Hello. My name is Rishi Singh, and I'm welcoming me to this program called Preventing the Inevitable Blindness and Diabetic Patients. An evidence based approach, and I'm glad to be back with you For the second module, we discussed more advanced cases and the proliferated stages through some of the case based discussions will have my name is Richard saying from Cleveland Clinic in Cleveland, Ohio. And again, we'll be disgusting again. The optimization and management of Treatment strategies in diabetic eye disease for our program today. This is a CMI and CE certified webinar that is jointly provided by the University of Massachusetts Medical School and See Me Resources LLC. It's supported by an unrestricted independent educational grant from Regeneron Pharmaceuticals, and this activity may include discussions of off label medications for unapproved uses for specific agents and to receive CMI credit or C E. Credit. There'll be a link provided at the end of this video to obtain those credits. So we talked in our last module about the risk factors for diabetic economic progression, and those include some of the following that are listed here both that are modifiable and non modifiable in nature. Modifiable ones include hyperglycemia, hypertension, hyper epidemiology and smoking cessation and the non modifiable one might be things like sleep apnea or pregnancy or underlying kidney dysfunction. And we know that from a variety of different trials, as I mentioned to you before, that improvement in glycemic control can reduce the progression. Who? The most worsened state of diabetic retinopathy, which is in the far right here, where you have traction and neo vascular ization and hemorrhage present in this patient with proliferated diabetic eye disease. And we know that they're vascular complications related to this disease, both which are microvascular and macro vascular nature. The microvascular changes occur within the eye within the kidneys as well as within the neuro neurological system, causing the prophet and the neuropathy. But they're also going to be a significant risk for cardiovascular and cerebral morbidity and mortality as a result of being diabetic and having uncontrolled disease in this population. And we talked about how blood sugar and blood pressure control can reduce the progression in patients with diabetic eye disease. You can have a 1% decrease in hemoglobin, a one C, which will cause a 50% decrease in risk progression in patients with in the U. K P. D s study, and this is something I talked to my patients about a lot where I can talk about the benefits, um, of improving diabetic retinopathy by reducing the level of hemoglobin a one C. As a result of this of this study. Again, the screening guidelines are important to understand because they have been changing over the past few years, where we initially used to see patients without any diabetic retinopathy yearly. Now they're recommending they can be seen up to every two years, assuming they're human woman agencies less than seven. And in addition, we want to see those patients with severe non proliferated and proliferated these earlier than before because we have both anti vascular endothelial growth factor drugs as well as surgical methods to manage these patients and laser treatments to manage patients much better than we have ever had in the past few years. And again, the problem is that despite our best efforts in treating patients with this condition, 50% of patients don't not receive appropriate care, meaning that either a dilated eye examination or referral to the right specialist and 50% do not receive follow up as needed, as recommended by the American Diabetes Association or the American Society of Ophthalmology. We talked about the path of physiology of diabetic retinopathy, which includes micro aneurysms, which is due to the loss of parasites in this condition. And when these microorganisms become worse, these vasculature become unsupported and start to leak and eventually cause closure. And that's when you have the proliferated form of diabetes due to the resulting ischemia that forms as a result of capillary closure in this patient population. So this is a case that we're going to discuss as a result of sort of looking at these patients a little bit more in detail. This is a 49 year old African American male with a history of diabetes. For the past seven years, his hemoglobin, a one C, is 8.9% his eye pressure is normal and his direct examination was performed with an act by an optometrist. And this is what they found. They essentially saw this patient and said, Well, the patient has a lot of hemorrhages present here, and four quadrants or more. There's no really detectable level of of the of accusation present, but they do have, you know, some changes in the phobia or the macula, and we should get an O. C. T. And so here you can see some of the changes present on the pictures, which are concerning for maybe diabetic macular oedema. And so the optometrist recommended a six month follow up after getting a normal O. C T. And unfortunately, patient returned six weeks later with decreased visions in both eyes and eye pain. So they were seen again by the optometrist event. Examination was normal. Visual acuity was 2020 in both eyes, but the eye pressure was elevated. 43 millimeters in the right and 35 are left. The question was what to do next? And so I There's lots of options here to consider, but they chose to do a same day referral to the retina specialist, and I happen to see this patient and I did an angiogram, and what you can see here on the right eye is that they're severe amounts of caterpillar closure and non profusion present in the right eye. On the top frames on the bottom frames, there's definitely a presence of leakage and micronesians presences, nonproliferation President left eye, but in the right eye in particular. If you look at the optic nerve, you see a large bright spot present, which indicates patient as neo vascular ization of the optic disc. And in fact, we know that some of our imaging technologies have become better at finding these patients in our practices. We found that through the analysis that ultra white cell imaging can pick up more patients that have these diabetic retinopathy progressions, or progressions to proliferate disease than traditional funding photography alone. And this paper actually did a study where they compared traditional cameras to fund to large field images and found 3.2 times more rental service. That was imaged 3.9 times more areas of non profusion, 1.9 times more areas of the of accusation and 3.8 times of more Panorama laser that was found. These patients, who had the wide full image in comparison to the traditional image and we diagnose this patient was diagnosed with proliferated diabetic neuropathy with neo vascular glaucoma. So our treatment options are pandering to laser into ritual injections and interrupt depression drops that should be given to the patient and in this patient. We started them on two medications, uh, and started them on bilateral anti bgf injections. Their visual acuity remained 2020 and the eye pressure was 15 after treatment. And here you can see the before picture and the after picture with the results of the improvements in the diabetic anomaly severity. Quite an impressive result. Here's the right eye before and after again showing you that this patient had nice improvement in their overall fund. This image, albeit in the far periphery. Now you can really make out these ischemic vessels that are present as a result of diabetic retinopathy. And this was actually looked at in, um with regards to the level of to step response to these anti V G F drugs and a variety of front trials, which was the Vivid and Vista study, which looked at the two step improvement in retinopathy scoring with a flipper cept during the course of the trial in front significant percentage of patients 44 47% of patients had a two step improvement across all d r severity scores, uh, and improving of the patient. And in fact, if you look at some of the more recent data, it goes up to 80 to 85% and those patients who have severe proliferate disease. This is another case. A 63 year old African American female, her left eye, her arms, her eyes had ocular hypertension. She had cataracts in her eyes as well, which were very minor. She's morbidly obese. Her human woman a one c, was 10.2, and her medications include the following, which notably includes insulin. And she had really a lot of insurance coverage lapses, and she was lost to follow up multiple periods of time, and she came again. Her timeline, initially when she presented was in 2017, where she had good vision. But then she was lost to follow for three years, and now she presents again this year with a significant decrease in both eyes, vision and again, she had these the following presence. So here you can see the optics image in the right and the left and those circles you're seeing. The black circles are really photographic. Abnormalities are not not necessarily real, but you see there's severe attraction and hemorrhage president. Both eyes, as well as extensive amounts of the of accusation, President. Both eyes. This patient unfortunately, will become a surgical candidate to treat this level of diabetic retinopathy within this patient. Um, here you can see again the presence of subregional fluid presence in this patient as a result of attraction that was occurring due to the diabetic retinopathy. And again, the treatment options include here. Whether you want to continue anti V g f therapy, you want to add Patrick laser or schedule for pars plane of a truck to me for removing the scar tissue and the detachment areas and one study that evaluated this in a lesser form to compare to this was the protocol s study. This study compared patients who got PRP to run a business treatment, who had severe to who had proliferate disease but not high risk characteristics, as I showed you in some of these photographs. But what inevitably found was that over a two year period, study these patients to see what the outcome was, and what they found was that those patients who got the anti V g f had far less issues with regards to retract Amis and far lower levels of vitreous hemorrhage and lower levels of any sort of retinal detachment comparison to the PRP group. In addition, they saw improvements in the overall visual field in comparison to those patients who had, uh, molecular disease and, as a result, at the five year time, point actually showed a better visual field because of not receiving laser. And those patients got injections versus those who did not. Here's case. Three again. You can see a patient who has a 33 year old African American female people and a one c of eight. Um, she was diagnosed, um, at a Sears location with prolific disease back in 2015. He has a hemoglobin, a one C, most recently actually, um uh, 5.6 in May of this year. But she has a more obviously had a significant change where she presented here now with an 8% team aluminum, so some flight major changes have occurred in her. As a result, he is on insulin as well, and she's a former smoker, and again here you can see her presence of her pictures here would show a severe amount of traction components present in the left eye on the CT with tenting of the retina. In addition, on the right, I you actually see a macular hole that's formed as a result of the severe traction that's present here, and thus it needs. It requires surgical intervention. This would not be a patient. You'd object to either, um, uh, laser treatment ahead of time unless the retinal was really attached to the periphery and trying to reduce the investigation prior to surgery. You could give this patient an anti bgf injection because that's something we do give for patients with this condition to help with the surgical procedure and reduce vascular ization. And we do that sometime. Here's just some more pictures of her following that. And here's her angiogram just showing you again how severe her proliferated disease was with severe peripheral disease and the of accusation. Here's the left eye showing again, the multiple franz of the evacuation present within this patient. So you saw from some of these patients there was some discontinuation in their therapy, and this has been a topic of significant interest for myself and my laboratory as well as other groups. Well, to see what the effect is of discontinuing some of these anti V GFs period these injections for periods of time. And this is a study from the Mid Atlantic Retina Group in in Philadelphia. They showed a 25% loss to follow up of injections over time and again. They attributed this to those with lower socioeconomic status. Uh, and, uh, and severity of eye disease, uh, most with severe nonpolitical. He's actually lost to follow more commonly. And, um, and patients with bad vision were actually more likely to be lost to follow up than those who have good vision, which again probably speaks to their level of independence and their ability to care for themselves. There's no study from Munich University which actually looked at the same thing, breaks within 100 days. And 46% of patients actually had that change as well. Uh, that you saw that there was a 46% difference with regards to having 100 daybreak in their treatment patterns. And this these studies demonstrated significant loss to follow up in diabetic micro demon. We did our own study, which I can show you here, um, which showed again that there was a fairly small number of patients who had this break But when you had this break that there was a significant changes in the visual acuity in those patients who had this break as well. And alternatively, we realized from some of the studies by women and Johnson that this interruption in treatment of 12 months, can be really detrimental patients. This is looking at patients within the d. R. C R Net studies and found that those patients who had lost to follow up in compliance issues, many of them came back with vision threatening retinopathy complications including vitreous hemorrhage, glaucoma and retinal detachment. And many eyes had bad vision at the end of this sort of study. So we had done some additional looking at that, that additional information I talked about before with regards to visual field preservation, which occurs with anti bgf and Protocol s. And here you can see the outcomes in the Humphrey visual fields in those patients with them without treatment over a period time and again, this shows you the five year outcome, which again shows you that improvements in the powerful visual field and those patients who got anti bgf versus laser, albeit all patients, had some detriment with the guards there, Um, peripheral, uh, field. Unfortunately, due to this condition, however, some of this was due to the fact that obviously patients with diabetes develops ischemia despite getting these anti bgf over time. So just to conclude this part of the presentation, I've shown you some really bad cases of prolific disease and patients that need surgical urgent or emergent evaluation by a retina specialist. Well, we all know that the presenting vision of these patients is important and referring them early in managing them early is the most important way of preserving their vision. Long term and anti VDs have increased the patient outcomes, including vision and retinopathy progression. But despite that, some patients do still progress and require referral. Do the retina specialist to manage their surgical retinal conditions and again, prompt referral to the specialist even in moderate and severe diabetic retinopathy can be important because I've shown you some of the cases looked like they were either moderate or severe, but truly ended up being proliferated in nature. And that, I think, is again we're retina specialist, really can be helpful to the patient and to you and managing these patients. Thank you very much for attention
