Management of Diabetic Retinopathy

Management in D.R. through prophylactic treatment (maintaining a glycemic level as close as possible to normal, control hypertension <150/85 mmHg, hyperlipidemia) and curative treatment of D.R. does not cure the disease, but may slow the evolution of D.M. and D.R. AntiVEGF agents are indicated as adjuvant therapy in pan-photocoagulation laser and / or vitrectomy in patients with DR to block angiogenesis by inhibiting VEGF. All antiVEGF agents are an effective treatment for the clinically significant macular edema. Photocoagulation laser is a treatment of choice in preproliferative and proliferative DR and an effective treatment of diabetic macular edema. The indications for laser treatment in diabetic retinopathy are related to the incidence, evolution of neovessels, duration of diabetes, HbA1c level, presence of macular edema, stage of DR. The laser for macular lesions reduces the risk of vision loss in the eyes with incipient and moderate non-proliferative DR and macular edema concomitant; the laser should be applied to all patients with clinically significant macular edema. Vitrectomy in proliferative DR is indicated in vitreous hemorrhage, tractional retinal detachment in order to remove the vitreous hermorrhage and excision of tractional preretinal membranes.

Panretinal photocoagulation laser in diabetic retinopathy patients

Background: It was reported that corneal endothelial cell depletion is a complication of the retinal laser. In this study, the effect of panretinal laser on corneal endothelium was investigated. Method: A group consisting of 47 eyes of 47 Diabetic patients who need a panretinal photocoagulation laser was compared with another group of 47 diabetic patients who did not require a laser. The patient's age was chosen in the range of 50-70 and the tools included Ellex double frequency LASER, Specular microscopy, Pachymetry, and Condense Lens 90. Time course of coefficient of variation, endothelial cell density, hexagonal cells and central corneal thickness were evaluated. ANOVA, Dennett's, and Mann-Whitney test was used to compare the data. P-value of <0.05 was considered statistically significant. Results: We found no significant differences in age, gender between the two groups. There was no significant differences in hexagonal cells, coefficient of variation, endothelial cell density and central corneal thickness between the two groups at any time points. Conclusion: This study suggests that the "panretinal photocoagulation laser" conserves corneal endothelial cells of subsequent damage in diabetic retinopathy patients Keywords: photocoagulation laser, corneal, endothelial cell, argon laser, double frequency laser.

Involvements of choroidal vascular structures with local treatments in patients with diabetic macular edema

Purpose: To examine changes of the choroidal morphology in patients with diabetic macular edema (DME) before and after local treatments. Methods: This study was on 20 eyes with DME, observed for more than 24 months. All patients underwent laser photocoagulation (Laser), sub-tenon triamcinolone acetonide injection (TA), or intravitreal aflibercept injection (IVA). Central macular and choroidal thicknesses (CMT/CCT), and choroidal vascular structures consisting of the total choroidal area (TCA), luminal area (LA), and stromal area (SA) were measured by a binarization method. The ratios of LA in TCA were eventually determined as the L/C ratio in each case. Results: The L/C ratio significantly decreased for 24 months in patients with DME ( p = 0.01), whereas no significant differences were noted in other parameters including TCA, LA, SA, or CCT. Among patients treated with Laser ± TA ± IVA, a significant correlation was found between a high L/C ratio at pretreatment and a lower cumulative number of injections (1–2 times/24 months) ( p = 0.04). The L/C ratio in pretreatment showed a significantly inverse correlation with CMT (−0.60, p = 0.02) and subsequent BCVA (logMAR) (−0.59, p = 0.03). Conclusion: This study highlighted that the L/C ratio in pretreatment might predict a change of the visual acuity in DME.

Patients' Preference Regarding Laser Photocoagulation or Cryoretinopexy for the Treatment of Retinal Pathology

Purpose: High-risk peripheral retinal pathology can be prophylactically treated with both laser photocoagulation (laser) and cryoretinopexy (cryopexy). We sought to identify a possible preference by patients toward one modality and any underlying association. Methods: A single-center survey was conducted of patients with peripheral retinal pathology who received both laser and cryopexy at Associated Retinal Consultants (Royal Oak, Michigan). The main outcome measure was the preferred treatment modality. Results: Patients reported more pain after cryopexy (46%) than laser (11%). Most patients felt it was easier to recover from laser (52%) than cryopexy (13%). Overall, patients preferred laser (60%) to cryopexy (25%), with a minority (15%) having no preference. There was a negative relationship between a patient’s likelihood of preferring cryopexy and the number of applications ( P = .009). Conclusions: Most patients preferred laser (60%) to cryopexy. If cryopexy is performed, minimizing the number of freezes may improve the patient’s experience and recovery.

Comparative quantitative assessment of the placement and intensity of laser spots for treating diabetic macular edema

Aim: to compare the uniformity and adequacy of the placement of laser spots after mono-impulse and pattern photocoagulation for diabetic macular edema (DME). Patients and Methods: fundus photographs of 83 patients (121 eyes) taken right after retinal photocoagulation for DME were analyzed. Group 1 included images of 63 eyes after pattern photocoagulation and group 2 included images of 58 eyes after mono-impulse photocoagulation. Laser burns of varying intensity based on LʹEsperance scale (including grade 0 burns that were not seen on fundus photos) were calculated. Grade 2 burns were considered optimal. The number of non-optimal laser burns placed on retinal hemorrhages, blood vessels, hard exudates or healthy retina was calculated. The uniformity of the position of laser spots was assessed by calculating the standard deviation from the average distance between laser spots. Results: the percentage of laser spots of optimal intensity was 31.85% in group 1 and 25.15% in group 2. The percentage of non-optimally placed laser spots was 24.34% in group 1 and 7.99% in group 2. The uniformity of the placement was good in both groups (8.16 pixels and 8.44 pixels, respectively), no significant difference was reported (p=0.0591). Conclusion: pattern photocoagulation is preferable for DME compared to mono-impulse photocoagulation to provide adequate intensity of laser burns. Meanwhile, mono-impulse regimen provides more precise placement of laser spots. However, both conventional techniques are not effective enough due many intrinsic drawback, i.e., many laser spots are non-optimal in terms of intensity or placement. In routine practice, these drawbacks are outweighed by the skills and experience of laser surgeon. Planned precise placement of laser spots and the introduction of techniques of more precise preventive adjustment of energy level for each laser spot will contribute to the maximum effect of photocoagulation for DME. Further studies on personalized precise laser photocoagulation will improve the quality and efficacy of the treatment of macular edema. Keywords: diabetic retinopathy, diabetic macular edema, mono-impulse photocoagulation, pattern photocoagulation, navigated photocoagulation. For citation: Zamytskiy E.A., Zolotarev A.V., Karlova E.V. et al. Comparative quantitative assessment of the placement and intensity of laser spots for treating diabetic macular edema. Russian Journal of Clinical Ophthalmology. 2021;21(2):58–62. DOI: 10.32364/2311-7729- 2021-21-2-58-62.

Les ostéomes ostéoïdes du pied et de la cheville : à propos d’une série de 17 cas à 93 mois de recul moyen

L’ostéome ostéoïde (OO) représente 10 à 12 % des tumeurs osseuses bénignes. Le pied et la cheville sont concernés dans 2 à 15 % des cas. La résection chirurgicale à ciel ouvert est maintenant supplantée par les techniques percutanées guidées par le scanner qu’il s’agisse de la thermocoagulation par radiofréquence, de la photocoagulation laser ou de la cryoablation. Cette étude a pour but d’évaluer l’efficacité thérapeutique de la thermocoagulation scanoguidée (TPS). Il s’agit d’une étude rétrospective monocentrique incluant tous les OO traités par TPS au CHRU de Lille entre 2003 et 2015, ayant un recul minimum d’un an. Dix-sept patients ont été inclus, dix hommes et sept femmes, d’âge moyen 24 ans. Quinze patients ont fait l’objet d’une évaluation par questionnaire téléphonique au recul moyen de 93 mois. Les douleurs ont disparu dans un délai moyen de 4,5 jours. La reprise du travail se faisait en 11 jours en moyenne. Le degré de satisfaction moyen est de 92 %, le score SF-36 de 93, le score FAAM de 177. Une seule récidive est à signaler, mais aucune complication cutanée ou vasculonerveuse. Le traitement des OO localisés au pied et à la cheville par TPS permet d’excellents résultats sans morbidité.

Management of Clinically Significant Macular Edema

Introduction. Macular edema is the most common cause of visual impairment in NPDR. Macular edema occurs due to increased perifoveal capillary permeability resulting in fluid accumulation in the macular area. Control of blood sugar levels is an important factor in the management of diabetic retinopathy because it can reduce the risk of progression of retinopathy, decreased vision and macular edema. Currently, focal photocoagulation argon lasers are the only proven long-term treatment for diabetic macular edema. Case presentation. Reported case of a 55-year-old woman, address outside the city, came to the Palembang RSMH eye clinic with complaints of blurred vision since ± 6 months ago. three days ago, the patient went to an internal medicine clinic and was said to have high blood sugar and blood pressure. The views of both sufferers' eyes are increasingly blurred. The treatment chosen for this patient was intravitreal anti-VEGF (bevacizumab) injection in the right and left eye to reduce vascular permeability thereby reducing macular edema. 1-time bevacizumab injection has only a short-term optimal effect so re-injection is needed at 4-6 weeks intervals. Conclusion. A clinically significant case of macular edema (CSME) has been reported that is treated with intravitreal anti-VEGF combined with focal photon photocoagulation laser. The patient's final vision 1 week after the focal photocoagulation argon laser was performed showed improvement

Anti-Vascular Endothelial Growth Factor Injection in Wet Age-Related Macular Degeneration

Introduction. AMD is a macular progressive degeneration that arises at the age of more than 50 years, which is characterized by the presence of drusen which is a deposit of material between the retinal pigment epithelium (RPE) and the Bruch membrane. The prevalence of AMD is 29.2% unilateral and 70.8% bilateral. In unilateral wet AMD, 50% will develop on the other eye in a period of 5 years. Case Presentation. A woman, Mrs. S, 59 years old, civil servant working, located in the city, came to the Polyclinic RSMH on January 21, 2019. Anamnesis (Auto-anamnesis) the main complaint of vision of the left eye blurred since, 2 months ago. Since about two months ago, sufferers complained of vision in the left eye blurred, blurred felt suddenly, darker vision in the middle. Since about two weeks ago, sufferers complained that his left eye vision had become blurred. The view in the middle is covered with black shadows and accompanied by waves. Working diagnosis of macular oculi sinistra ec wet age-related macular degeneration. The treatment is informed consent, Pro injection of anti-VEGF intravitreal oculi sinistra, Pro laboratory check, Pro X-ray of thorax PA, Pro consul of internal medicine. Conclusion. A clinically significant case of macular edema (CSME) has been reported that is treated with intravitreal anti-VEGF combined with focal photon photocoagulation laser. A woman aged 55 years, with complaints of vision both eyes blurred since ± 6 months ago.

Management of Diabetic Retinopathy

Introduction. Diabetic retinopathy (RD) is one of the most common complications of diabetes mellitus, and is a major cause of blindness in patients aged 20-64 years worldwide. The main principle of the management of RD is to prevent, inhibit and overcome complications that occur. Vitrectomy, laser photocoagulation, intravitreal anti VEGF injection become modalities in RD therapy. If PDR has occurred, vitreous hemorrhage can occur or the retina is attracted by proliferation tissue, vitrectomy should be performed. Case Presentation. The patient is a 52-year-old man who came with the main complaint that both eyes have blurred slowly since ± 6 months ago. Blurred vision is not accompanied by red eyes, there is smoke-like vision. In the past the history of the disease obtained a history of DM 15 years of irregular control and hypertension of 3 years with regular control, a history of spectacles present. The ophthalmological examination of the right eye revealed a vision of 6/30 pH (-), TIOD within normal limits, and a grade II nuclear cataract in the lens. Right eye fundoscopy revealed decreased foveal reflexes and exudates in the macula, dot, blot, flame-shaped bleeding in 4 quadrants of the retina, exudate, venous beading, micro-aneurism. Management in these patients is pars plana vitrectomy, endolaser, and intravenous OS anti-VEGF injection under general anesthesia. Whereas the right eye was intravitreal photocoagulation laser and anti-VEGF laser (done 2 weeks before). Conclusion. A case of advanced left eye PDR with severe NPDR and right eye DME and grade II nuclear cataracts has been described in both eyes. Patients treated with laser photocoagulation in the right eye. In the left eye pars plana vitrectomy, endolaser, and intravitreal bevacizumab injection. Sharp vision of the left eye progressed postoperatively.