Browning Diabetic Retinopathy

Evidence-Based Management
1. Auflage 2010
ISBN: 978-0-387-85900-2
Verlag: Springer
Format: PDF
Kopierschutz: 1 - PDF Watermark

E-Book, Englisch, 454 Seiten

Contains information from the Diabetic Retinopathy Clinical Research network not to be found in other published works Evidence-based approach includes material labeled with level of supporting evidence and many clinical examples Includes discussions of area of controversy

Dr. Browning is Retina Specialist at Charlotte Eye Ear Nose and Throat Associates in Charlotte, North Carolina, USA, and is involved with the Diabetic Retinopathy Clinical Research network.

Autoren/Hrsg.

Browning, David J.

Inhaltsverzeichnis

1;Preface;8
2;Acknowledgments;10
3;Contents;12
4;Contributors;14
5;Pathophysiology of Diabetic Retinopathy;15
5.1;1.1 Retinal Anatomy;15
5.1.1;1.1.1 History;15
5.1.2;1.1.2 Anatomy;15
5.1.3;1.1.3 Microanatomy of the Retina Neurons;19
5.1.4;1.1.4 Intercellular Spaces;20
5.1.5;1.1.5 Internal Limiting Membrane;21
5.1.6;1.1.6 Circulation;21
5.1.7;1.1.7 Arteries;21
5.1.8;1.1.8 Veins;22
5.1.9;1.1.9 Capillaries;22
5.2;1.2 Hemodynamics, Macular Edema, and Starling’s Law;22
5.3;1.3 Biochemical Basis for Diabetic Retinopathy;24
5.3.1;1.3.1 Increased Polyol Pathway Flux;25
5.3.2;1.3.2 Advanced Glycation End Products (AGEs);26
5.3.3;1.3.3 Activation of Protein Kinase C (PKC);27
5.3.4;1.3.4 Increased Hexosamine Pathway Flux;28
5.4;1.4 Macular Edema;29
5.4.1;1.4.1 Blood-Retinal Barrier;31
5.4.2;1.4.2 Mechanism of Blood-Retinal Barrier Breakdown;33
5.4.3;1.4.3 Renin-Angiotensin System;37
5.5;1.5 Development of Proliferative Diabetic Retinopathy;38
5.6;1.6 Summary of Key Points;39
5.7;1.7 Future Directions;39
5.8;References;39
6;Genetics and Diabetic Retinopathy;45
6.1;2.1 Background for Clinical Genetics;45
6.2;2.2 The Role of Polymorphisms in Genetic Studies;46
6.3;2.3 Types of Genetic Study Design;49
6.4;2.4 Studies of the Genetics of Diabetic Retinopathy;53
6.4.1;2.4.1 Clinical Studies;53
6.4.2;2.4.2 Molecular Genetic Studies;54
6.4.3;2.4.3 EPO Promoter;54
6.4.4;2.4.4 Aldose Reductase Gene;54
6.4.5;2.4.5 VEGF Gene;54
6.4.6;2.4.6 IGF-1;59
6.5;2.5 Genes in or Near the HLA Locus;59
6.6;2.6 Receptor for Advanced Glycation End Products (RAGE) Genes;59
6.7;2.7 Endothelial NOS2 and NOS3 Genes;60
6.8;2.8 Renin-Angiotensin System-Associated Genes;60
6.9;2.9 Solute Carrier Family 2 (Facilitated Glucose Transporter), Member 1 Gene (SLC2A1);60
6.10;2.10 Gene-Environment Interaction;60
6.11;2.11 Potential Value of Identifying Genetic Associations with Diabetic Retinopathy;60
6.12;2.12 Summary of Key Points;61
6.13;2.13 Future Directions;61
6.14;Glossary;61
6.15;References;63
7;Epidemiology of Diabetic Retinopathy;67
7.1;3.1 Introduction and Definitions;67
7.2;3.2 Epidemiology of Diabetes Mellitus;70
7.3;3.3 Factors Influencing the Prevalence of Diabetes Mellitus;71
7.4;3.4 Epidemiology of Diabetic Retinopathy;73
7.5;3.5 Diabetes and Visual Loss;73
7.6;3.6 Prevalence and Incidence of Diabetic Retinopathy;74
7.7;3.7 By Diabetes Type;75
7.8;3.8 By Insulin Use;75
7.9;3.9 By Age;76
7.10;3.10 By Duration of Diabetes Mellitus;76
7.11;3.11 By Ethnicity;77
7.12;3.12 Gender;78
7.13;3.13 Age at Onset of Diabetes;79
7.14;3.14 Socioeconomic Status and Educational Level;79
7.15;3.15 Family History of Diabetes;79
7.16;3.16 Changes Over Time;79
7.17;3.17 Epidemiology of Diabetic Macular Edema (DME);80
7.18;3.18 Epidemiology of Proliferative Diabetic Retinopathy (PDR);83
7.19;3.19 Socioeconomic Impact of Diabetes;83
7.20;3.20 Socioeconomic Impact of Diabetic Retinopathy;85
7.21;3.21 Summary of Key Points;85
7.22;3.22 Future Directions;86
7.23;References;86
8;Systemic and Ocular Factors Influencing Diabetic Retinopathy;90
8.1;4.1 Introduction;90
8.2;4.2 Systemic Factors;90
8.2.1;4.2.1 Glycemic Control;90
8.2.1.1;4.2.1.1 Type 1 Diabetes Mellitus;91
8.2.1.2;4.2.1.2 Type 2 Diabetes Mellitus;95
8.2.1.3;4.2.1.3 Rapidity of Improvement in Glycemic Control;97
8.2.2;4.2.2 Glycemic Variability;99
8.2.3;4.2.3 Insulin Use in Type 2 Diabetes;99
8.2.4;4.2.4 Pancreas and Pancreas-Renal Transplantation;99
8.2.5;4.2.5 Blood Pressure;99
8.2.6;4.2.6 Serum Lipids;101
8.2.7;4.2.7 Anemia;102
8.2.8;4.2.8 Nephropathy;102
8.2.9;4.2.9 Pregnancy;102
8.2.10;4.2.10 Other Systemic Factors;104
8.2.11;4.2.11 Influence on Visual Loss;104
8.3;4.3 Effects of Systemic Drugs;105
8.3.1;4.3.1 Diuretics;105
8.3.2;4.3.2 Renin-Angiotensin System Drugs;105
8.3.3;4.3.3 Aldose Reductase Inhibitors;106
8.3.4;4.3.4 Drugs That Target Platelets;106
8.3.5;4.3.5 Statins;107
8.3.6;4.3.6 Protein Kinase C Inhibitors;107
8.3.7;4.3.7 Thiazolidinediones (Glitazones);107
8.3.8;4.3.8 Miscellaneous Drugs;107
8.4;4.4 Ocular Factors Influencing Diabetic Retinopathy;107
8.5;4.5 Diabetic Retinopathy and Associated Comorbidity;109
8.6;4.6 Economic Consequences;109
8.7;4.7 Summary of Key Points;110
8.8;4.8 Future Directions;110
8.9;References;110
9;Defining Diabetic Retinopathy Severity;117
9.1;5.1 Summary of Key Points;126
9.2;5.2 Future Directions;126
9.3;5.3 Practice Exercises;126
9.4;References;131
10;Diagnostic Techniques in Clinical Practice - OCT, FA, Ultrasound;133
10.1;6.1 Optical Coherence Tomography (OCT);133
10.2;6.2 Heidelberg Retinal Tomograph (HRT);140
10.3;6.3 Retinal Thickness Analyzer (RTA);141
10.4;6.4 Microperimetry;141
10.5;6.5 Color Fundus Photography;141
10.6;6.6 Fluorescein Angiography;141
10.7;6.7 Ultrasonography;145
10.8;6.8 Multifocal ERG;145
10.9;6.9 Miscellaneous Modalities;145
10.10;6.10 Summary of Key Points;146
10.11;6.11 Future Directions;146
10.12;6.12 Practice Exercises;146
10.13;References;148
11;Diabetic Macular Edema;152
11.1;7.1 Epidemiology and Risk Factors;152
11.2;7.2 Pathophysiology and Pathoanatomy;153
11.2.1;7.2.1 Anatomy;153
11.3;7.3 Physiology;158
11.4;7.4 Clinical Definitions;163
11.5;7.5 Focal and Diffuse Diabetic Macular Edema;165
11.6;7.6 Subclinical Diabetic Macular Edema;168
11.7;7.7 Refractory Diabetic Macular Edema;168
11.8;7.8 Regressed Diabetic Macular Edema;169
11.9;7.9 Recurrent Diabetic Macular Edema;169
11.10;7.10 Methods of Detection of Diabetic Macular Edema;169
11.11;7.11 Case Report 1;171
11.12;7.12 Case Report 2;173
11.13;7.13 Other Ancillary Studies in Diabetic Macular Edema;178
11.14;7.14 Natural History;178
11.15;7.15 Treatments;179
11.15.1;7.15.1 Metabolic Control and Effects of Drugs;179
11.16;7.16 Focal/Grid Laser Photocoagulation;180
11.16.1;7.16.1 ETDRS Treatment of CSME;180
11.17;7.17 Evolution in Focal/Grid Laser Treatment Since the ETDRS;184
11.18;7.18 Macular Thickness Outcomes After Focal/Grid Photocoagulation;185
11.19;7.19 Resolution of Lipid Exudates After Focal/Grid Laser Photocoagulation;186
11.20;7.20 Inconsistency in Defining Refractory Diabetic Macular Edema;187
11.21;7.21 Alternative Forms of Laser Treatment for Diabetic Macular Edema;187
11.22;7.22 Peribulbar Triamcinolone Injection;188
11.23;7.23 Intravitreal Triamcinolone Injection;188
11.24;7.24 Intravitreal Dexamethasone Delivery System;189
11.25;7.25 Intravitreal Injections of Anti-VEGF Drugs;189
11.26;7.26 Combined Intravitreal Anti-VEGF Drugs and Triamcinolone;190
11.27;7.27 Combined Intravitreal and Peribulbar Triamcinolone and Focal Laser Therapy;190
11.28;7.28 Vitrectomy;190
11.29;7.29 Supplemental Oxygen and Hyperbaric Oxygenation;196
11.30;7.30 Resection of Subfoveal Hard Exudates;196
11.31;7.31 Subclinical Diabetic Macular Edema;196
11.32;7.32 Cases with Simultaneous Indications for Focal and Scatter Laser Photocoagulation;198
11.33;7.33 Exacerbation of Diabetic Macular Edema by Scatter Photocoagulation;198
11.34;7.34 Factors Influencing Treatment of Diabetic Macular Edema;199
11.35;7.35 Sequence of Therapy;199
11.36;7.36 Interaction of Cataract Surgery and Diabetic Macular Edema;201
11.37;7.37 Summary of Key Points;201
11.38;7.38 Future Directions;202
11.39;References;202
12;Diabetic Macular Ischemia;214
12.1;8.1 Introduction;214
12.2;8.2 Pathogenesis, Anatomy, and Physiology;214
12.3;8.3 Natural History;218
12.4;8.4 Clinical Evaluation;219
12.5;8.5 Clinical Significance of Diabetic Macular Ischemia;226
12.6;8.6 Controversies and Conundrums;227
12.7;8.7 Summary of Key Points;228
12.8;8.8 Future Directions;229
12.9;References;229
13;Treatment of Proliferative Diabetic Retinopathy;237
13.1;9.1 Introduction;237
13.2;9.2 Laser Photocoagulation;239
13.2.1;9.2.1 Indications;243
13.2.2;9.2.2 PRP Technique;246
13.2.3;9.2.3 Complications;253
13.2.4;9.2.4 Outcome;254
13.3;9.3 Intraocular Pharmacological Therapy;254
13.4;9.4 Vitreoretinal Surgery;256
13.4.1;9.4.1 Indications;256
13.4.2;9.4.2 Preoperative Management;266
13.4.3;9.4.3 Instrumentation;267
13.4.4;9.4.4 Techniques;269
13.4.5;9.4.5 Postoperative Management;277
13.4.6;9.4.6 Complications;278
13.4.7;9.4.7 General Outcome;283
13.5;9.5 Follow-Up Considerations in PDR;284
13.6;9.6 Case Management: Decision-Making in Complicated Cases;284
13.6.1;9.6.1 Cataract and PDR;284
13.6.2;9.6.2 Dense Vitreous Hemorrhage and Untreated PDR;286
13.6.3;9.6.3 Untreated PDR with Diabetic Macular Edema;286
13.6.4;9.6.4 PDR with Severe Fibrovascular Proliferation/Traction Retinal Detachment;287
13.6.5;9.6.5 PDR with Neovascular Glaucoma;287
13.6.6;9.6.6 Conditions Altering the Clinical Course of PDR;287
13.7;9.7 Summary of Key Points;290
13.8;9.8 Future Directions;291
13.9;References;292
14;Cataract Surgery and Diabetic Retinopathy;315
14.1;10.1 Scope of the Problem of Diabetic Retinopathy Concomitant with Surgical Cataract;315
14.2;10.2 Visual Outcomes After Cataract Surgery in Patients with Diabetic Retinopathy;315
14.3;10.3 Postoperative Course and Special Considerations After Cataract Surgery in Patients with Diabetic Retinopathy;315
14.4;10.4 The Influence of Cataract Surgery on Diabetic Retinopathy;317
14.5;10.5 The Role of Ancillary Testing in Managing Cataract Surgery in Eyes with Diabetic Retinopathy;322
14.6;10.6 Candidate Risk and Protective Factors for Diabetic Macular Edema Induction or Exacerbation Following Cataract Surgery and Suggested Management Actions;322
14.7;10.7 The Problem of Adherence to Preferred Practice Guidelines;323
14.8;10.8 Management of the Diabetic Eye Without Macular Edema About to Undergo Cataract Surgery;323
14.9;10.9 Treatment of Diabetic Macular Edema Detected Before Cataract Surgery When the Macular View Is Clear;324
14.10;10.10 Management When Cataract Sufficient to Obscure the Macular View and DME Coexist or When Refractory DME and Cataract Coexist;325
14.11;10.11 Patients with Simultaneous Indications for Panretinal Photocoagulation and Cataract Surgery;325
14.12;10.12 Management of Cataract in Patients with Diabetic Retinopathy Undergoing Vitrectomy;326
14.13;10.13 Influence of Vitrectomy Surgery on Cataract Formation;326
14.14;10.14 Summary Flow Chart of Management Principles and Estimated Outcomes for Diabetic Eyes Facing Cataract Surgery;327
14.15;10.15 Postoperative Endophthalmitis in Patients with Diabetic Retinopathy;328
14.16;10.16 Summary of Key Points;328
14.17;10.17 Future Directions;329
14.18;References;329
15;The Relationship of Diabetic Retinopathy and Glaucoma;334
15.1;11.1 Interaction of Diabetes and Glaucoma;334
15.2;11.2 Iris and Angle Neovascularization Pathoanatomy and Pathophysiology;335
15.3;11.3 Epidemiology;337
15.4;11.4 Clinical Detection;338
15.5;11.5 Classification;341
15.6;11.6 Risk Factors for Iris Neovascularization;341
15.7;11.7 Entry Site Neovascularization After Pars Plana Vitrectomy;343
15.8;11.8 Anterior Hyaloidal Fibrovascular Proliferation;344
15.9;11.9 Treatments for Iris Neovascularization;344
15.10;11.10 Modifiers of Behavior of Iris Neovascularization;345
15.11;11.11 Management of Neovascular Glaucoma;346
15.12;11.12 Summary of Key Points;350
15.13;11.13 Future Directions;350
15.14;References;350
16;The Cornea in Diabetes Mellitus;356
16.1;12.1 Introduction;356
16.2;12.2 Pathophysiology;356
16.3;12.3 Anatomy and Morphological Changes;357
16.4;12.4 Clinical Manifestations;358
16.5;12.5 Ocular Surgery;359
16.6;12.6 Treatment of Corneal Disease in Diabetes Mellitus;360
16.7;12.7 Conclusion;360
16.8;12.8 Summary of Key Points;360
16.9;12.9 Future Directions;361
16.10;References;361
17;Optic Nerve Disease in Diabetes Mellitus;365
17.1;13.1 Relevant Normal Optic Nerve Anatomy and Physiology;365
17.2;13.2 The Effect of Diabetes on the Optic Nerve;366
17.3;13.3 Nonarteritic Anterior Ischemic Optic Neuropathy and Diabetes;367
17.4;13.4 Diabetic Papillopathy;369
17.5;13.5 Disk Edema Associated with Vitreous Traction;370
17.6;13.6 Superior Segmental Optic Hypoplasia (Topless Optic Disk Syndrome);370
17.7;13.7 Wolfram Syndrome;371
17.8;13.8 Summary of Key Points;372
17.9;13.9 Future Directions;373
17.10;References;373
18;Screening for Diabetic Retinopathy;377
18.1;14.1 Introduction;377
18.2;14.2 Who Does Not Need to Be Screened;378
18.3;14.3 Screening for Diabetic Retinopathy by Adjunctive or Stand-Alone Visual Acuity Testing;378
18.4;14.4 Screening with Undilated Direct Ophthalmoscopy by Non-eye Care Professionals;378
18.5;14.5 Screening with Dilated Ophthalmoscopy by Ophthalmic Technicians or Optometrists;379
18.6;14.6 Screening with Dilated Ophthalmoscopy by Ophthalmologists;379
18.7;14.7 Screening with Dilated Ophthalmoscopy by Retina Specialists;380
18.8;14.8 Photographic Screening;381
18.9;14.9 Nonmydriatic Photography;383
18.10;14.10 Mydriatic Photography;384
18.11;14.11 Risk Factors for Ungradable Photographs;384
18.12;14.12 Number of Photographic Fields;384
18.13;14.13 Criteria for Referral;384
18.14;14.14 Obstacles to the Use of Teleophthalmic Screening Methods;385
18.15;14.15 Combination Methods of Screening;385
18.16;14.16 Case Yield Rates;385
18.17;14.17 Compliance with Recommendation to Be Seen by an Ophthalmologist;386
18.18;14.18 Intravenous Fluorescein Angiography and Oral Fluorescein Angioscopy;386
18.19;14.19 Automated Fundus Image Interpretation;387
18.20;14.20 Subgroups Needing Enhanced Screening Efforts;387
18.21;14.21 Screening in Pregnancy;387
18.22;14.22 Economic Considerations;387
18.23;14.23 Comparisons of the Screening Methods;388
18.24;14.24 Accountability of Screening Programs;390
18.25;14.25 Summary of Key Points;390
18.26;14.26 Future Directions;390
18.27;References;391
19;Practical Concerns with Ethical Dimensions in the Management of Diabetic Retinopathy;394
19.1;15.1 Incorporating Ancillary Testing in the Management of Patients with Diabetic Retinopathy;394
19.2;15.2 Patients with Sight-Threatening Diabetic Retinopathy and Insufficient or No Ability to Address Medical Bills;399
19.2.1;15.2.1 Case 1;399
19.2.2;15.2.2 Case 2;401
19.3;15.3 Communications with Primary-Care Physicians;402
19.4;15.4 Working in a Managed Care Environment (Capitation);402
19.5;15.5 Interactions with Medical Industry;403
19.6;15.6 Interactions with Ambulatory Surgery Centers;406
19.7;15.7 Comanagement of Patients;406
19.8;15.8 Relationships with Investment Firms;406
19.9;15.9 Summary of Key Points;406
19.10;15.10 Future Directions;406
19.11;References;407
20;Clinical Examples in Managing Diabetic Retinopathy;409
20.1;16.1 Case 1: Proliferative Diabetic Retinopathy with Dense Premacular Hemorrhage in a Patient on Coumadin;409
20.1.1;16.1.1 Discussion;409
20.2;16.2 Case 2: Bilateral Proliferative Diabetic Retinopathy with Acute Vitreous Hemorrhage in One Eye and a Chronic Traction Retinal Detachment in the Other Eye;411
20.2.1;16.2.1 Discussion;412
20.2.2;16.2.2 Opinion 1;413
20.2.3;16.2.3 Opinion 2;414
20.2.4;16.2.4 Opinion 3;414
20.3;16.3 Case 3: Sight Threatening Diabetic Retinopathy in a Patient with Concomitant Medical and Socioeconomic Problems;415
20.3.1;16.3.1 Discussion;415
20.4;16.4 Case 4: Asymptomatic Retinal Detachment Following Vitrectomy in a Patient Who Has Had Panretinal Laser Photocoagulation;416
20.4.1;16.4.1 Discussion;417
20.5;16.5 Case 5: Management of Progressive Vitreous Hemorrhage Following Scatter Photocoagulation for Proliferative Diabetic Retinopathy;417
20.5.1;16.5.1 Discussion;418
20.6;16.6 Case 6: Post-surgical, Inflammatory Macular Edema, or Diabetic Macular Edema?;419
20.6.1;16.6.1 Discussion;420
20.7;16.7 Case 7: Proliferative Diabetic Retinopathy with Macular Traction and Ischemia;421
20.7.1;16.7.1 Discussion;421
20.8;16.8 Case 8: What Is Maximal Focal/Grid Laser Photocoagulation for Diabetic Macular Edema?;425
20.8.1;16.8.1 Definition of the Problem;425
20.8.2;16.8.2 Discussion;426
20.9;16.9 Case 9: What Independent Information Does Macular Perfusion Add to Patient Management in Diabetic Retinopathy?;429
20.9.1;16.9.1 Discussion;429
20.10;16.10 Case 10: Macular Edema Following Panretinal Photocoagulation for Proliferative Diabetic Retinopathy;431
20.10.1;16.10.1 Discussion;431
20.11;16.11 Case 11: Diabetic Macular Edema with a Subfoveal Scar;433
20.11.1;16.11.1 Discussion;433
20.12;16.12 Case 12: How Does the Severity of Diabetic Macular Edema Affect the Therapeutic Approach?;434
20.12.1;16.12.1 Definition of the Problem;434
20.12.2;16.12.2 Discussion;436
20.13;16.13 Case 13: Management Options for a Complicated Case of Proliferative Diabetic Retinopathy with Severe Fibrovascular Proliferation, Sub-clinical Macular Edema, and Recent Vitreous Hemorrhage;438
20.13.1;16.13.1 Definition of the Problem;438
20.13.2;16.13.2 Discussion;438
20.14;16.14 Case 14: How Is Diabetic Macular Ischemia Related to Visual Acuity?;440
20.14.1;16.14.1 Definition of the Problem;440
20.14.2;16.14.2 Discussion;441
20.15;References;442
21;Subject Index;446