LASER therapy and Newer treatments for Diabetic Retinopathy

Dr Adrian H.C. Koh

Senior Consultant, Eye Clinic Singapura International Retinal Foundation

What is Diabetic Retinopathy?

Diabetic retinopathy is a result of disease of the small blood vessels in the retina
High blood sugar damages fine blood vessels in 2 ways:
- leakage - blockage

Diabetic retinopathy

Diabetic maculopathy

Diabetic retinopathy is a blinding disease

Effective treatment: 1. Laser photocoagulation 2. Newer therapies
Steroid injection into vitreous (triamcinolone) Anti-Growth Factor therapy (Vascular Endothelial Growth Factor, VEGF)

What is LASER?
Light Amplification by Stimulated Emission of Radiation

Photocoagulation
Majority of ophthalmic lasers employ photocoagulation Heating/burning/thermal effect of laser on tissues: temperature rises above 100C Dependent on wavelength of laser, absorption by target tissue, duration, and spot size (power density)

Laser wavelengths
Argon
488 nm (blue) 514 nm (green)

YAG (double-frequency)
532 nm (green)

Dye
577 nm (yellow) 590 nm (orange) 630 nm (red)

Krypton
647 nm (red)

Diode
810 nm (red)

YAG
1064 nm (infra-red)

Tissue absorption of laser

Melanin: RPE, iris
Blue, green, yellow > red

Hemoglobin: retinal blood, vitreous hage

Green-yellow>>red

Xanthophyll: macular pigment (yellow)

Blue>green>>yellow, red

2 forms of Laser
Panretinal laser photocoagulation (PRP)
Retinal new vessels Severe ischemia (lack of oxygen)

Macular laser
Macular swelling (oedema) Leaking capillaries

Panretinal laser photocoagulation

Panretinal laser

Effects Decreases vascular leakage Causes neovascular regression

Postulates Improves oxygenation Reverses overproduction VEGF Laseroftime

Obstructive ischemic pre-proliferative DR

Panretinal laser for new vessels and bleeding

Before laser After laser

Panretinal laser

Before laser

After laser

Panretinal Laser for Proliferative DR

Before laser

After laser

Effect of laser treatment

Rate of severe retinopathy & blindness reduced by half Laser does not improve vision, but stabilises vision

Macular Laser

Vision threatening diabetic maculopathy

Diabetic maculopathy

Focal laser treatment

Before treatment After treatment

Focal Laser for Maculopathy

Grid laser

Diabetic Macula Edema

Laser Grid Photocoagulation

Grid laser for maculopathy

Low intensity small burns

Laser maintains vision at presenting level in 80%

Important points about laser

Laser IS:
safe and effective done as an outpatient procedure relatively painless effective in preserving vision compared to no treatment

Laser MAY NOT:

1. restore original vision 2. result in improvement in vision 3. be effective with a single treatment

Importance of Blood Sugar Control

Glycohaemoglobin (HbA1c) levels in top quartile are 3 times more likely to progress than lowest quartile (DCCT 1982-93) reduced risk of diabetic retinopathy by 76% slowed progression of NPDR by 54% reduced PDR by 47%

Injection of Triamcinolone into the vitreous

Triamcinolone deposit in the vitreous

Intravitreal triamcinolone is effective for treating macular oedema

Pre-injection

Post-injection

Potential problems with intravitreal triamcinolone

Infection Glaucoma Cataract

Role of VEGF in diabetic retinopathy

Modulates endothelial leakage and proliferation VEGF blockers already in advanced stage of clinical trials Macugen (pegaptanib) already approved for use in wet AMD

VEGF gene product effect on retinal capillaries

Ad.CMV.VEGF - vascular leakage after vitreous injection

Macugen: An Anti-VEGF165 Aptamer

Selective VEGF inhibition
Binds selectively to VEGF165
Pathologic isoform Spares normal vasculature
Pegaptanib binds to VEGF165
Pegaptanib

Dual mechanism
Anti-angiogenesis Anti-permeability

Anti-VEGF therapy for proliferative DR

Summary
Best form of preventing blindness from diabetic retinopathy is early detection and timely treatment through regular eye screening Laser is a safe and effective treatment for sight-threatening diabetic retinopathy Newer therapies are very promising

LASER for DIABETES

Prevents VISUAL LOSS