VEGF (Vascular Endothelial Growth Factor)-‐ DRCR: Bevacizumab*, Rhanibicizumab*, Aﬂibercept*, Pegaptamib* l  Pars Plana Vitrectomy Treatment of Re7na Complica7ons-‐ Prolifera7ve / Trac7on Re7na Detachment l  Examina7on/ diagnos7c imaging/ guarded visual prognosis l  An7 VEGF (Vascular Endothelial Growth Factor): Bevacizumab*, Rhanibicizumab, Aﬂibercept*, Pegaptamib l  Laser: pan re7na photocoagula7on l  Pars Plana Vitrectomy, Repair of Trac7on Re7na Detachment l  Neovascular Glaucoma Summary l  Preven7on and public policy is very relevant l  Mul7disciplinary approach , communica7on and systemic control l  Understanding of Pathophysiology l  Improved diagnos7c and imaging modali7es l  Improved medical treatment op7ons , an7 VEGF in par7cular l  Improved surgical vitrectomy modali7es with improved outcomes References l  Na7onal Diabetes Informa7on Clearinghouse l  Silva P et al, Nat rev Endocrinology 2010;6(9):494-‐508 l  ACCORD study group et al. N Engl J Medicine. 2010;363(3): 233-‐244 l  American Academy of Ophthalmology. Preferred Prac7ce Guidelines: Diabe7c Re7nopathy. 2008, 2012 l  Early Treatment Diabe7c Re7nopathy Study Group. Ophthalmology . 1987; 94(7):761-‐774 l  Diabe7c Re7nopathy Clinical Research Network. Opthhalmology 2008;115(9): 1447-‐1449. www.drcr.net