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+ Larger Font / - Smaller Font NTRC Newsletter Volume 1 Issue 1 March, 2005 Diabetic Macular Edema By S. Young Lee, M.D. Welcome to the inaugural issue of our quarterly newsletter. With each edition, we will explore the current and emerging management options of common retinal diseases. In addition, we will share our thoughts on how we approach these complex problems and our outcomes after treatment. Diabetic retinopathy remains the leading cause of new blindness in the United States for adults under the age of 65 years. In particular, diabetic macular edema may be present at any level of retinopathy occurring in approximately 10% of all diabetic patients.(1) Diabetic macular edema can be classified as localized or diffuse edema. Localized diabetic edema can be defined as a discrete area of retinal thickening resulting from a foci of leaking micro aneurysms. This was further elucidated by the landmark Early Treatment Diabetic Retinopathy Study (ETDRS) study which defined clinically significant macular edema or CSME (Table 1).(2) From that grew the current treatment paradigm centering on focal laser Photocoagulation for CSME. In contrast to localized diabetic macular edema, diffuse diabetic macular edema has been defined as more widespread retinal thickening. This may result from generalized leakage of abnormally permeable and dilated capillaries throughout the posterior pole. While localized diabetic edema often responds well to laser Photocoagulation, diffuse diabetic edema can be more difficult to treat with laser alone. This has led to a change in recent approaches to diabetic macular edema. Today laser is only one of many viable options used in the treatment of diabetic macular edema.
Pilot studies suggest that intraviteal triamcinolone acetonide (Kenalog) can reduce macular edema and improve vision in diabetic patients with macular edema. Jonas et al have recently studied 25 consecutive patients with bilateral, diffuse, diabetic macular edema. Unilateral intravitreal injection of triamcinolone acetonide was performed in the study group, while the contralateral eye served as a control group. in the study group, visual acuity increased significantly (P < 0.001) by 3 + 2.6 Snellen lines, while the control groups showed no significant change from baseline.(3) Our own experience with intravitreal Kenalog injections agrees with the literature. Mrs. L.F. presented with background diabetic retinopathy with diffuse diabetic macular edema. Her visual acuity at her initial visit was 20/400 in her right eye. An Optical Coherence Tomography (OCT) showed that she did have diffuse macular edema. She was given an intravitreal Kenalog injection, with improvement of her visual acuity to 20/40 and significant reduction in her macular edema (Figure 1).
Another approach to diabetic macular edema involves surgical intervention with pars plana vitrectomy. It has been proposed that a major contributing factor to diffuse diabetic macular edema is an attached posterior hyaloid applying traction to the macula. Several small, uncontrolled clinical trials have suggested the benefit of vitrectomy for diffuse diabetic macular edema associated with an intact posterior hyaloid.(4-6) With consideration of our clinical experience and evaluation of the current literature, our treatment approach to diabetic macular edema can be summarized in Table 2. Laser Photocoagulation for diabetic macular edema has been the standard of care since the first published report by the ETDRS in 1985. More recently intravitreal Kenalog injection and pars plana vitrectomy have helped in the complex management of diffuse DME. Future therapies for diabetic macular edema include implantable sustained release steroid devices such as Retisert by Bausch and Lomb. Other therapies include injectable antiVEGF inhibitors such as Macugen sponsored by Eyetech. In any case, we stand ready to meet the current and future needs of your patients with proven techniques and the promise of new therapies to come.
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