Ocular Disease III: Exam 2: Lecture 6-7: Diabetic Retinopathy 2 Flashcards
High Risk PDR Characteristics
- Risk of Severe Vision Loss (
- b. 26%
c. 4% - a. 26%
b. 9% - a. 37%
b. 20% - a. 30%
b. 7%
How do you Treat High Risk PDR?
Panretinal Photocoagulation (PRP) for PDR
- What kind of Laser is used?
- How many burns/Eye over 3 SESSIONS?
a. The Amt of Tx during any one Session is governed by what?
b. Spot Size is what?
c. Duration of BURN time?
d. Power of Laser is ENOUGH to Stimulate the RPE to do what?
- Argon Blue-Green Laser
- 1500-2500 Burns/Eye over 3 Sessions
a. by Pt threshold for pain and ability to maintain Concentration
b. 100-500 microns
c. 0.1-0.2 sec
d. to Ablate the retina
PRP (2)
- It can be applied up to how close to around the Fovea?
- Grid Laser up to how many microns from the fovea?
- Focal laser where?
- up to 2 DD around the Fovea
- 500 microns from the Fovea
- Focal laser 50 micron spot for 0.1 Sec Exposure Time w/in 500 Microns of Fovea
* Focal laser is 10x’s Smaller than Grid Laser…(used for MICROANEURYSMS!!)
PRP (3)
- What does it DESTROY?
- What does it Reduce?
- May cause THINNING of what Retinal Layers?
a. This allows Choroidal Blood and O2 to reach what Retinal Layers? - Can Cause Regression of what?
- Reduces RISK of SEVERE VISION LOSS by what %?
- When should you DO PRP Promptly?!
- HYPOXIC RETINA (destroys ischemic area and Amt of Angiogenesis Factors Released)
- Vasoproliferative Stimuli
- of Outer Retinal Layers
a. the Inner Retinal Layers - NEO Regression
- by 50%
- for EYES w/HIGH RISK CHARACTERISTICS and NVI
PRP: Mechanism: Unknown: But he thinks it works like this…
- Basically, you are BBQing the Fundus to prevent what?
- Causes Destruction of what?
a. What is the Black stuff after doing PRP? - Leads to Decrease demand of what molecule?
- Get Regression of what?
- Proliferation of new BVs (avoid Macula, posterior pole, disc)
- of RPE
a. Hyperplasia - of O2
- of Blood Vessels
PRP Complications
- If you have Worsening Macular Edema and Pucker (So CSME and DR): What will they DO FIRST?
- Major Complications? (5)
a. Severe reduction in what?
b. What happens to Night vision and color?
c. What about dark adaptability (is it affected)
d. Central vision affected?
e. What about pupil?
- They will do FOCAL LASER First for CSME (macular laser) then they’ll do PRP!
- a. Severe Field Reduction
b. Impaired Color/Night Vision
c. Decreased Dark Adaptability
d. Mild Decrease in Central Vision (14%)
e. Residual dilated pupil & Accommodative Paresis due to Lasering the Ciliary Nerves
PRP Complications (2)
- Burns on what 2 things?
a. How does this work? - What can happen from Treating NEO DIRECTLY?
- What TRACTION can develop?
- If you use TOO HEAVY of a Laser, what will happen? (2)
- What can happen from ANTERIOR ROTATION of the CB? (Malignant GIc)
- What can form from EXCESSIVE Tx?
- Foveal and Disc Burns
a. Pt moves eye during procedure; Doctor gets lost during Tx; Can be prevented by using a temporal barrier of burns. - Hemorrhage
- Vitreoretinal Traction
- Choroidal Detachment and 2ndary Exudative RD
- Angle Closure
- CNVM
PDR
- WHAT is the GOLD STANDARD still?
- PRP (came up in the 60s/70s, nothing is better)
* Know the Difference b/w FOCAL (20 seconds and you’re done) and PRP
* Reduces risk of Visual Loss by 50%
Early Treatment Diabetic Retinopathy (ETDRS) (1)
- Eligibility: Diabetes types?
a. What kind of DR did they look at? - Randomized patients into 3 groups: what were they?
- Endpoints
a. VA of what for AT LEAST 4 Months?
b. Doubling of what?
c. Progression of what?
- Type 1 or Type 2 DM
a. Mild NPDR thru Early PDR - a. EARLY vs. DEFERRED SCATTERED (Panretinal) Laser Photocoagulation (PRP) (They were wondering if PRP should be done before NEO forms, or after)
b. FOCAL Laser Photocoagulation for MACULAR EDEMA vs. No Treatment
c. 650 m Aspirin vs. Placebo (wanted to see if aspirin helped out) - a. VA
Early Treatment Diabetic Retinopathy (ETDRS): RESULTS
- 650 mg aspirin/day
a. Did it alter progression of Retinopathy?
b. Did it prevent Cataracts?
c. Did it Increase risk of Vitreous Hemorrhage?
i. It was associated with DECREASED Risk of what?
d. BASICALLY, can they TAKE ASPIRIN?
- Early Scatter Laser
a. Reduction in Risk of Severe Loss?
b. Benefit of Early Tx MORE PRONOUNCED for PTs w/what?
c. So, what does that tell us?
3. Focal Laser for CSME
a. % DECREASED RISK of MODERATE VISUAL LOSS?
b. % Decreased risk of Severe Vision Loss (3 or more lines) if CSME is thru the Fovea?
c. Caused occasional moderate visual gain?
d. If there’s FOCAL Microaneurysms leakage on FA, what would they use?
e. If there was Diffuse Leakage on FA?
f. Re-evaluate when?
g. Is need for Additional Tx common?
h. What SHOULD BE TREATED BEFORE PRP use?
i. What can WORSEN CSME?
- a. NO
b. No
c. No
i. of CVD. Thus, no Ocular CI to Aspirin use when required for CVD or other indications
d. YES. It’s okay to take Aspirin w/DR - a. SMALL (3.7% vs. 2.6%)
b. w/Type 2 DM or Pt with Type I DM of LONG DURATION
c. There really isn’t any benefit with the RISK of Laser Tx until later on (but small) - a. 50% (12-23%, Absolute Visual Gain)
b. 80% (3 or more lines)
c. Yes.
d. Do FOCAL Photocoagulation
e. Do Grid Photocoagulation!
f. in 2-4 months.
g. YES
h. CSME!!
i. CATARACT EXTRACTION!
ETDRS: TAKE HOME LESSON
- What Tx is INDICATED for CSME?
- What about PDR?
a. The idea is to TREAT before VISION does what? - If you have a PATIENT who has 20/15 and HAS CSME?
a. What about PDR?
- FOCAL (Focal Microaneurysms)/GRID (diffuse leakage) Photocoagulation Tx.
- DO PRP!! REGARDLESS OF VA LEVEL!!!!
a. Idea is to TREAT BEFORE VIsion gets WORSE! - REFER IT OUT!!!
a. REFER IT OUT!! (any neo…get it OUT!)
Clinical Trials
- What are the 5 Trials?
- DRS: Diabetic Retinopathy Study
- ETDRS: Early Treatment Diabetic Retinopathy Study
- Diabetic Vitrectomy Study (DRVS)
- Diabetes Control and Complications Trial (DCCT)
- United Kingdom Prospective Diabetes Study (UKPDS)
Diabetic Retinopathy Study (DRS)
- What were they evaluating?
- Qualifications for the study?
- This Study was looking at what Tx?
- THIS STUDY DEFINED WHAT?
- Vision loss from PDR
- PDR in at LEAST ONE EYE or SEVERE NPDR in BOTH EYES
- Scatter Photocoagulation vs. No Treatment (PRP vs. no PRP)
- HIGH-RISK PDR!!!
Diabetic Retinopathy Study (DRS)
RESULTS
- This Study defined that PRP did what with Vision loss?
- If he asks a question, which study defined that we should do PRP as a Treatment for PDR, what study would you choose?
- Greatest Benefit for Patients with what kind of PDR?
- that PRP reduced the RISK of Severe Vision Loss with PDR by >50%!
- DRS!! (Diabetic Retinopathy Study)
- with HIGH RISK PDR!
The Diabetic VITRECTOMY Study (DRVS)
- It defined that VITRECTOMY is INDICATED for what? (alot..)
a. If you have Tractional RD, you’re going to get what?
- TRACTION RD INVOLVING MACULA (was what he had highlighted)
a. YOU’RE GOING to GET A VITRECTOMY!