Retina – what are your concerns
Somdutt Prasad MS FRCSEd FRCOphth FACS Consultant Ophthalmologist I4vison, 13 A, Jatin Bagchi Road, Kolkata 70029 AMRI Medical Centre, 97 A, Kolkata 700029 Divyadrishti, Howrah Westbank Hospital, Andul Road, Howrah
sprasad@rcsed.ac.uk
098 30 50 7754
UK Training Dorchester – Rick Powell – 1994 Swindon – Paul McCormack – 1995 Oxford – 1996 – Paul Rosen & Hung Cheng Wirral – Russell P Phillips -1997-1999 Sheffield – Prof Ian Rennie, John Talbot, James West – 2000-2001
MS Kolkata – 1993 FRCS Edinburgh – 1994 CCST - 2001 FRCOphth (London) – 2006 FACS American College of Surgeons – 2008 AAO Achievement Award 2008 AAO International Education Award 2009 ASCRS Film Festival Award 2010 ASRS Honors Award 2013
The Retinal Surgeon - 1995 • Is your retina detached? • Do you have a cataract? • No! • What are you doing in my clinic?
DIABETIC VITRECTOMY
What do I do? • Medical Retina • Vitreo-retinal surgery • Cataract surgery – Premium IOLs – Toric IOLs – Multifocal IOLs
Diabetes • 1550 BC - Ebers Papyrus of ancient Egypt – too great emptying of urine – “the river Nile between the thighs”
• Remedies recommended – diet of wheat grains, grapes, honey and berries – –
Papyrus discovered - Luxor 1872 George Maurice Ebers
Diabetes • 17.1 crores worldwide • India – 2000 – 3.17 crores • 36.6 crores in 2030 – Maximum increase in India – 7.94 crores India – 4.23 crores China
Behaviour & Environment
Vital Function %
100
Good
Bad
0 Failure
25
50
75
Life Expectancy of Function (Years)
100
India • One Ophthalmologist / 1 lakh population – UK 2.3 Ophthalmologists / 1 lakh population
• 70% + specialists - Urban • 70% + population - Rural
Diabetic Retinopathy Classification Background
Preproliferative
Maculopathy
Proliferative Advanced Diabetic Eye Disease The commonest cause of decreased visual acuity due to diabetic retinopathy is maculopathy
Examination • Slit lamp – External exam – Pressure measurements – Fundus examination
Retinal Examination • Direct Ophthalmoscope – small field – 2 D view – Uniocular
11 November 1998
Retinal Examination …(2) • Slit lamp biomicroscopy – Large field – 3 D view – Binocular
Binocular indirect ophthalmoscope
Retinal Examination • Fundus photography – Large field – Can be done by technician
Laser treatment for diabetic retinopathy is effective‌‌.
Diabetic maculopathy
Diabetic maculopathy • 12% of treated eyes developed moderate visual loss in spite of treatment • Less than 3% of treated eyes improved VA significantly (15 ETDRS letters)
Intra vitreal triamcinolone IVTA
Personal experience‌10+ years Pre 6/60
d 5
s y a Post 6/9
Case …2 Pre RE 6/36
Pre LE 6/60
Post RE 6/9
Post LE 6/12
Steroids • Triamcinolone – Pseudophakic eyes – Resistant cases
• Dexamethasone – Ozurdex
• Fluocinolone Acetonide – Iluvien, Retisert
Sustained Delivery Fluocinolone Acetonide Vitreous Inserts Provide Benefit for at Least 3 Years in Patients with Diabetic Macular Edema Peter A. Campochiaro, MD, David M. Brown, MD, Andrew Pearson, MD, Sanford Chen, MD, David Boyer, MD, Jose Ruiz-Moreno, MD, Bruce Garretson, MD, Amod Gupta, MD, Seenu M. Hariprasad, MD, Clare Bailey, MD, Elias Reichel, MD, Gisele Soubrane, MD, Barry Kapik, MS, Kathleen Billman, BS, Frances E. Kane, PhD, Kenneth Green, PhD Ophthalmology Volume 119, Issue 10, Pages 2125-2132 (October 2012)
Copyright Š 2012 American Academy of Ophthalmology Terms and Conditions
Figure 5
Ophthalmology 2012 119, 2125-2132DOI: (10.1016/j.ophtha.2012.04.030) Copyright Š 2012 American Academy of Ophthalmology Terms and Conditions
Ranibizumab • 9 RCTS in DME – – – – – – –
READ-2 REVEAL RESOLVE RESTORE RISE & RIDE DRCRN trial 2 years ≥10 letters gain in BCVA
– No difference between • Ranibizumab + prompt laser (deferred laser worse) • Laser alone
Bevacizumab • 8 RCTS in DME – BOLT Avastin vs Laser – N=80, two years – iVB +8.6 letters – Laser -0.5 letters
Key points • Laser therapy = standard of care – non-center-involving oedema – DME without decreased VA
• anti-VEGF treatment standard in – center-involving DME and – VA of 6/9 or worse
• Ranibizumab injections – monthly for 3 visits, – then as needed depending on VA (with or without OCT) stability
somduttprasad@gmail.com 09830507754