당뇨황반부종에서의 레이저 치료 의정부 성모병원 안과 양지욱

Laser in diabetic macular edema Focal/grid laser has been the mainstay of treatment for diabetic macular edema(DME) until the recent findings of the Diabetic Retinopathy Clinical Research (DRCR) network, which suggested that intravitreal ranibizumab with prompt or deferred laser is more effective... Diabetic Retinopathy Clinical Research Network. Randomized trial evaluating ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema. Ophthalmology 2010;117(6):1064 –1077.

When treating diabetic macular edema... Focal laser photocoagulation Grid laser photocoagulation In ETDRS, after 3-years of F/U, 24% of the control group experiences moderate visual loss compared with 12% of the treated eyes. Focal/grid photocoagulation reduced the risk of moderate visual acuity loss for all eyes with diabetic macular edema by about 50 %.

Focal laser photocoagulation Focal macular edema - Direct treatment of all leaking microaneurysms in the edematous retina between 500 and 3000 µm from the center of the macula

Focal laser photocoagulation Wavelength – green or yellow Spot size - 50 ~ 100 µm Exposure time - 0.1 sec Power – initially quite low and slowly increased to obtain either whitening or darkening of the microaneurysm with minimal power

Laser wave length - Laser absorption Why green or yellow wavelength?! Hemoglobin : strong absorption in violet(420 nm), green(540, 580 nm) Xanthophyll : peaks in the blue(460 nm)

Laser wave length - Laser absorption Power?? - whitening or darkening of the microaneurysm with minimal power Usually, a microaneurysm or area of diffuse edema that is slightly distant from the fovea is treated first The power is increased in 10 mW increments until a desired end-point It is important not to place intense burns close to the fovea !!

2) Focal macular treatment Focal photocoagulation in focal ME with diabetic retinopathy

2) Focal macular treatment 시술직후 시술전 시술후 4주 시술후 4개월

2) Focal macular treatment Focal photocoagulation in focal ME with diabetic retinopathy

2) Focal macular treatment 시술직후 시술후 2주 시술전 시술전 치료 효과를 판단하는 기간이 laser는 triamcinolone이나 anti-VEGF intravitreal injection보다 오래 걸린다... 시술후 6개월

Grid laser photocoagulation Diffuse macular edema - Primarily used for areas of diffuse leakage with no identifiable focal areas of leakage Spot size - 50 ~ 200 µm Exposure time - 0.1 sec Power – light intensity burns Producing a grid of equally spaced burns more than one burn-width apart

2) Focal macular treatment Grid laser in CSME with diabetic retinopathy 시술후 4개월

Modified grid laser photocoagulation Direct treatment of visible microaneurysms + Grid pattern of treatment to fill-in the rest of the edema

Visual outcome Less favorable visual outcome 1) Diffuse macular edema 2) Macular ischemia in addition to edema 3) Old lipid exudate involving the center macular edema Better favorable visual outcome 1) Focal macular edema – round lipid ring threatening the macular center

Benefits of laser treatment for CSME Mainly manifested by a reduction of the rate of visual loss Very few patients experience significant visual improvement

Complications Sx) Immediate or late visual acuity loss Scotoma Fd) Choroidal neovascularizaion Preretinal or subretinal fibrosis Laser scar expansion Exacerbation of preexisting macular edema Tractional retinal detachment

Complications Initial treatment closer than 500 µm to the foveal center is avoided Excessive treatment should be avoided - can lead to extensive chorioretinal atrophy that can spread and impair central vision - Heavy focal burns may induce CNV

Thank you for your attention! 3년전 diabetic macular edema로 FRP(OS) Thank you for your attention! FRP후 3년 FRP후 4년 FRP후 5년 FRP후 9년

Complications – laser scar expansion FRP후 3년 FRP후 9년

Modified ETDRS laser photocoagulation protocol Focal photocoagulation Wavelength – green or yellow Spot size – 50 µm Exposure time - 0.05 ~ 0.1 sec Power – Change in microaneurysm color – not requires, but at least a mild grey-white burn should be evident beneath all microaneurysms Writing Committee for the Diabetic Retinopathy Clinical Research Network, Fong DS, Strauber SF, Aiello LP, et al. Comparison of the modified Early Treatment Diabetic Retinopathy Study and mild macular grid laser photocoagulation strategies for diabetic macular edema. Arch Ophthalmol. 2007;125:469–480.ㅇㅀ

Modified ETDRS laser photocoagulation Grid photocoagulation Wavelength – green or yellow Spot size – 50 µm Exposure time - 0.05 ~ 0.1 sec Burn intensity – Barely visible (light gray) 2 visible burn widths apart No burns are placed within 500 µm of the disc & fovea center

SDM photocoagulation 치료직후 Subthreshold diode-laser micropulse photocoagulation Grid photocoagulation mETDRS protocol SDM photocoagulation 치료직후

mETDRS photocoagulation SDM Photocoagulation

mETDRS photocoagulation SDM Photocoagulation

Laser in diabetic macular edema Does laser still have a role in the management of diabetic macular edema?? 1) Focal macular edema - focal laser may still be a good treatment option 2) Patients who cannot tolerate or comply with the need for monthly visits and injections 3) Poor response to anti-VEGF 4) Decrease the frequency of injection??