1. Update on Prevention, Diagnosis & Treatment of Diabetic Macular Edema (DME) Part 1 A. Paul Chous, MA, OD, FAAO Specializing in Diabetes Eye Care & Education Tacoma, WA Adjunct Instructor, Nova Southeastern University College of Optometry Principal Investigator for the Diabetes Visual Function Supplement Study (DiVFuSS)

2. What IS DME? Fluid accumulation and retinal thickening within the macula as a result of diabetes mellitus Fluid accumulation and retinal thickening within the macula as a result of diabetes mellitus Cross-sectional view via OCT Ophthalmoscopic view of DME

3. What Are The Symptoms? Often asymptomatic in the earliest stages that are most amenable to treatment Often asymptomatic in the earliest stages that are most amenable to treatment More severe disease results in visual distortion, loss of color perception & loss of detail vision More severe disease results in visual distortion, loss of color perception & loss of detail vision May result in ‘legal blindness’ but not total blindness, unless concomitant proliferative retinopathy with tractional retinal detachmentMay result in ‘legal blindness’ but not total blindness, unless concomitant proliferative retinopathy with tractional retinal detachment

4. What Are the Risk Factors? Established risk factors for diabetic macular edema include disease duration, HbA1c, BP, obstructive sleep apnea and cigarette smoking T1DM, Latino or Black race, HTN, diabetic nephropathy and neuropathy significantly increase risk per recent retrospective analysis of 440,000 patients Association for Research in Vision & Ophthalmology 2013, Seattle Ophthalmology. 2009 Mar;116(3):497-503 Retina. 2012 Oct;32(9):1791-8. Diabetes Res Clin Pract. 2013 Jun;100(3):298-305

5. DME & A1c 27% of pts in the DCCT had DME by 9 years Diabetes 2010;59:1244–1253 27% of pts in the DCCT had DME by 9 years Diabetes 2010;59:1244–1253 Each 1 point increase in HbA1c (e.g. from 7.5% to 8.5%) raised the odds of DME by 37% in WESDR over 25 years of follow-up Each 1 point increase in HbA1c (e.g. from 7.5% to 8.5%) raised the odds of DME by 37% in WESDR over 25 years of follow-up. WESDR = Wisconsin Epidemiologic Study of Diabetic Retinopathy Ophthalmol 2009; 116(3):497-503

6. Risk for DME w TZDs (thiazolidinediones ) Hi-dose TZDs may increase risk T2DM Tx w pioglitazone (Actos TM ) increased odds of DME by 5x Risk increased 21x with concomitant insulin Analysis not controlled for BMI, and pioglitazone pts were generally “sicker” If Rx’d, lower doses may reduce risk of DME EASD Sept 2013 Abstract #67 Arch Intern Med. 2012 Jul 9;172(13):1005

7. CSME and Center-Involved DME CSME (clinically significant macular edema) established treatment criteria per ETDRS (Early Treatment Diabetic Retinopathy) findings CSME (clinically significant macular edema) established treatment criteria per ETDRS (Early Treatment Diabetic Retinopathy) findings Diagnosis dependent on retinal thickening & proximity to the foveaDiagnosis dependent on retinal thickening & proximity to the fovea Based on stereoscopic, clinical examinationBased on stereoscopic, clinical examination Center Involved DME means foveal involvement requiring therapy Center Involved DME means foveal involvement requiring therapy

8. Optical Coherence Tomography (OCT): THE Most Sensitive Tool to Detect DME (98.6% sensitivity) 1-1.7 um wavelength, non-ionizing light Resolution to 1 micron 17,000 scans/sec Can detect DME long before clinical exam BUT, not all detected DME requires treatment 30% of patients with DME detected by OCT are not detected by clinical examination These patients are 4x more likely to develop CSME Ophthalmology.2004 Apr;111(4):712-5. Ophthalmologica.2013;230(4):201-6.