Download Diagnosis & Management of Diabetic Eye Disease

Diagnosis &
Management of
Diabetic Eye Disease
Part 7
A. Paul Chous, M.A., O.D., F.A.A.O.
Tacoma, WA
Specializing in Diabetes Eye Care & Education
Newest Therapies for DR

VEGF Inhibitors: MacugenTM, LucentisTM,
AvastinTM in trials
Macugen & Lucentis both improved VA and
reduced OCT thickness in DME
 Macugen & Avastin caused regression of
PDR; Avastin reduced iris
neovascularization
 Avastin caused rapid resolution of VH (n=2)
 DRCR.net now links multiple researchers &
centers

VEGF in Diabetic Retinopathy



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Retinal VEGF levels elevated
in experimental diabetes
VEGF165 injected in primates
induces vascular leakage
within 30 minutes
Increased VEGF levels found
in vitreous of eyes with
proliferative DR & DME
DR patients have higher
VEGF levels in the aqueous
Quam et al. IOVS. 2001; Tolentino et al. Ophthalmology. 1996; Funatsu et al. AJO. 2002;
Adamis et al. AJO. 1994; Aiello et al. NEJM. 1994.
Courtesy of Jeffry Gerson, O.D., F.A.A.O.
Newest Therapies for DR

PKC Inhibitors:
Ruboxistaurin (ArxxantTM, Lilly/Alcon)
showed modest benefit for DME
 FDA approval in question


Inflammatory Modulators:

Steroids reduce VEGF production (IV/subtenon’s)
Sustained release steroids: RetisertTM,
AlimeraTM, PosurdexTM
 Infliximab: a monoclonal antibody against
TNF-a that inhibits breakdown of the bloodretinal barrier (in trials)

Newest Therapies for DR


Micro-pulsed laser: lower duration &
energy causes less retinal damage,
possibly less severe scotomata and
improved scotopic visual function
Nutraceuticals
Benfotiamine: fat-soluble form of thiamine
that blocks all 4 biochemical pathways of
hyperglycemic insult in vivo & totally
prevented DR in rats
 Pycnogenol: patented pine bark extract
reduces capillary leakage and reduced
retinal thickening in one RCCT of DME

Newest Therapies for DR
Low energy laser:
Reduces visual field
Defects, improves
Night vision, lower
Risk of pain during
procedure
SDM
Laser
Sub-threshold Diode Micropulse Laser
By dramatically increasing levels
of intracellular thiamine, benfotiamine
reduces F-6-P and G-3-P via
the pentose phosphate shunt
Glucose
Glucose Metabolism
Polyol Pathway
Glucose-6-phosphate
Fructose-6-phosphate
G-3-P
Glyceraldehyde-3-phosphate
GAPDH
1,3 Diphosphoglycerate
(harmless metabolite)
Hexosamine Flux
Protein Kinase C
Advanced Glycation
Endproducts
Benfotiamine Update

A recent trial of 600 mg
benfotiamine daily for 3 weeks in
patients with longstanding T1DM
 Normalized
elevated activity in:
 Polyol
Pathway
 Hexosamine Pathway
 AGE Pathway
 PKC not assessed (too much blood
required)
Brownlee M. Diabetologia Sept 2008
Effective Communication



Clear explanation of the patient’s ocular
conditions
treatment
options
Use &positive
language
Information about the link between
diabetesAvoid
& eye disease
(& vice versa)
scare tactics
Realistic appraisal of the individual risk
of vision
Build loss
a Relationship through


risk of blindness < risk of CV disease
Knowledge & Compassion
risk of blindness ranges from 0.5%-19%
Key Points
 Diabetes
and diabetic eye
disease are epidemic
 Ocular complications are myriad
and associated with large blood
vessel disease
 State-of-the-art care is evolving
rapidly
“The only thing to do
with good advice is to
pass it on to others…
It is of absolutely no
use to oneself.”
- Oscar Wilde
Thank You!!
A. Paul Chous, O.D.
[email protected]