Ординатура / Офтальмология / Английские материалы / Retinal and Vitreoretinal Diseases and Surgery_Boyd, Cortez, Sabates_2010

13.Bourke RD, McHugh D, Blach RK, Cooling RJ. Experimental long-term vitreous replacement with purifiedandnonpurifiedperfluorodecalin. Ametican Journal of Ophthalmology 1994; 1 18:403 -4.

14.Le Tien V, Pierre-Kahn V, Azan F, Renard G, Chauvaud D. Displacement of Retained Subfoveal Perfluorocarbon Liquid After Vitreoretinal Surgery. Arch Ophthalmol. 2008;126(1):98-101.

15.Lee GA, Finnegan SJ, Bourke RD. Subretinal perfluorodecalin toxicity.AustNZJOphthalmol. 1998;26(1):57-60.

16.de Queiroz J M Jr, Blanks JC, OzlerSA,AlfaroDV,Liggett PE. Subretinal perfluorocarbon liquids: an experimental study. Retina. 1992;12(3)(suppl):S33-S39.

17.Elsing SH, Fekrat S, Green WR, et al. Clinicopathologic findings in eyes with retainedperfluoro- n-octaneliquid. Ophthalmology. 2001;108(1):45-48.

18.Lai JC, Postel EA, McCuen BW II. Recovery of visual function after removal of chronic subfoveal perfluorocarbon liquid. Retina. 2003;23(6):868-870.

19.Roth DB, Sears JE, Lewis H. Removal of retained subfoveal perfluoro-n-octane liquid. Am J Ophthalmol. 2004;138(2):287-289.

20.Lesnoni G, Rossi T, Gelso A. Subfoveal liquid perfluorocarbon. Retina. 2004;24(1):172-176.

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Aslan 0, Batman C, Cekic 0, Ozlap S. The use of perfluorodecalin in retinal detachments with retinoschisis. Ophthalmic Surg Lasers 1998 Oct; 29(10):818-21

Batman,C, Cekic 0. Effects of long-term use of perfluoroperhydrophenanthrene on the retina. Ophthalmic Surg Lasers 1998 Feb; 29(2): 144-6

Berglin L, Ren J, Algreve PV. Retinal detachment and degeneration in response to subretinal perfluorodecalin in rabbit eyes. Graefes Arch Clin Exp 1993 April; 231(4): 233-7

Bottoni F, Bailo G, Arpa P, et al. Management of giant retinal tears using perfluorodecalin as a postoperative short-term vitreoretinal tamponade: a long-term follow-up study. Ophthalmic Surgery 1994;25:365-73.

Bourke RD, McHugh D, Blach RK, Cooling RJ. Experimental long-term vitreous replacement with purifiedandnonpurifiedperfluorodecalin. Ametican Journal of Ophthalmology 1994; 1 18:403 -4.

Bourke RD, Cooling RJ. Perfluorocarbon heavy liquids. Aust N Z J Ophthalmol 1995;23:165–71. [PubMed]

Simpson RN, Cooling RJ, Sparrow JR. The stability of perfluoro-n-octane during procedures. Archives of Ophthalmology, 1996;1 14:537-544

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Brazifikos PD, D’Arnico DJ, Tsinopoulos IT, Stangos NT. Primary vitrectomy with perfluoro-n-octane use in the treatment of pseudophakic retinal detachment with undetected retinal breaks. Retina 1999;19(2):103-9.

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Global prevalence of diabetic retinopathy is dramatically increasing. The most rapid growth will occur in low and middle income countries. Blindness from diabetic retinopathy will also dramatically increase, unless effective interventions take place. A large proportion of diabetic patients do not know they have diabetes and many patients with known diabetes have poor glycemic control as well as insufficient treatment of arterial hypertension and other risk factors for diabetic retinopathy.

Evidence-based treatment for diabetic retinopathy (DR) is available. Clinical trials, such as the Diabetic Retinopathy Study (DRS), the Early Treatment Diabetic Retinopathy Study (ETDRS) have demonstrated that laser treatment can reduce severe vision loss by 90%.

A clinical classification of diabetic retinopathy, describing different levels of severity of the disease is critical in decision-making and appropriate management of diabetic retinopathy by the ophthalmologist. The gold

standard for classification of DR is the ETDRS severity scale. Each level of the ETDRS classification is based on the risk of progression to sight-threatening retinopathy. This scale is most useful in a research setting, but is not practical for every day use in clinical practice; each of 20 ophthalmoscopic lesions has to be graded in a scale from 2 to 6 levels; the grading requires comparison with standard photographs; the scale has too many levels, impossible to remember in a clinical setting.

For those reasons, the American Academy of Ophthalmology launched the Global Diabetic Retinopathy Research Group, inviting 31 experts from 16 countries around the world, to develop consensus on an international clinical classification of DR that could be used around the World.(1) This clinical classification has a strong scientific basis and was based on the ETDRS scale and the Wisconsin Epidemiological Study of Diabetic Retinopathy (WESDR).

By categorizing DR and diabetic macular edema (DME), the clinical classification provides a framework forimprovedcommunicationsamong ophthalmologists, endocrinologists and other care providers. Specific treatment recommendations for each category can be formulated.

Treatment recommendations may differ slightly in different regions of the world. The classification is most useful also for screening of diabetic populations.

International Clinical

Classification of DR

Figure 1: Moderate NPDR. Retinal hemorrhages and cotton wool spots.

1.No apparent retinopathy. No abnormalities related to DR found on dilated ophthalmoscopy. If the glycemic control is good, follow up examination at 24 months.

2.Mild non proliferative diabetic retinopathy.

Microaneurysm only. (Equivalent to level 20 of the ETDRS scale). Educate patient on importance of maintaining good glycemic control and monitoring HbA1c and the importance of reducing blood pressure and serum lipids if necessary. Fluorescein angiography is not indicated. Follow up at 12 months.

3.Moderate non proliferative diabetic retinopathy (moderate NPDR) (Figure 1). More than just microaneurysms but less than severe non proliferativediabeticretinopathy. This patients may have cotton wool spots and lipid deposits (“hard exudates”), retinal

hemorrhages (but less numerous than 20 intraretinal hemorrhages in the four quadrants). Venous beading (irregular dilation of the retinal veins), but only in one quadrant. Moderate NPDR is equivalent of level 35 of the ETDRS scales (probability of progression to proliferative DR: 5.4% in one year). It also includes level 43 (11.9 probability of progression to DR) and level 47, with beading in one quadrant. Level 47 was a higher risk of progression to PDR (26.3%).

Because the probability of progression to PDR is relatively low, there is universal consensus: laser photocoagulation is not indicated in this category if there is not macular edema. If the patient is under the care of an endocrinologist or

generalist, the patient should be referred to an ophthalmologist. Follow up is 6 to 12 months. Patients with venous beading in one quadrant should be carefully monitored. Optimization of medical treatment and education of the patient is mandatory. Fluorescein angiography is not generally indicated, unless there is macular edema or the retinopathy looks too florid. Fundus photography may be valuable to document progression of the disease.

One major problem in the difficulty in recognizing IRMA (Figure 3) and, in a lesser degree, venous beading by observers not fully trained in ophthalmoscopy. Recognizing IRMA (Intraretinal Microvascular Anomalies) requires a very careful and prolonged examination. There are intraretinal small vessels of tortuous design, they are different to retinal neovascularization, which grows above the retina and leaks on fluorescein angiography. In some patients, biomicroscopic examination with a contact lens will be necessary to

confirm the presence of IRMA. However, data from the WESDR demonstrated that the use of hemorrhages alone was not as strongly related to risk of progression to PDR as hemorrhages plus IRMA and venous beading.

Venous beadings are localized dilation of the venous wall (Figure 4). Venous loop can also be observed; the vein shows a loop or divides in two secondary channels that reunite distally.

These venous abnormalities are associated with severe ischemia and are more frequently observed in the nasal fields.

The risk of progression to PRN of severe NPDR is 50.2% in one year and 14.6% to high risk PDR. If the three characteristics are present (severe intraretinal hemorrhages x 4 quadrants + venous beading x 2 quadrants + IRMA x 1 quadrant), the risk of progression to high risk PDR is 45% in one year.

Severe NPDR is a sight threatening condition, with a high risk of progression. Pan retinal laser photocoagulation should be considered if:

•Poor compliance

•Advanced proliferative disease in the fellow eye

•Impending cataract surgery

•Poor glycemic control

•Advanced renal disease

•Extensive capillary closure at wideangle fluorescein angiography.

•Pregnancy

The benefit of early scatter pan retinal photocoagulation is greater in patients with type 2 Diabetes. Treatment should be considered in patients with severe NPDR and Type 2 diabetes.

International guidelines recommend scatter pan retinal laser photocoagulation onlyintheabovementionedcircumstances; however, the threshold for initiating laser treatment is a decision that should be

Figure 4: Venous beading.

made by each country (WHO consultation in Geneva, November 2005). In Latin America laser pan photocoagulation should be considered for patients with severe NPDR, because of poor patient compliance; besides, follow up every 2 to 4 months, as recommended if laser is deferred, is a completely unrealistic recommendation for developing countries, with overcrowded facilities.

Panoramic fluorescein angiography should ideally be ordered in every case of severe NPDR

5.Proliferative diabetic retinopathy (PDR). One or more of the following: neovascularization of the retina or disc and vitreous or preretinal hemorrhage. This category includes the following:

a) Mild PDR, with retinal neovascularization, less than 1⁄2 disc area in size in one or more quadrants (ETDRS level 16).

b)Moderate PDR with retinal neovascularization greater than 1⁄2 disc area and optic disc neovascularization less than 1/3 disc area (ETDRS level 65).

c)High risk PDR (Figure 5). High risk characteristics for severe visual loss are:

•New vessels within 1 disc diameter of the optic nerve head that is larger than 1/3 disc area.

•Vitreous or preretinal hemo-rrhage.

d)Advanced PDR with fibrovascular proliferations, (Figure 6) retinal detachment (tractional or reghmatogenous) and complete obscuration of the ocular fundus by vitreous hemorrhage.

Fluorescein angiography is not mandatory in PDR, unless macular edema is present.

Patients with high risk PDR should receivescatterpanretinalphotocoagulation immediatelyafterdiagnosis. Indeveloping countries, pan retinal scatter photocoagulation should also be considered for PDR without high risk characteristics, because patients may return many months later with an advanced form of PDR.

In patients with advanced PDR not amenable for photocoagulation, vitreous surgery may be indicated. In patients with PDR and macular edema, the ophthalmologist may choose to treat the macular edema first and perform the pan retinal photocoagulation later. If the PDR

is sight-threatening, combined focal and pan retinal photocoagulation at the first session should be considered. Pan retinal photocoagulation should be divided in at least two sessions.

Scatter Laser Treatment of Diabetic Retinopathy

(Pan Retinal Photocoagulation or PRP)

Information to the Patient

•PRP reduces the probability of vision loss, but some patient’s vision may worsen in spite of laser treatment.

•In patients with disc/retina neovascularization, the risk of vitreous hemorrhage persists after PRP, since regression of neovascularization is slow. The vitreous hemorrhage is not caused by the laser treatment. PRP may induce moderate