Finally: A Long-lasting resorption of Diabetic Macular Edema.
Avinoam Ophir, MD [ ophir45avi@gmail.com ]
In our experiments during the recent years, which were published in the Ophthalmic literature, we disclosed the major cause of the blinding pathology, the intractable diffuse diabetic macular edema. Based on these it became possible to achieve a long-lasting resorption of the macular edema.
Accumulation of fluids at the center of the retina, or "macular edema", is the major cause of visual loss in diabetic patients and is the leading cause of vision loss in the working population, worldwide. Until recently the cause of the most common and severe type of diabetic macular edema, the widespread "diffuse" type, was obscure, and therefore the various treatments to dry the edema are unsatisfactory. These are:
1. Grid-laser to the macula. The outcome of thatvtreatment when all eyes in a series were treated ranged between 15-20% after 2-3 years of follow-up;
2. Intravitreal injections of various medications, such as Avastin. Their effect is, as a rule, temporary and partial, and repeated injections are often required, for years. In many others that treatment fails;
3.Vitrectomy operation.The surgery is often beneficial, however it is often done late, after all other options (medications and laser) had failed. That delay could often result in an irreversible injury to the photoreceptors at the central visual center at the retina, associated with permanent reduction of visual acuity. The only situation that vitrectomy surgery was done early enough was if vitreous traction membranes were detected at the central macula. These membranes that pulled the macula were removed at the operation and the macular edema most often resolved.
Accumulation of fluids at the center of the retina, or "macular edema", is the major cause of visual loss in diabetic patients and is the leading cause of vision loss in the working population, worldwide. Until recently the cause of the most common and severe type of diabetic macular edema, the widespread "diffuse" type, was obscure, and therefore the various treatments to dry the edema are unsatisfactory. These are:
1. Grid-laser to the macula. The outcome of thatvtreatment when all eyes in a series were treated ranged between 15-20% after 2-3 years of follow-up;
2. Intravitreal injections of various medications, such as Avastin. Their effect is, as a rule, temporary and partial, and repeated injections are often required, for years. In many others that treatment fails;
3.Vitrectomy operation.The surgery is often beneficial, however it is often done late, after all other options (medications and laser) had failed. That delay could often result in an irreversible injury to the photoreceptors at the central visual center at the retina, associated with permanent reduction of visual acuity. The only situation that vitrectomy surgery was done early enough was if vitreous traction membranes were detected at the central macula. These membranes that pulled the macula were removed at the operation and the macular edema most often resolved.
Based on our published studies (since 2009), I recently summarized our findings in the
prestigious American ophthalmological Journal, the "IOVS" (Ref.
1), and presented them also at the 5th Vitreo-Retinal Summer
School in Thessaloniki, Greece (Link):
By using full-field 3D OCT (with the aid of video clips) and a revised OCT examination we found that the major cause of diffuse diabetic macular edema are vitreous membranes that have extrafoveal traction sites (Figure) at either the macula (rather than only at the central macula) and/ or the optic nerve head. These extrafoveal traction sites were previously overlooked. Their detection or exclusion enables tailoring a treatment for a long-lasting resorption of the diffuse macular edema.
By using full-field 3D OCT (with the aid of video clips) and a revised OCT examination we found that the major cause of diffuse diabetic macular edema are vitreous membranes that have extrafoveal traction sites (Figure) at either the macula (rather than only at the central macula) and/ or the optic nerve head. These extrafoveal traction sites were previously overlooked. Their detection or exclusion enables tailoring a treatment for a long-lasting resorption of the diffuse macular edema.
Based on these, our treatment protocol for diffuse diabetic macular edema, as was published in IOVS is (Ref. 1):
A) In case of traction - removal of the tractional membranes by vitrectomy operation, or just careful observation and follow-up. Neither intravitreal injection of the current medications nor laser treatment would release these tractional membranes and the resulting edema. Rather, sometimes these repeated treatments might even worsen the traction;
B) In case of diffuse macular edema without traction, after verification that extrafoveal traction is not present: Grid laser photocoagulation to the macula;
C) Injections of medications into the vitreous (in the eye) are, as a rule, not indicated.
A) In case of traction - removal of the tractional membranes by vitrectomy operation, or just careful observation and follow-up. Neither intravitreal injection of the current medications nor laser treatment would release these tractional membranes and the resulting edema. Rather, sometimes these repeated treatments might even worsen the traction;
B) In case of diffuse macular edema without traction, after verification that extrafoveal traction is not present: Grid laser photocoagulation to the macula;
C) Injections of medications into the vitreous (in the eye) are, as a rule, not indicated.
Ref. 1: A. Ophir. Full-Field 3-D Optical Coherence Tomography
Imaging and Treatment Decision in Diffuse Diabetic Macular Edema. IOVS
2014;55:3052.
Link: 5ο Διεθνές Θερινό Σχολείο Υαλοειδούς-Αμφιβληστροειδούς στη Θεσσαλονίκη
Link: 5ο Διεθνές Θερινό Σχολείο Υαλοειδούς-Αμφιβληστροειδούς στη Θεσσαλονίκη
