how and when retinopathy should be treated · how and when retinopathy should be treated poma 111th...

“How and When Should Retinopathy be Treated”Leonard H. Ginsburg, MD

POMA 111th Annual Clinical Assembly & Scientific SeminarMay 1-4, 2019

How and When Retinopathy Should Be Treated

POMA 111th Annual Clinical Assembly & Scientific SeminarKing of Prussia, PA

May 2, 2019

Leonard H. Ginsburg, M.D., C.D.E.Chairman, Moore Eye InstituteActing Chairman, Ophthalmology Residency Program, PCOMClinical Chief, Department of Ophthalmology, Drexel University College of Medicine

Financial Disclosure

EHR Command Center, LLC

• Chief Medical Officer

• Equity

#POMA19 #ChooseKnowledge

Diabetic Retinopathy

Type II Diabetes

• 21% may have retinopathy at diagnosis

• 30% have retinopathy within 5 years

• 80% have retinopathy after 15 or more years

Type I Diabetes

• Nearly all have retinopathy within 20 years


1

2

3



The Problem

• 20% present with end-organ complications

(eg, retinopathy 21%, neuropathy, nephropathy)

• Often asymptomatic in its most treatable stages

• Denial


The number one fear of Americans is blindness.

Doctor = Teacher

Give a man a fish and you feed him for a day.

Teach a man to fish and you feed him for a lifetime.

-Maimonides

What is the responsibility of every doctor?


Systemic Relationship

• DCCT showed improved glycemic control reduces complications from Diabetes by 76%

• Each 1% ↓of HgbA1C reduces DR progression by 50%• Results in 30-50% reduction in development of DME

• Blood pressure control• Each decrease of 10mm of SBP ↓ of 10% DR progression

• ACCORD and FIELD studies• Lipid management can ↓ progression of DR by 30%


4

5

6



Classification of Diabetic Retinopathy and Predictive Value of Retinal Lesions

Classification of Diabetic Retinopathy and Predictive Value of Retinal Lesions

Proliferative Diabetic Retinopathy


7

8

9



• #POMA19 #ChooseKnowledge

Tissue hypoxia (nonperfusion)

(VEGF)

Neovascularization

(Proliferation)


10

11

12






13

14

15



Protocol S in PDR Eyes with and without Baseline DME

Source: https://www.reviewofophthalmology.com/article/a-deeper-look-at-protocols-s-and-t. (John A. Wells, M.D. 2016)

If DME• Ranibizumab superior over PRP

Without DME• Ranibizumab vs. PRP no significant

difference

PRP vs. Intravitreal Injection


05/02/2006

05/02/2006

05/16/2006

05/16/2006



16

17

18

https://www.reviewofophthalmology.com/article/a-deeper-look-at-protocols-s-and-t



Diabetic Retinopathy and Diabetic Macular Edema

• Diabetic macular edema

• Leading cause of vision loss in patients with diabetes

• Accounts for ≈ 75% of cases of visual loss in these patients

• Prevalence 11.1% in patients < 30 years

• Prevalence 8.4% in patients > 30 years


Pathogenesis of Diabetic Macular Edema

• Duration of diabetes

• High glycosylated HgB

• Obesity

• Pregnancy

• Sleep Apnea

• High Blood Sugar

• Cardiac and renal Failure

Multifactorial

• Proteinuria• Ischemic Peripheral

retina (VEGF)• Inflammation• Mechanical


Diffuse Macular Edema

• Does it have a systemic relationship?• Patients with DME↑ rates of complications by 3 years.

• Myocardial infarction (5.4% vs. 3%)

• Stroke (4.2% vs. 1.6%)

• CHF (11.9% vs. 4.2%)

• Peripheral vascular disease (11.7% vs. 4.5%)

• Cerebrovascular disease (14.6% vs. 7.5%)

• Renal disease (22% vs. 4.9%)

• Mean outpatient visits in 1 year 10 days ↑ in DME vs. patients without.


19

20

21



Diabetic Macular EdemaCategory Description

Focal edema Localized edema from MA or localized vascular abnormality lipid exudates (i.e., circinate ring)

Diffuse edema Diffuse leakage from injured vasculature

Tractional edema Due to vitreous traction (Figure 2)

Ischemic maculopathy Occlusion of perifoveal capillaries (requires FA for Dx). Thickening may be present or absent. (Figure 3)


Diabetic Macular Edema - Traction

• Diabetic eyes with macular edema have a statistically lower rate of posterior vitreous detachment than those without macular edema.

• Risk of developing ME is 3.4x lower in patients with complete PVD.



22

23

24




Focal Edema



25

26

27



Laser Management of DME

Early Treatment Diabetic Retinopathy Study (ETDRS) of the 1970s and 1980s

Laser treatment moderate visual loss by 50%

• 35% of these patients continued to have DME after 1 year and 24% at 3 years

• Only 3% had >3 lines improvement in center involving macular edema

• Only 17% had any improvement in vision after 5 years

Prior to advent of intravitreal injections, visual improvement rare in center-involved macular edema




28

29

30




Laser Effects

• Closure of distinct lesions

• Increases reabsorption of fluid from:• Retinal pigment epithelium• Adjacent healthy vasculature

• Decreases leakage by changing balance at choriocapillaris and retinal pigment epithelium

• May change the vitreoretinal interface

• Change the biochemical needs within the macula


• Laser leaves permanent scars

• Injections risk endophthalmitis, RD

Is there another option?

Doctor First Do No Harm!!


31

32

33






34

35

36




Laser photocoagulation: The mainstay of treatment from 1969 to 2012 for 43 years

Until

VegF inhibitors shifted the paradigm

From

Phototherapy to pharmacotherapy


Anti VEGF Treatment of DME

• Designed to bind and inhibit active VEGF-A isoforms

• Approved by FDA

• Ranibizumab (0.3 mg)

• Aflibercept (2.0 mg)

• Off-label

• Bevacizumab


37

38

39



Protocol S: The Difference between Aflibercept and RanibizumabSeen at One Year in the Worse Vision Group Wasn’t Seen at Two Years



Protocol T: Avastin Treated Eyes Half as Much Reduction as Other Two Treatment Groups through Two Years



In Protocol T, Year One, Avastin Group Was Inferior to Other Two Groups, But Caught Up in Year Two



40

41

42






Ours is an era of unprecedented advances in the ability to diagnose and treat disease,

yet the importance of healing is being lost.

In the past, caring was the very soul of our profession, partly because we were powerless to affect many ailments.

Now machines, drugs and the knife replace sensitivity, communication and touch.

-Ken Ginsburg, M.D.

Children’s Hospital of Philadelphia

1998

What Does the Patient with Diabetes Most Need?


What is the Newest Challenge to Good Diabetes Care?

Paper to EMR: A Step Backwards?

We went from this: to this:


Paper to EMR: A Giant Leap Forward for All Insurance Payers

They went from this: to this: and this:


43

44

45



Source: Dr. Stephen Mussey, April 4, 2015, https://www.flickr.com/photos/drmussey/16848928870/.

And the Doctor Patient Relationship…


“The U.S. government claimed that electronic health records would lead to safer, cheaper health care: 10 years and $36 billion later, the system is a mess.”


There are two ways to live your life.

One is as though nothing is a miracle.

The other is as though everything is a miracle.

―Albert Einstein


46

47

48



Shoshana Garfinkle


49

https://www.youtube.com/watch?v=cyTqTP8_spI

how and when retinopathy should be treated · how and when retinopathy should be treated poma 111th...

Documents