Foreword

A new era in the management of diabetic retinopathy has started, offering for the first time recovery of visual acuity compared to previous treatments, such as laser photocoagulation which aimed at disease stabilization. However, in this new environment of recently approved treatments and new promising therapeutic strategies, clinicians are faced with difficult decisions to choose the appropriate practice in each individual case.

The purpose of this practical guide is to assist ophthalmologists in making decisions in the management of diabetic retinopathy. This richly illustrated manual is based on the best evidence available and provides the practical and complete recommendations to guide clinicians in the management of diabetic retinopathy, including diagnosis, decision-making, and treatment.

This book is designed to address all the different and complex stages of diabetic retinopathy starting from the early stages up to the more advanced and sightthreatening levels of the disease. The publication provides also new insights in the management and surgical approach of diabetic retinopathy, providing the more updated techniques to fight this serious eye disease.

The chapters of this manual are enriched by practical tables and easy-to-read summaries that explain the progression of the disease and help the clinician to choose the best therapeutic approach. Moreover, the manual is enriched by algorithms that describe the suggested treatment approach, helping ophthalmologists in the difficult task of making treatment decisions.

The text is supplemented by almost one hundred illustrations, which contain in some of the cases a further follow-up. Several clinical cases are presented through multipart figures that represent the evolution from baseline to final follow-up of the clinical features of the eyes that have been treated with the more recently introduced drugs and surgeries. The case reports run in parallel with the text, showing practical examples of the effects of the treatment described in the text.

Clinical strategies in the management of diabetic retinopathy examine all stages of diabetic retinopathy to provide the latest developments in diagnosis and treatment of this severe disease.

I believe that this contribution is timely and will be appreciated by anyone that is faced on a day-to-day basis with the management of diabetic patients with retinal disease.

vii

Preface

Diabetic retinopathy remains the leading cause of visual impairment among the working-age population. There is evidence that visual loss could be reduced substantially by strict glycometabolic and effective blood pressure control. Nevertheless, diabetic macular edema and proliferative diabetic retinopathy currently remain the more dramatic and sight-threatening complications, which need a prompt and effective treatment.

For nearly a half century, focal laser photocoagulation was the only scientifically proven effective treatment to prevent visual loss due to diabetic macular edema. Recently, new intravitreal agents, such as anti-vascular endothelium growth factor agents and steroids, have been introduced in the management of the disease. The main advantage of the intravitreal injections compared to focal laser photocoagulation is the chance not only to prevent visual decline but also to promote visual recovery. In addition, combination therapy involving intravitreal injection and laser photocoagulation recently has been considered a promising strategy to improve the results further. In some cases of diabetic macular edema and advanced proliferative diabetic retinopathy, surgical intervention with pars plana vitrectomy and membrane peeling remains the mainstay of treatment.

Considerable evidence now shows that prompt treatment is necessary to prevent the visual impairment from non-proliferative as well as from proliferative diabetic retinopathy. However, the introduction of several treatment strategies has created the need for new worldwide guidelines to manage all the stages of diabetic retinopathy.

This book derives from two different schools, the European and the American groups, which are geographically distant from each other, but share the same approach and methodology in the management of this complex disease, diabetic retinopathy, resulting from evidence-based medicine and from randomized clinical trials.

This clinical manual covers all the stages of diabetic retinopathy, including clinical manifestations, imaging, and treatment, from the early signs to the more advanced levels of severity. This guide is designed to present to the reader multiple practical and useful suggestions for the management of each stage of diabetic retinopathy, using algorithms, tables, and summaries.

ix