DR Flashcards
DCCT (T1 DM)
Tight control beneficial in T1DM Rapid normalization and tight control after period of prolonged hyperglycemia can lead to initial worsening of DR
UKPDS
T2DM benefit from intensive glycemic control
Intensive control of blood pressure slowed progression of retinopathy
RIDE
•Objective: Ranibizumab (0.3mg, 0.5mg) vs sham + laser in DME
Result: At 2 years: 34% (0.3mg) and 46% (0.5mg) able to read >15 ETDRS letters compared to baseline vs 12% (sham+laser)
Conclusion: Ranibizumab effective in DME
VISTA
- Objective: Eylea vs laser for DME
- Conclusion:
- Eylea significantly superior in functional and anatomic endpoints over laser
- 2q4 and 2q8 groups similar efficacy
- Results held for 3 years of follow-up
Protocol I
Objective: Ranibizumab + focal laser vs ranibizumab alone vs triamcinolone + focal for DME
(protocol I found that lucentis is Incredible)
Conclusion
- Rani + laser or deferred laser had superior VA and OCT outcomes vs laser alone
- focal/grid laser treatment at the initiation of intravitreal ranibizumab is no better, and is possibly worse, for vision outcomes than deferring laser treatment for 24 weeks
- treatment with intravitreal triamcinolone acetonide in combination with laser was substantially inferior to treatment with ranibizumab with or without laser
Protocol T
Objective: Aflibercept vs bevacizumab vs ranibizumab for DME
(finding the very Top antiVEGF in protocol T)
Conclusion
Eylea, avastin, lucentis all improved vision with DME at VA >20/50
Eylea best when the Va is 20/50 or WORSE
Protocol B
Objective: Triamcinolone 1mg or 4mg vs macular laser for DME
(Protocol B for Steriods which make you Buff)
Conclusion
Triamcinolone NOT superior to focal laser and had more adverse events
Focal laser for ME
adverse effects and complicatins of focal laser photocoagulation? (6)
Clinic features associated with poorer visual acuity outcomes after laser for DME (3)?
- paracentral scotoma
- transient increase of edema/decrease of vision
- photocoagulation scar expansion
- subretinal fibrosis at the side of laser scar
- CNV
- inadvertent foveal burns
- diffuse ME with central involvement
- macular ischemia
- HE in the fovea
Focal Laser for DME
What are the laser parameters?
spot sizes of 50–100 µm and burn durations of 0.1 second or less.
For focal leakage laser the MAs btwn 500 - 3000 um from the center of the macula with the goal of whitening or darkening them
for diffuse leakge or zones of capillary nonperfusion adjacent to the macula a light intensity grid pattern can be applied (more than 500 µm from the center of the macula and 500 µm from the temporal margin of the optic disc)
Definition of severe NPDR
What is the risk of progession to PDR in 1 year for severe NPDR and very severe NPDR
4: 2:1
1. 4 quadrants with severe intraretinal hemorrhages and MAs
2. 2 quadrants with venous beading
3. 1 quadrant with IRMAs
Severe NDPR 15% -> high risk PDR @ 1 year
Very severe (2 or more of above) NPDR 45% -> high risk PDR @ 1 year
How do we define high-risk PDR? What study defined this?
DRS study
Having any 1 of the following:
- mild NVD with VH
- NVD 1/3 - 1/4 disc area
- NVE 1/2 disc area with VH
Protocol S
Objective: Noninferiority of ranibizumb 0.5mg vs PRP for PDR
Started with monthly injections for 6 months
Injections can be deferred when stable at the current and 2 previous visits (definition of stability)
Conclusion
•Ranibizumab is noninferior to PRP at 2 years
Ranibizumab had less VF loss, fewer PPV, superior gain in Va.
DRS
what are the laser parameters for PRP?
•Objective: Does PRP prevent severe vision loss in DR
Result: PRP reduced risk of severe vision loss (<5/200) by 50-60% in patients with high-risk characteristics
Conclusion
- Perform PRP for high-risk PDR regardless of vision
1200 or more 500-µm burns using argon green or blue-green laser, separated from each other by one-half burn width
What are the infications for PPV in patients with DR?
- nonclearing (>1–6 months) VH
- tractional RD involving or threatening the macula
- combined tractional and rhegmatogenous RD
- diffuse DME associated with posterior hyaloidal traction
- significant recurrent VH despite use of maximal PRP
- red blood cell–induced (erythroclastic) glaucoma and “ghost cell” glaucoma
- anterior segment NV with media opacities preventing PRP
- dense premacular subhyaloid hemorrhage
DRVS
Objective: Observe severe DR in type 1 and 2 DM over 2 years for visual outcomes
Conclusion
- Early PPV for severe visual loss from nonclearing VH (1 month for T1DM and monocular pts)
- Early PPV for eyes w/ useful vision and advanced active PDR
