Ophthalmic Complications in Older Adults with Diabetes
Medha N. Munshi, Lewis A. Lipsitz in Geriatric Diabetes, 2007
The comprehensive eye examination is the mainstay of such evaluation and is necessary on a repetitive, lifelong basis for patients with diabetes (64,126). Dilated ophthalmic examination is superior to undilated evaluation because only 50% of eyes are correctly classified with respect to the presence and severity of retinopathy through undilated pupils (127,128). Because of the complexities of the diagnosis and treatment of PDR and CSME, ophthalmologists with specialized knowledge and experience in the management of DR are required to determine and provide appropriate surgical intervention (129). Thus, it is recommended that all patients with diabetes should have dilated ocular examinations by an experienced eye care provider (ophthalmologist or optometrist), and diabetic patients should be under the direct or consulting care of an ophthalmologist experienced in the management of DR at least by the time severe NPDR or diabetic macular edema is present (64). Effort must be made to help the elderly patient overcome their additional barriers to acquiring timely and consistent quality eye care.
Important Studies in Vitreoretinal Surgery
Pradeep Venkatesh in Handbook of Vitreoretinal Surgery, 2023
This was the first study to use a prefilled syringe for intravitreal delivery of an implant. The implant is non-biodegradable and contains 0.19 µg of fluocinolone acetonide [FAc]. It is cylindrical in shape with a length of 3.5 mm and diameter of 0.35 mm and is injected through a 25G needle. The release rate is 0.2 µg/day, and the release duration is 36 months. Following submission of results from two parallel studies [FAME A-in the United States and FAME B-in Canada, Europe, and India] with the same protocol but in different geographic locations of the world, it was approved by the FDA in 2013 for use as second-line therapy in patients with chronic or resistant diabetic macular edema. FAME studies were multicentric, randomized, and double masked with three study arms [low-dose 0.20-µg implant, high-dose 0.50-µg implant, and placebo]. The main inclusion criteria was persistent diabetic macular edema [mean duration, 3 years]. A total of 953 patients were randomized in the ratio 2:2:1; 375 with the low-dose implant, 393 with the high-dose implant, and 185 with placebo. Visual gain of 15 or more letters was seen in 28% of treatment eyes versus 16% in placebo eyes [both 2- and 3-year end points]. Treated patients also needed much lower secondary interventions like laser and/or other intravitreal injections. This implant is marketed as Iluvien and has been further evaluated with phase 4 studies like the ICE-UK study [Iluvien Clinical Evaluation, United Kingdom], RESPOND study [evaluation of safety and efficacy in patients with chronic diabetic macular edema and inconsistent response to other therapies], Medisoft audit study, and Retro-IDEAL study. Some ongoing studies include PALADIN study [primary outcome being the need for intraocular pressure lowering procedures] and NEW DAY study [to evaluate Iluvien as baseline therapy in diabetic macular edema].
Intravitreal triamcinolone acetonide in macular edema
A Peyman MD Gholam, A Meffert MD Stephen, D Conway MD FACS Mandi, Chiasson Trisha in Vitreoretinal Surgical Techniques, 2019
One of the main reasons for reduced vision in patients with diabetic retinopathy is macular edema. This can be divided into a focal type and a diffuse type.98 The Early Treatment of Diabetic Retinopathy Study (ETDRS) has shown that focal laser coagulation of leaking circumscribed retinal areas in eyes with focal DME is therapeutically useful to improve visual outcome compared with no treatment.99,100 In eyes
Emerging drugs for the treatment of diabetic retinopathy
Published in Expert Opinion on Emerging Drugs, 2020
Elio Striglia, Andrea Caccioppo, Niccolò Castellino, Michele Reibaldi, Massimo Porta
The prevalence of diabetes is constantly increasing worldwide, its rise affecting both urban and rural areas. In addition to the absolute numbers of the disease, the prevalence of diabetes-related complications is also predicted to rise in the next 20 years. In Western countries, diabetes is already the main cause of blindness in working age groups. In the near future, Asia will be the major epicenter of diabetes epidemiological growth. The proportion of subjects affected by diabetic retinopathy will be on the rise as a consequence of the increasing expected lifespan of patients. This trend will be most evident in India and China. Diabetic macular edema is the main retinal complication of diabetes. Thus, future developments in research on DME detection and treatment will be of critical importance in the management of diabetes. Future treatments of DME will require close integration with the various national systems according to their available financing resources, health care organization, and national priorities.
Emerging corticosteroid delivery platforms for treatment of diabetic macular edema
Published in Expert Opinion on Emerging Drugs, 2020
Janika Shah, Anagha Vaze, Timothy Tang Lee Say, Mark C Gillies, Samantha Fraser-Bell
Diabetic macular edema is a known microvascular complication of diabetes, characterized by accumulation of excess fluid and lipid exudates intracellularly and extracellularly leading to increase in retinal thickening. It is secondary to inner retinal barrier rupture, which is in turn secondary to a range of metabolic changes brought about by hyperglycemia [45]. Glycemic control and systemic blood pressure are important in the prevention of diabetic microvascular complications [46,47]. Although VEGF is an important molecule in retinal barrier disruption, around 25% of patients with DME are resistant to intravitreal treatment with VEGF inhibitors [48]. Topical delivery of VEGF inhibitors is challenging because it has to traverse various layers of cornea, bypass dynamic barriers such as dilution by tear film and systemic clearance through conjunctival vessels and penetrate the inner layers of the retina to reach the blood vessels. VEGF inhibitors are proteins that require the preservation of their fragile tertiary and quaternary structures for its activity and sensitive to various environmental factors, including heat, pH changes, and proteolytic enzymes making it difficult for sustained drug delivery implant [49].
Ischemia-Modified Albumin Levels and Thiol-Disulphide Homeostasis in Diabetic Macular Edema in Patients with Diabetes Mellitus Type 2
Published in Current Eye Research, 2021
Mustafa Kalayci, Ersan Cetinkaya, Kenan Yigit, Mehmet Cem Sabaner, Reşat Duman, Ahmet Rifat Balik, Özcan Erel
Diabetic retinopathy (DR) is a condition characterized by retinal angiopathy and neuropathy that occurs as a result of dysregulated blood glucose, and if left untreated, it may cause blindness.1 Diabetic retinopathy is the leading cause of untreatable vision losses in the population aged 20 to 65 years in developed countries.2 Long-term hyperglycemia-related toxicity is the primary mechanism in the development of DR. Long-term exposition to hyperglycemia is believed to result in a series of biochemical and physiological changes that ultimately lead to endothelial damage. Specific retinal capillary changes include capillary occlusion and thickening of basement membrane leading to retinal non-perfusion and decompensation of endothelial barrier function that results in pericyte losses and serum leakage, namely macular edema.3 The main cause of visual impairment in diabetic patients is diabetic macular edema. In general, macular edema is an indicator of fluid accumulation in the extracellular area in the retina in the macular region and threatens visual acuity if the retinal region in the macular center becomes thicker. Prevalence and severity of DR and macular edema show a positive correlation with abnormal hematological and biochemical parameters. However, the exact role of these abnormalities, either individually or in combination, in the pathogenesis of retinopathy has not been clearly defined yet.
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