State of the art treatments in diabetic eye disease Dr Sanj Wickremasinghe

Diabetes and the eye Cataract Refractive changes Cranial nerve palsies Diabetic retinopathy

10% will likely develop visual impairment secondary to diabetic retinopathy Leading cause of blindness in working aged people DME accounts for 2/3 of cases

Chronic hyperglycaemia Inflammation, ischaemia, retinal hypoxia, endothelial damage Increased VEGF and inflammatory mediators Breakdown of blood–retina barrier Increased permeability and neovascularisation Diabetic macular oedema VISION LOSS Leakage of fluid/proteins

OCT

Treatment

Diabetic Retinopathy Retinal laser treatment can prevent blindness Retinal laser treatment can not restore sight that is already lost

DME MA- too close to foveal centre Diffuse odema Disrupted foveal architecture Lipid++

Intravitreal anti-VEGF injections Lucentis® Avastin® Eylea®

Anti VEGF

Difficulties Often younger patients Works well in 50-60% of cases Reproductive age Works well in 50-60% of cases But many injections 40-50% have minimal or no benefit Risks

What else??

Studies DISCERN Wide variation in VEGF levels = response to VEGF inhibition. Pts with higher VEGF concentrations may respond better to VEGF blockade Those with low VEGF concentration may have DME driven by inflammation= poor response

Studies LADAMO

New drugs Gene therapy platforms that release anti- VEGF drug over long periods Refillable implant device Longer acting anti-VEGF agents DROPS/ subcutaneous injections that inhibit VEGF or stabilise blood vessels