ovali diabetic retinopathy laser treatment anti vegf

Diabetic RetinopathyLaser Treatment

ANTI VEGF

Diabetic RetinopathyDiabetic RetinopathyLaser TreatmentLaser Treatment

ANTI VEGFANTI VEGF

Dr. Tunç OvalıDr. TunDr. Tunçç OvalOvalıı

Dr. Tunç Ovalı

Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

No financial interestNo financial interest

Dr. Tunç Ovalı

Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

Diabetic RetinopathyDiabetic Retinopathy Laser TreatmentLaser Treatment

Peripheric retinal ischemiaPeripheric retinal ischemia …… panretinal laser photocoagulationpanretinal laser photocoagulation

Macular edemaMacular edema …… focal / grid laser photocoagulationfocal / grid laser photocoagulation

Dr. Tunç Ovalı

Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

Diabetic RetinopathyDiabetic Retinopathy Laser TreatmentLaser Treatment

Peripheric retinal ischemiaPeripheric retinal ischemia …… panretinal laser photocoagulationpanretinal laser photocoagulation

The laser treatment recomendations for diabetic retinopathy are The laser treatment recomendations for diabetic retinopathy are based on based on

the results of two randomized clinical trials :the results of two randomized clinical trials :1. Diabetic Retinopathy Study Research Group, report no 14, Int. Ophthalmol. Clin 19871987

2. Early Treatment Diabetic Retinopathy Study Research Group,ETDRS report no 2, Ophthalmology

19871987

% 50 reduction in severe visual loss in eyes with severe NPDR or% 50 reduction in severe visual loss in eyes with severe NPDR or PDR in two yearsPDR in two years

Dr. Tunç Ovalı

Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

Panretinal photocoagulationPanretinal photocoagulation

spot size : 500 spot size : 500 –– 800 800 µµm at the retina m at the retina

( magnification of the wide field lenses ! )( magnification of the wide field lenses ! )

one burn apartone burn apart

1.200 1.200 –– 1.600 burns ( in 3 1.600 burns ( in 3 –– 5 sessions )5 sessions )

exposure : 0.1 exposure : 0.1 –– 0.2 sec.0.2 sec.

burns : nasaly 500 burns : nasaly 500 µµm apart from the discm apart from the disc

temporally 2 disc diameter from the center of the maculatemporally 2 disc diameter from the center of the macula

Dr. Tunç Ovalı

Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

Complications of panretinal photocoaculation :Complications of panretinal photocoaculation :

⇨⇨ damage of the cornea / iris / lensdamage of the cornea / iris / lens

⇨⇨ rise of intraocular pressure ( ciliochoroidal effusion )rise of intraocular pressure ( ciliochoroidal effusion )

⇨⇨ macular edemamacular edema

⇨⇨ choroidal detachmentchoroidal detachment

⇨⇨ optic disc damageoptic disc damage

Dr. Tunç Ovalı

Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

Complications of panretinal photocoaculation :Complications of panretinal photocoaculation :

⇨⇨ pretinal fibrosis macular tractionpretinal fibrosis macular traction

⇨⇨ vitreus hemorrhagevitreus hemorrhage

⇨⇨ scotomascotoma

⇨⇨ subretinal fibrosissubretinal fibrosis

Diagnostic toolsDiagnostic tools

⇨⇨ Biomicroscopic fundoscopyBiomicroscopic fundoscopy

⇨⇨ Fundus Florescein AngiographyFundus Florescein Angiography

⇨⇨ Optic Cohorens TomographyOptic Cohorens Tomography

Dr. Tunç Ovalı

Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

Dr. Tunç Ovalı

Diabetic macular edema and interpretation with OCTDiabetic macular edema and interpretation with OCT

1.1.Diffuse microcycstsDiffuse microcycsts

2.2.Big cycstic edemaBig cycstic edema

3.3.Subfoveal serous elavationSubfoveal serous elavation

Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

Dr. Tunç Ovalı

NAK

Diabetic MaculopathyDiabetic Maculopathy

⇨⇨ Diffuse / focal leakageDiffuse / focal leakage

⇨⇨ Ischemic maculopathyIschemic maculopathy

⇨⇨ Vitreomaculer tractionVitreomaculer traction

Dr. Tunç Ovalı

Dr. Tunç Ovalı

Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

Diabetic RetinopathyDiabetic Retinopathy Laser TreatmentLaser Treatment

Macular edemaMacular edema …… focal / grid laser photocoagulationfocal / grid laser photocoagulation

Dr. Tunç Ovalı

Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

Diabetic RetinopathyDiabetic Retinopathy Laser TreatmentLaser Treatment

Macular edemaMacular edema …… focal / grid laser photocoagulationfocal / grid laser photocoagulation

Dr. Tunç Ovalı

Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

Diabetic RetinopathyDiabetic Retinopathy Laser TreatmentLaser Treatment

Macular edemaMacular edema …… focal / grid laser photocoagulationfocal / grid laser photocoagulation

Dr. Tunç Ovalı

Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

Diabetic RetinopathyDiabetic Retinopathy Laser TreatmentLaser Treatment

Macular edema Macular edema …… focal / grid laser photocoagulationfocal / grid laser photocoagulation

Parameters for focal photocoagulation :

spot size : 100 – 200 µm ( at the retina )

exposure time : focalfocal 0.1 – 0.3 sec. gridgrid 0.1 sec

power increase : 10 – 20 mW

focalfocal : gray – white burns gridgrid : barely visible burns

Dr. Tunç Ovalı

Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

Intravitreal administration of drugsIntravitreal administration of drugs

-- Pathogenesis of DME is complex and multifactorialPathogenesis of DME is complex and multifactorial

-- VEGF and inflamation have both a central role VEGF and inflamation have both a central role

ANTI VEGFANTI VEGF Bevacizumab Bevacizumab Avastin Avastin ®®

RanibizumabRanibizumab Lucentis Lucentis ®®

Aflibercept Eylea ®®

SteroidsSteroids TriamcinolonTriamcinolon

Dexamethasone implantDexamethasone implant Ozurdex Ozurdex ®®

Dr. Tunç Ovalı

Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

Two-Year Outcomes of the Ranibizumab for Edema of the mAcula in Diabetes - READ 2 StudyNguyen QD, Shah SM, Khwaja AA, et al. Ophthalmology 2010 117: 2146-2151

Dr. Tunç Ovalı

Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

Randomized Trial Evaluating Ranibizumab Plus Prompt or Deferred Laser or Triamcinolone Plus Prompt Laser for Diabetic Macular Edema

The Diabetic Retinopathy Clinical Reseach Network The Diabetic Retinopathy Clinical Reseach Network Ophthalmology 2010 117: 1064-1077

Dr. Tunç Ovalı

Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

Safety and Efficacy of Ranibizumab in Diabetic Macular Edema - RESOLVE StudyRESOLVE StudyMassin P, Bandello F, Garweg JG, et al. Diabetes Care 33:2399–2405, 2010

Dr. Tunç Ovalı

Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

Ranibizumab Monotherapy or Combined with Laser versus Laser Monotherapy for Diabetic Macular Edema - The RESTORE StudyThe RESTORE Study

Mitchell P, Bandello F, Schmidt-Erfurth U, et al. Ophthalmology 2011 118: 615-625

Dr. Tunç Ovalı

i.vit. Ranibizumabi.vit. Ranibizumab

ACACÖÖ type II diabetestype II diabetes

After 2. inj.

After 1. inj.

0.4

0.9

0.6

Dr. Tunç Ovalı

i.vit. Ranibizumabi.vit. Ranibizumab

FCFC type II diabetestype II diabetes

After 1. inj.

After 2. inj.

0.05

0.05

0.1

Dr. Tunç Ovalı

i.vit. Ranibizumabi.vit. Ranibizumab

BBÇÇ type II diabetestype II diabetes

After 2. inj.

After 1. inj.

After 3. inj.

0.4

0.1

0.8

0.5

Dr. Tunç Ovalı0.2 2 months later - 0.5

Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

i.vit. Triamcinoloni.vit. Triamcinolon

Dr. Tunç Ovalı

Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

i.vit. Triamcinoloni.vit. Triamcinolon

i.vit. Triami.vit. Triam. GGööz z Antiglaucoma therapy Lens sclerosisLens sclerosis Cataract surgeryCataract surgery

1.injec.1.injec. n : 103n : 103n : 11 n : 11

% 10.7% 10.7

n : 8n : 8

% 7.8% 7.8

n : 3n : 3

% 2.9% 2.9

2. injec.2. injec. n : 38n : 38n : 6n : 6

% 15.8% 15.8

n : 8n : 8

% 21.1% 21.1

n : 3n : 3

% 7.9% 7.9

>> 3. injec.3. injec. n : 21n : 21n : 3n : 3

% 14.3% 14.3

n : 9n : 9

% 42.9% 42.9

n : 2n : 2

% 9.5% 9.5

Dr. Tunç Ovalı

Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

Dexamethazone implant

Dr. Tunç Ovalı

Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

Dexamethazone implant

Dr. Tunç Ovalı

Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

AA

Dexamethazone implant

Dr. Tunç Ovalı

Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

Dr. Tunç Ovalı

Diabetic Retinopathy – Laser Treatment and ANTI VEGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VEGFLaser Treatment and ANTI VEGF

How I do it How I do it ……

-- Systemic control is every thing !!!Systemic control is every thing !!!

-- Fundus florescein angiography ( wide field ?? ) + OCT Fundus florescein angiography ( wide field ?? ) + OCT Laser / Surgery ?Laser / Surgery ?

- ANTI VEGF ( prevents bleading / macular edema )

- Focal laser / modified grid laser phocoagulation

- Panretinal photocoagulation ( until extrem far periphery )

- Steroidal implant

- … and waiting for the next big thing !!!

Thank youThank you

tuncovali @ fulyaretina.comGSM : + 90 532 737 00 17

Dr. Tunç Ovalı

Diabetic Retinopathy – Laser Treatment and ANTI VGFDiabetic Retinopathy Diabetic Retinopathy –– Laser Treatment and ANTI VGFLaser Treatment and ANTI VGF