The Division of Endocrinology, Diabetes and Bone Disease presents a Grand Rounds discussion by Gareth Lema, MD, PhD, Director of Quality, Safety, and Experience, Department of Ophthalmology. Dr. Lema provides an overview of the physiology of diabetic retinopathy, followed by an in-depth discussion of diagnostic imaging technology including fluorescein angiography and optical coherence tomography, as well as the advantages and limitations of imaging used in telemedicine. Dr. Lema discusses the classifications of diabetes and incidence of retinopathy, varieties of macular thickening, hemorrhages, and blood vessel proliferation. Dr. Lema describes different approaches to treatment, including focal laser therapy, micropulse laser therapy, intravitreal injection, and surgery. But then it started. A Houston Review. Staff care. Lima and Lima has recently joined the Department of Ophthalmology and outside a hospital site. Director for Quality and Experience for About Sinai Hospital. A. Yeah, you just got a, uh at University of Buffalo, where he's from. He was briefly at the University of Pennsylvania for his internship. He returned to University of Buffalo, where he completed his presidency of the i R G. Ross Institute. He completed his fellowship and read the surgery at the University of Rochester Strong Memorial Hospital and his because your career is distinguished in service to the patient's residents and fellows, a swell of the ophthalmology community at large with leadership positions within the New York State Ophthalmological Society. While at the University of Buffalo, he scaled clinical programs to serve the very geographically spread out population from areas of Pennsylvania all the way Tonight Falls, which I had to Google map to figure out how big of an area. Uh, my my own geographic Nativity on, which is in dire need of high quality ophthalmology care. Eso Today we're excited. Thio have him speak to us about retinal imaging and the management of diabetic retinopathy on. I'm also looking forward to our faculty, collaborating with him and finding innovative ways to reach our patients who may not be a geographically spread out but have justice Mary many barriers. Access to care s Oh, thanks. That was a much nicer E. So yeah, I hope hope this will be informative. It is mostly sort of a review of findings are use of damaging for diagnosing and treating diabetic retinopathy. And hopefully we'll just give you some information that you may need. And it sounds like from talks about having before the meeting will submit some discussion. So I'm open to talking during the presentation. If you have a question that comes up, just raise your hand or interrupt show financial disclosures. So I always start with a picture of the I just so that we all are on the same page, understand? Kind of what we're looking at. We know that guy looks like on the surface three. I is basically I tell my patients it's a bag of jelly. It's the Jell O is that is the vitreous right in here. You can see kind of listening in this picture. It's also directly analogous to a camera, so there's a lens system in the front with the cornea and lens. The lens is flexible and so allows you to focus on near and distance almost instantaneously on. Then light is focused onto the retina and specifically the macula, which is what we use for very fine division, like reading the paper or distinguishing appreciating a high def TV or screen like this. And actually, the part of the eye does. That is less than a half a millimeter in diameter. So it's a really small area in the central part of the retina that's really responsible for your high definition. This is some pictures from analysis of the retina. Uh, this is about 80 to 100 degree view of a good portion of the retina. This is the macula right here, and the very central vision. You can see how the are the temporal arcades, sort of spread out around the macula so that it doesn't keep flow. The flow of lights, that very central area right here. Um, there's two things to appreciate here. One is the retinal circulation that we all know about. We could see what the director telescope but behind. And what supplies? The photoreceptors are these striations and sort of raised back here. It's actually a cap Hillary bed of of blood vessels that supply the photoreceptors. It's a very low pressure system, but it has the highest of blood flow in the body. Histological. We can see what it looks like here. The red is a very highly organized structure. This is a very central region. All the retinal Interneuron kind of spread out of the way. So that light has an unimpeded view to that very small center in this section or sexual center. The retinal vessels, they're seen here in the middle of the retina, but also in the surface, um, sort of the surface of the retina here. This is why, if you get a vitreous hemorrhage and a person who maybe doesn't have diabetes were concerned retinal detachment, but 30% of time it's not because it just rips the vessel without detaching the retina. This is that Cavalleria bed behind the photoreceptors I was talking about here. There's much larger, larger vessels called the core oId in a very small network called the Korea Capillaries. Another note to Although we save arcades and arteries. Every every rental vessel is the caliber of arterial. Technically so these are very, very small vessels. What happens in diabetic retinopathy? These are some of the classic pictures you might remember from medical school, their trips and digests of the vasculature. In diabetic retinopathy, you could see thinning of the blood vessels due to damage to the end of filial cells. Thes air, micro aneurysms, some could be highly cellular with neutrophils, others. They're just expansions of the vessel wall. And this is later on where you've got a lot of capital, a drop out, these sort of bulbs there the terminal ends of capital raise their trying thio. But or maybe there was a micro aneurysm there. And then the rest of the capital ary has sort of died off. But this is what ischemia looks like a diabetic retinopathy. How this appears in the, uh in photos that we see and on our exam. The earliest findings are hemorrhages and micro aneurysms. Microns, Andrews air, obviously very small attachments to the blood vessels, and then dot blot hemorrhages are generally around the blood vessels, but can be sort of anywhere a little bit more advanced or cotton wool spots. You know something like this. We've got a ski. Me of the small capital areas causes cotton wool spots. You can see one here. Hard exit dates are lipid, and proteins that are left behind with macular oedema is re absorbed. The the executive portion gets reabsorbed more quickly than the than the solid particles. And so those stay in the retina and causes heart exhibits. They're called heart exhibits distinguish them from macular degeneration, Druze and which are sometimes called soft. Today is we don't really use that terminology so much, but way still use hard exhibits for diabetic Ganapathy, and this is not a vascular ization. The optic nerve new blood vessel formation on the optic disc emerging is a very powerful tool, but it doesn't substitute completely for a complete eye exam. The reason for that is emerging is great, but it's one piece of the picture. To be honest with an eye exam, we're getting best corrected visual acuity way. Have a formal system examination. We could live in this case. You can look at the iris in the front of the I. We do have lenses that allows the depth of the retina. You know, if you do this for a couple years, you actually do see depth in this, you know, half a millimeter structure and comptel when they're sticking in the retina. So we get a little more information that way. But above, above all that, we sort of understand what the patients coming from and what their needs are. And also, you know how they're interacting with their vision. Some patients are 2050 and perfectly happy, another 2025 are going crazy. So it's really a total it, you know, knowing how the patient is perceiving their vision is very important. Funding photography is one of the hallmarks of what way do for tracking diabetic retinopathy. And also it's very important to telemedicine like way should be coming Very uh, critical right now. This, um it allows us to track the retinopathy, but also for grating thes were e think this author was really trying to make bad old pictures look bad, but this will be started. Used to do. We would take a whole bunch of fondest photos and kind of merge them together into this map of the retina. The reason I say that you know this. This looks like a badly Photoshop and the algorithms refers. These photos now is really good. I mean, it looks almost like one photo from together, but the big issue is you really can't get that far out again. These were standard photographs based on older studies of diabetes, where we've used standard frames to sort of look at how bad the diabetic graph, but not wasn't graded e. I can tell you a good photographer, the 50 degrees lens and having the patient look out could get out to here pretty easily. I learned how to do Is a fellow just, like attracts the on call? So it's not like something that's all that hard to do, but we weren't doing it, um, regularly. The cameras now are 200 degree cameras that can get almost all the retina, which you can see here, and you see a lot, a lot of large hemorrhages out preferred. This is what florist angiography looks like in a wide field image. Florissant angiography is a dye injected into one of the veins, and then we can watch it in zero. Photographs or video go through the retinal vessels. We tend to still like serial photographs more than video. Just because they're easier to transport, send show to each other things like that. In terms of transit times, the the way that test has done is very, very important because the armed I times like 8 to 12 seconds. So you really have to have a well timed girls. You may think that there is a decreased blood flow for profusion, toe to the eyes in the brain. Transit through the eye is about 2 to 4 seconds. So something I can use this to see if those slow blood folks, if you could see when the artery spill, it takes 12 seconds for the for the blood to get through all the way through the veins. You know that there's a problem with profusion globally. And, you know, in general we say the whole I should be perf used within about 30 seconds, and that kind of you know it takes it takes account for some of the air you get from, uh, from the timing of the photographs and push of the i V, forcing adverse reactions that we all know about, they're actually fairly mild and very, very tolerable in someone who has paler skin. They might see some going the skin of the injunctive Uh, that passes in about a day. We tell all patients that their urine, orange or greenish or weird colors, so just don't worry about that for about 24 hours. Some get a little wave of nausea within about 30 seconds that passes in about two minutes. Leakage from the vein is uncommon, but obviously is going to be a little bit dependent on the skill of the person doing the needle stick on. But it can cause of irritation that believe with ice Hives are fairly mild and could be true with Benadryl. But I will tell you that most ophthalmologists do not wanna have anaphylactic reaction. So someone does get hives or has a really bad reaction to the floor, saying we probably won't do it again. You know, just so we'll try not to unless it's really necessary. Theater flats reaction is very rare, but can be deadly. I don't know what study figured out. That's 120,000, because they must have a huge number of patients, but there actually is a study that says the one about 1 200,000 and you can see the critical difference that we get. From what? We used to be a little more generous here with these schematic drawings What the fields are. But these were the older pictures, and you can see what they can miss. You know, we've got this huge sort of see fan of new revascularization that's going into an area of the scheme IQ Retina. This is a scheming retina Here. You can see that when you got a nice cap, Hillary bed got sort of this great sort of appearance thio in a retina. And here you just have no capital is whatsoever. This is extremely ischemic. These cells are kind of starving for for blood. They call out to it and you get in the vascular ization, the problem. Diabetes that you have global ischemia. You get revascularization anywhere. It could be on the nerve. It could be in the iris. It could be in the periphery. Um, in most other things that cause a scheme like sickle cell retinopathy, you'll see just the sea fat, because the the new accusations going to the part of the right now that systemic and diabetes and can go anywhere. And that's what makes it so much harder to treat and also so much more threatening division. Some special considerations from Florissant angiography and these air just some things that come with patients a lot in pregnancy. There's no known risk, but it also hasn't been studied. So it's not like we have data that says it's a safe. It's generally not using the first trimester. Most retina specialist, if it's necessary, would say that probably safe. But we also aren't doing it routinely. You know, we're not sitting here saying, You know, don't worry about it. Someone's pregnant. Try not to do it when you steal photographs. Instead, we'll try other ways of tracking during the pregnancy that doesn't involve forcing. But it is something that if it was really, really necessary first of your case, you could probably do it. For nursing mothers, it is transmitted breast milk. It's safe for Children. It's basically a vegetable. Diets, not a contrast Contrast dye. It does change the taste of milk, which obviously most most mothers are not happy with eso. We can recommend the starting look for 24 hours, but again. A lot of a lot of mothers and will be Joan's were kind of concerned about it. So just to allay those concerns that we could get get around it for the 6 to 12 months, Uh, then we'll do that. Renal insufficiency. This is not I d contrast dye. So it is safer than that. We usually use about a half does. But, I mean, I use this in patients with transplants and are on dialysis without much concern. Um, poor vascular access, this'll I really never really done although here. But you can't swallow it and get sort of ah, more diffuse reading. It won't be nice sharp pictures like this, but but you can actually swallow it and probably find some ischemia that way as well. You just gotta give it five minutes, Thio Circulate. Yes, that's exactly but oh, it's, uh, e want to say it's about it's sorry. Don't know e should. It's something but e want to say about 400 nanometers. It's individual spectrum. Yeah, it z excited by it. Fluorescent green. That's excited by a uh Yeah, pretty close. Yeah, very close. And these are just some other findings. Uh, the key. Finally see our leakage. So these are leaking vessels. They're usually in a scheme IQ areas here because they're butting into the ischemia. This is blockage by a hemorrhage. We call it the pre retinal hemorrhage. That's kind of pin. Thio has this shape because it's pinned to the retina by the Petraeus, which is still attached on it rather than being diffused, sleep, spreading through guy like food coloring and that Z cause blockage of the Florentine, obviously and then non profusion is what is the hallmark of ischemia. And this is just severe case where the central vision is just kind of wiped out by the steam make right now. Obstacle parents tomography we do over and over again. That's almost you. Heavily utilized test because it takes seconds. It's not invasive. It's non contact on interpretation. Once you looked a bunch of them is fairly straightforward. It's a way do debates and things, but it's it's very useful. It's analogous an all star O. C. T. But it looks at the reflections of light rather than sound waves or radiation. It gives about seven microns resolutions so you can see the cell layers very well, which you can't see individual cells, and this is how analogous it is and how representative it is of histology slide. So it's really kind of amazing. What we can waken see, Brighter is more reflective and a newer technology I'll show their side. I was O. C. T angiography. I this one of the things that kind of amazed me about our technology. It uses something called motion contrast and is the principle that retinal cells don't move, but blood vessels blood cells do so. It actually tracks the movement of red blood cells in serial photographs through the blood vessels to map the blood vessels in the retina. Eso it's a great technology, takes a few extra seconds on the O. C. T scanner but could give us a lot of information. Not the same is flourishing and geography always, but it's still a lot of information. These are typical findings were looking for. This is sort of a little less severe, but focal macular oedema were swelling in the retina caused by leakage of blood vessels from diabetes. This is more diffuse. Macular oedema this year is a thin layer of sub retinal fluids, so the flu is bad enough that's actually attaching the photo receptors in the central part of the retina. This is called cyst oId Macular Oedema, which you may have heard off. Also pedal Lloyd on the floors and angiograms. A lot more pedal Lloyd Pattern of Leakage. But this is gonna look as a characteristic appearance, and Ossetia's well, it sort of stretching of the rental inter neurons and the photoreceptors. These actually are stretched photo receptors. It's kind of amazing how resilient they are that they can stretch this much recover, if you can treat it. These air more severe cases, So this is a membrane that's proliferated over the retina in diabetes. It's particularly severe because a lot of times these membranes are either from or integrated into the vitreous. Ah, lot of membranes on the retina form after the vitreous is detached from the retina. And that's a very important distinction because the vitreous is detaching and this is an almost everybody will cause. Enter post their attraction on those membranes so it actually pull on the retina cause a retinal detachment on. That's one of the problems and diabetes, this one, this really looks like an integrated sort of vitreous, highly face membrane that's attached to the central retina. And that part that's supposed to be depressed is being pulled up to the membrane and causing swelling in the central retina. This is a very severe one, where it looks like there's a preacher's where it looks like there's vitreous membrane here and then a proliferated membrane here and there they're pulling up. He's also be fiber vascular membranes caused by a new vascular ization proliferation revascularization, and this will be treated with surgery. This is O. C. T angiography and sort of shows some of the power of it. A. Z talked about its most motion contrast, and you can use it to create density maps of the blood vessels in the retina. So this is not accepted classifications system yet. There was one that was proposed that you could look at the debt you could start classifying. Diabetic retinopathy is the density of the blood vessels in the capital to drop out that you have Onda Gennett just kind of amazing how much they are. Diagnostic assessors started Look like our histology slides, uh, for telemedicine. These are actual pictures from our telemedicine service way. Do have cameras in New York I and here in some primary care offices that are actually they will take photographs and send them to us. And I'm one of the readers sport. We basically say this person needs to be seen or doesn't need to be seen. Thes highlight both the power of it, but also some of the limitations off the It's an extremely effective screen tool. You can get a great picture of the fund ist You know, we're not looking in the far periphery for these. This is a screen test is not a full exam, but for someone who is just diagnosed and it's the difference is saying you need to see a rent a specialist versus, you know, go for annual eye exam. Gonna get dilated. Just you don't make sure things okay periodically, um, some of the issues with it it is operator dependent, you know, if you're not trained well to take the pictures or even you don't clean the lens enough, it can. The pictures could be could be altered by that. Here, you can see that there's Ambassador tortuous ity. There's some copper wiring. There are some micro aneurysms here, a small cotton wool spot dot Blot hemorrhage. This crater is some artifact from dust on the left. I don't know what things you know and these I should from this series of pictures. These with these were the best. And these are actually great. These air Really great herbal. I can read this and say This person you know has moderate, uh, maybe bordering on severe diabetic non polar for diabetic retinopathy and they should be they should be monitored. But in other pictures in this, Siri's thes craters were all over this and all over the in front of a picture. E wish I knew there's more interested. There was so much interesting that would show more pictures. Some The cataract is so bad we can't see through the cataract at the same time. Then we you know, that's another reason Thio ophthalmologist. So we'll put on there No, no diabetic retinopathy unnecessarily. And then we could see. But the person does have a different cataract that maybe she would see for that. I picked up macular generation on these two and said, you know, there's no diabetic monopoly, but I do a lot of Drew's in and they need someone to do. Dilated. Um, so it is. It is an effective tool, but there are some limitations to it. Okay, In terms of classifications for diabetes and some of the demographic data for us adults over 40 28 almost 3% of population, about four million people. Vision threatening that better right now about 4.4% by 2022. Project on six million people with diabetic retinopathy in the U. S. Type one is obviously less common, but can be much, much more severe at five years. But 25% of patients have some form of diabetic retinopathy at 20 years, more than 90% have at least micro mannerisms or john hemorrhages. And at 20 years, about 50% will have proliferate. Diabetic right now that most of your kind type two insulin dependent seems to be an important risk factor. Patients who are on insulin tend to be doing worse. 20 years, 84% of the that we'll have we'll have some form of diabetic retinopathy in 25% will have proliferate diabetic retinopathy so it can. It can be very, very severe, but still about type two, about half the rate of color from diabetic or not use type one. So there is a big difference there. Our goals. I don't know what the goals are in endocrinology, but ours are. You know, we like to see the HBO and see between 6.5 and seven, if we can. I think I've been hearing that is getting lower and lower now It's more like under six. Alright. No, really, no, a really a is over today. Yes. Ohh, baby. Sometimes it's like read in opposite for the development. Use the special techniques inside. For that, I would think it's, um I mean, you would have to be another cost, you know? I mean, because by definition, if you have proliferate diabetic neuropathy that you have a diabetic right now, there also are some. I'm not sure what exactly that site was, but there are some case there's there's other sort of subtype, and part of the reason that Flores angiography so valuable and even it was T angiography on a systemic retina can just kind of looked like a bland or in just brown retina without a lot of micro aneurysms or hemorrhages. Because profusion has gotten so bad, but they haven't really developed a lot of revascularization. And so sometimes you look and you actually I mean, I've actually created patients or look, the patient said, this looks like modern, diabetic or not, but it seems much more severe because fun just looks so ischemic. And that could be very hard to serve a subset of patients that could be very hard to distinguish. And sometimes you look at the look at the patient will do a florist in, and they're actually better refused than I thought. And other times do that Flores ing. And they're horrible, not profusion. So it makes me wonder if maybe those patients developed diabetic retinopathy and really had a more severe Um, of course, in your case. But by definition, if someone's got PDR lands subject Oh, okay. Which of them, you know, shoot to do first? Oh, course. Angiogram. Eso For me, it's Everyone's gonna vary a little bit on this. It used to be much more prevalent than it is now because O. C. T. Is so fast. Give us a lot of information. People are very 70 c t a. But we don't have wide field C t again. I tend to do that. Patients who have morally severe, non prolific diabetic, but not if I see something that looks like maybe budding envy. But I'm not totally sure I'll get for geography for patients who have proliferate. Diabetic but not me. I like to get at least once a year, you know, if we're actually treat them and they get every every 3 to 6 months, depending on what we're treating. But if they just just monitoring someone who's been treated doesn't seem to be active, I'll get it once a year just to make sure there aren't little little Paris. I had a type one diabetic patients in Buffalo actually was 25 p r p. This is, I mean, if he's amazing and also it's sad you blind in one eye from diabetic retinopathy. The other idea so much getting a photo population second. But he had so much of it, and his visual field was about this 2020 2025 that I and he still was getting blood vessels way started. Thank you. Thanks for him. We have the Jeff treatments because there's nothing else delays every other places, and he still needed an injection every eight weeks or so. Start bleeding. Um, and so it's there. There are, um, some showers. That's why I like to get I like your strictly directed the lady in question. Too bad e a e. It's a great question, just anecdotally from my practice. I mean, I'll see patients who don't have much retinopathy, but they had been amputated e there's or some will be on dialysis and the right now is not that bad. E don't tell. You know why I e one of the same thing? Because they will. I'll see their eyes. There was a pretty good 2020 just regular exams. But you know, there there are dialysis. So there is some variability. Yes. Yeah. In terms of there is a classifications skill. This is actually pretty old. This is from the only shooting diabetic retinopathy study. There hasn't been a new classifications yet, based on fully new imaging. In fact, those wide field images we thought that you were gonna be able to just treat these pickpockets and that really didn't work out. There weren't many papers and, you know, they still found that that full treatment was better than just trying to target the areas of ischemia. Eso This still works really, really well in terms of grating for diabetic retinopathy. This is coming from our academy's prefer practice patterns. Um, you know these air so similar I wish they would just say that convergent. But there's us definition international definition. No retinopathy, things no abnormalities, mild. It's just micro aneurysms. Moderate is sort of between severe and mild on. Do you think the reason I say that and I accept the fluffy nous of it is because this is this is the standard. The standard was photographed 10 A. You know that there was a paper basic classified diabetic retinopathy a long time with a very careful job of it. Onda. This is sort of what we use, and we're having our minds of what mild, moderate severe is. Um, in fact, I think that with some of the newer technology, we're gonna get better classifications system soon. You're channeling AI beforehand. I think that's a big part of figure Those out a Z A z developed these systems, Um, but micro and aneurysms and hemorrhages. This would be considered severe, by the way. So these would be severe microorganisms hemorrhages, so you can see that there's not a lot considered severe. You know, this is not looking at this. There's a bunch in this one squadron, but it zits still doesn't look this person, this person may have no vision loss despite this being insurgents severe form of diabetic retinopathy. Venus beating This is actually a mild case, but it's this kind of thickening and out patching of the veins. And then, er, most is always the million dollar Question for ophthalmologist. Irma's are just weird little vessels that are growing into a scheming parts of the retina. The best definition I heard of them is that it z neo vascular ization that hasn't broken out of the red yet. It's basically a blood test that's trying to make its way on. It's a sign of severe, severe ischemia. Um uh, the severe, non prolific diabetic right off. He just kind of looks at the likelihood that person is going to go on to proliferate Diabetic right now, eso there's a great system for that and then prolific that better. But now he's revascularization or vitreous hemorrhage sometimes, especially with anti Jeff injections. Now we won't have trouble finding the vessels that are bleeding but personally vitreous hemorrhage that's more prevalent now. Classifications for PDR You could look at PDR with high risk characteristics as well. This is the standard photograph. It's 3 to 43 to four o'clock hours of PDR on a new vascular station on the disk or neo vascular Asian anywhere with the vitreous hemorrhage. So this is sort of the standard example of 3 to 4 o'clock hours of new vascular ization. Again very, very hard. I tend to look at, you know, I look at the the nerve like a clock, and I I've judge that way. Based on the circumference of the nerve. This is a little more severe form with vessels that have have grown over the nerve. There's a very severe form. Interestingly, this is a very treatable form because there's none of this fibrosis. He's having performed five of asking membranes yet. There probably is some. But, you know, before we had an TV Jeff, we could laser all the way up to here. This is all skinny right now. You can see the drop out of capital Aries Now we can do anti by Jeff injection hopefully clear that up. You have to be a little cautious because these can contract and caused attachments. But this would be one that's very severe but also treatable. Thes air more severe. This is what this is. A very secure traction rental attachment. The nervous is totally obscured by a fiber vascular membrane that's grown over the nerve in the macula. It's all supposed to be here. This is the peripheral retina, and you can see that it's being drawn in and tented up towards the center of the retina. And the reason for that is the victories is still. This membrane is kind of, you know. The new fascination grows into the victory is like Velcro, and then it kind of gets stuck there, and the vitreous moves and pulls on it cause distraction that elevates it. We call that a tabletop detachment because you've got this three and 60 degree sort of membrane that pulls up a Z 11 plate on dis is just the most severe of reforms. This we see more frequently. We've got sort of membranes. They're going around the central vision and then elevating it private e sort of elevating it these. The prognosis for these very guarded way often don't because diabetic patients do not respond to surgery Very well in general, you know, way all sort of know that. You know, you're going toe operate a diabetic patient, and sometimes it goes great, and sometimes it doesn't go great. And your surgery may have been the same. You know, I've had patients who didn't have bad traction. Andi lost vision for no reason that I can understand, You know, the membrane wasn't in. The central vision is off to the side. That was dispatching the Central vision e didn't go near the central vision, but they somehow lost photoreceptors. I think it has to do with just the fact that these guys were sick with poor profusion. Begin with you have this trauma or you're pulling on the rebel vessels and the rental neurons, and they just, you know, in some cases can't handle so again there's no substitute for dilated exam. The recommendations for type one or five years after diagnosis. The reason for that is Type one is picked up before patients are symptomatic often and so a lot of times within five years of diagnosis about 25% of some form of diabetic retinopathy. That's the basis for this recommendation. I I mean, I don't know if it was my kid. I would probably just wanna based on example Be honest. It's just but the recommendation is there for a reason, and it's it's perfectly acceptable. But it is. It's really because the patients are picked up before they're symptomatic with Type two, they often come in symptomatic. We have no idea how long have had diabetes for it. So that's why it's important to get an exam right, a diagnosis in pregnancy. It can go both ways. Usually it may not change it at all, but it can make diabetes a lot worse. I've seen patients who has written out he's gotten better during pregnancy about common, but I've seen it on DSO. We recommend within the first trimester, and then most threatened specialist want to see patients about every trimester just to make sure nothing's changing. It's really mild bill. Well, let it go. So the treatment laser is the standby first vocal laser. All lasers are not well actually not true theme. Standard lasers are a plate of therapies. They literally are scarring retina to prevent problems from the retina. The sort of principle here is that this written the general cells are really sick. They're releasing by Jeff calling off blood vessels. The bed Jeff makes the blood vessels leaky. Andi also proliferate and so weaken laser them that way can sort of get rid of that. That Jeff Load That's, uh, that's causing the problem. This is sort of extensive focal laser right here. You can see the laser burns that makes these whitish burns and scars here, uh, this, you know, amazingly, it could work really, really well and stabilize patients. And I have some patients who have the style of laser who are doing great than other patients. These scars over time, 5, 10, 20 years. They can spread into the central vision and caused central degeneration. So it's whereas it could be very effective and the best we had. It's not. It's a little out of favor now because we've got other treatments. There's a new one called Sub Threshold Laser. It's the same laser. It's just fractionated, so it gives a very low load of laser. Call it cool laser cold laser and what's basically doing is, they think that it's just kind of stimulating. It's just sort of stimulating the rental. Interneuron Bueller Cells support cells for the retina to kind of, um, uh, um, repair the damage of the field of cells in the basket insurance. Not totally understood how it's working, but we're finding that it may be as effective as the old focal laser on de. So it's a safer means of doing it for Focal Laser. This is based on the TDRS trial from 1985 and the important distinction. It's tried and true, but it's the but the important distinction here is that it decreased the likelihood of vision loss over three years by five by 50%. It didn't improve vision. It didn't. It wasn't a cure, but it was markedly better at preventing vision loss. That's for clinically significant macular oedema. What that means is the level of macular oedema that struggle by laser literally. I mean, they looked at different. They found that if it did not meet this criteria, then it laser wasn't effective. And then when it did meet certain criteria, laser was effective in fact. But the important distinction does not improve vision sub threshold or micro pulse laser against. It's a fractionated beam. Other treatment. Other lasers. That's proprietary technology. So other laser companies are trying to come out with sort of a cooler or just a decrease a dial down laser. Instead, I you could do that with Anyways, you have. I sort of do some threshold about micro pulse now because, you know, I just use a lighter laser. Um, but micro policy is the one that best tested doesn't cause a burn. The company says it's completely safe to just go right through the central vision, and it will be totally fine. A lot of us a little squeamish about that. We'll go very close, but not quite right through it. On there. There was a meta analysis recently. Looked at a lot of smaller trials to the left of line basically means that it's It's better than, uh, thin focal standard focal laser, and it looks like it's right about as equivalent. But with so much with much better safety, it may be something that's effective. There's a lot of debate and literate in literature among right, especially about whether or not this is effective and are necessary because of anti veg ECT treatments now and the fact that we have focal laser tried and true panorama photo coagulation is one of our you know, kind of hammers in a way, because it's just it really is. It's lays a ring all of these human right now to try to decrease that Jeff load on a global scale. And it's again, it's very effective. You know, I've got some cases who have heavy laser. This is these are all laser scars here. This is the central vision. You see how close they're getting to the central vision, but it could be very effective. They've got no new vascular ization anywhere. Um, there's a pale nerve. I've had patients like this who have a very poor visual field, but they're 2030 in a central vision. And so there are cases where this is very, very effective on dso It's not something that is something we still use because it has a much more permanent effect. But with the injections that talk about waken, treat it out, having a plate of therapy, Yeah, so injections. They are injections in the eye. You know, the surface really, really well the one thing that every page is fairly consistent on all patients is not as bad as they thought. You know, some patients do jump some patients like way. No, me, I really well, almost never to patients feel a sharp stick. But there is pressure on the globe that you can't really change, so they all will feel it. What happened? But almost I joke with patients because I try not to tell them that once is not as bad as I'd like. I'd rather set the expectation that, you know this is a basic procedure, but we're number here. I really, really well. And then they feel like it was as bad as I thought. It sounds awful, you know? I mean, it's like it literally is a needle in your eye and there's a kids joke. Eso people are scared of it, but really, you know, we bring patients back every month, and 98% are perfectly happy with their okay, You know, no one likes it, but it's very tolerable. Bay tonight is the antiseptic. It keeps the infection rate really, really low. I think it would speak. It is very important. There was a study that came out in 2014. That was sort of this panel that decided what you need to do when they were plus minus on the speculum. E think just because something don't like doing it I think it is not as important. Leads the dirtiest part of the I three ocular service because of E g A. And other, um, immune regulation is is actually pretty clean, but it is about 10 times more bacterial macular service, and there are on the skin, so it's a really clean area. But the lids are discussing their full of bacteria. And so I put it Looks like I'm gonna keep it out of the way. I also wear a mask, I think, in any teaching institution or big hospital. Some people said you don't need a mask, you know, talking policy during the injection. I gotta be honest and the time it takes to explain your patient what to do. So you want to talk during the injection, you just throw a mascot mascot. It's kind of silly to me. Um, but and I also don't believe you could ever do this in a number of patients a day without talking any of them on a teaching institution camp because you're you have residents, so I wear a mask. Gloves aren't really necessary. It's so quick bait, and I put it right over the actual injection site. You know, our hands aren't anywhere near the needle tip. You know, it's just it's way. Don't often glove, but we do wash your hands and are keeping the infection rate is rare, but very really. I mean, we e it's a peak in Buffalo was doing, I think 1500 injections a year or 4000 injections a year. And so if the infection rates one and 4000, I did calculates, I have one case in five years, and I think it was after, like, 8000 injections. So it does happen. Andi, you've gotta act fast because basically are getting contamination right into the vitreous. And if you act fast, the patients could do well. That depends on what bacteria it is and things like that. So it is a rare but very riel complication. And so we do talk to patients about it, um, pain at the injection site, you know, a little bit of irritation, mostly from the beta beta and little talks to the cornea, so patients to have a scratch your feeling afterwards. Onda floaters can be both from the medicine couple things medicine, disruption of the vitreous that kind of moves around. It brings a floater into their view. Or there were some cases that made the news, because now where we're looking for them of silicone oil droplets from the syringe being injected into the I was mostly with the vast in because they're prepared ahead of time. And so sitting in the syringe and kind of pull offs and drop with some of silicone coated syringe. Andi, those air, you know, to be honest, they don't affect vision. It's a nerd thing. They are super annoying. The only way to really get rid of them will be with attractive me where you're going to remove the whole vitreous gel, which is safe. But we're also the invasive, considering it's something that a procedure did, um, kind of unfortunate that has lost its over because everyone gets quarters. But it is. It is really now. What they're doing is they're using different um, syringe that are silicone line. But that was the issue a couple years ago. Three anti veg of drugs they're all based on a vast vast is off label. That is not America's question to get from from patients a lot. Um, it's basically a vast sin. Is Pride, All know is a cancer chemotherapy for breast cancer and colon cancer. It blocks proliferation blood vessels by blocking the jet. Exactly what happened to diabetes. You get this bed, Jeff load and blocking it takes away the blood vessels or get them to go away. The reason is a vast incentives. They're both made by the same company and the company. And Genentech said, Well, way cut off the active site of this of this Monaco antibody. We can make a drug tailored for the I in charge $2000 a dose for literally, E said. That way the doctors basically what it waas um, they had a vast in. The reason we have a vast is because while they were making the sentence, there was some smart people of basket, Palmer said. Well, almost got tried using a vast, so they gave it intravenous. First found that it was effective and then they realized they could inject into the eye, so they objected to Small goes into the I thought it was more effective. That was all while they were doing the clinical trials for the sentence. And so they came out about the same time. And it's been this debate ever since. Which one should we use? There are trials that show that from Macca degeneration they're fairly equivalent between the sentence in the vast in a lot of people with the sentence in the vast who sent this in terms of their use has gone down a lot because of assets just so equivalent to it. Not a lot of advantages. I li, on the other hand, came out later. It's based on a vast in, but it's actually the It's the veg F receptor. It's a sizable portions of vegetation budget receptor. That's some been soluble eyes that you can inject it into the victories. Eso it is a different molecule. Same idea blocks all that visible forms on it has it's a larger molecule last longer in the eye, and because of that, we think that it's more effective. We've actually had some studies that show that's more effective than could last longer from actively generation. It's approved for use every 4 to 8 weeks, so it gives us a little bit longer therapy. We all like a therapy called treating Extend now, which is the principle is you inject. You plan to inject every time a patient comes in, but you do your best to extend the follow up. What this does is the philosophy is we're trying to prevent the problems coming on like macular oedema, our new blood vessels. Um, but we're all It also allows the patient and not have the burden of coming in every month. So that's the trade off. This is mostly came from macular degeneration, but were adopted. I would say most I and I think most of about diabetes as well. Um, that you can use this principle, try to prevent Mac, you know, we're coming back, and in most cases you kind of find a sweet spot between eight and 10 weeks where they're not gonna come back every single month for an injection. So it's just one way we've tried to decrease the injection burden for patients. Hello. Okay. Trials. Yes. Yeah. Actually, I think I have a future side e. There are two. So, yeah, the big difference here in the next few slides will get to that. And the big difference here is cost. And this is why it's a controversy now. Basketball, $50 a dose. Ideas about $1800 a dose, Uh, just goes into literally. When I came out, they pulled right. A specialist on what they should charge for it. You know there's no well, no, there's drug costs has nothing to do with what it takes to make them e awesome. Yes, this is it. So the PRC are dot net or diabetic retinopathy. Um, critical research network has protocol as 30 different protocols and studies of the last several years, and this was one of the most recent ones that actually did do a head to head trial of all three of athletes. That idea, and they found that they were very, very equivalent. Almost every anti by Jeff Paper has this figure, whether it's max generation or diabetes, there's improvement over the first two or three months of therapy, and then levels off on and on, stay stable out one way started to drop off after 3 to 4 years in a clinical trial of, Interestingly, in a clinical trial like this, where it's a very regulated, they did see that in patients who are 2050 or worse. Idea was far superior to the other two in patients who were 2030 or 2040. They didn't notice the difference between any of them. They're all about the same, so that's a very important that's out toe. One year they're having some subsequent papers and pull Medicare data and things like that. They're showing a little more equivalents, and I think it's because in those trials in those, um, retrospective studies, your you've got patients who don't have no shows you a lot of different stuff, that kind of money, is it? I think I Leah is a lot better, but it's hard to show that when there's other other studies, they're kind of showing that on average they were. They were pretty well, eso with this constantly means according to the American side, retina specialists for both diabetes and macular degeneration, about 70% of right a specialist will start with a vast because you sort of I mean it just it's right. I mean, it's extremely effective much, much cheaper but if it fails over three or six injections, they'll switch to PYLEA pretty rapidly. About 75% of the right of specialists think that really is the best. Interestingly, in Europe I think this has internationally they do a North American international survey, uh, internationally they were finding that private primary idea uses just much, much higher. I'm assuming that's because the prices regulate a little bit or there are laws and that you've got to do something that's not able particularly two reasons. Why have we used some states even say you got your something on label so you can't use a massive, please individual injections of anti Geoff, Geoff versus PDR. So this was there was another protocol s from the DRC are dot net, um, trials was a really good It was good and bad. It kind of show that we already know we've been We've been using anti by Jeff Prior surgery for a couple of years now because we're noticing if you give anti Jeff injection within a week of surgery, those blood vessels shrink off. You don't have left bleeding during the surgery. Maybe the membranes or less in here, and it makes the surgery go more smoothly. So we kind of know anti Jeff is very effective for polar for diabetic retinopathy. But this did do a head to head trial and looked at Lucentis versus Prp or Prp, plus the sentence versus Prp to see if there was a difference. And basically any arm that sentence was better than was I'm sorry. Um uh they were equivalent for new vascular ization So we sent this plus Prp for the sentence alone or prp alone. We're all fairly equipment for the new vascular ization portion, but I visited macular oedema did much better with if they had sent this in the outer with the reason for that is Exanta Jeff drugs treat all everything that diabetes does to the I basically they're sort of remarkable. In fact, now just made the news that Leah was approved for diabetic retinopathy which just totally revolutionize how Americans before e It's kind of crazy that you have a 2030 patient with no symptoms and you might start you legally could inject $2000 drug every month based on the fact that salad you just diabetic right now, nobody does that. I actually pulled. I'm on a written forum. An online form I pulled are sort of 250 members, and not one came and said all and of all the time now I don't think it's change anyone's opinion. But when you use this, it was on Lee Data out to a year way. Do not know long term. You know, we don't know what happens if you just give. Someone has had a Jeff medication for 5, 10, 15, 20 years every month, every two months we have. There are some suspicions that maybe the repeat increasing pressure you get from the injection can cause glaucoma way. Wonder if the anti by Jeff Effects can cause, you know, small cap Hillary's to two in the optic nerve and maybe cause of generosity. We don't know that we sort of have some anecdotal thoughts about it, but nothing has been proven, so I don't advocate for a long term therapy that's unnecessary. Um, the problem with this study, it was great for showing that these were equivalent. The problem was, it didn't really say what you do after the four months of injections that they looked at, so they basically said. After four months after these four injections, you can you know, either, basically, first advocated just monitoring. I was never that satisfied with that because you're gonna have what vessels come back. We're gonna have this person come in every three months and do a floor. Seeing action eventually led us will come back, so I personally, often nutrient extend. I'll just rapidly extend them out to an injection every three months for about a year, and then I'll once they've gone through everybody year, I'll do another florist saying that there's no new blood vessels. Try, stop you. But there's no There's not a lot of good data on what you do for a long term treatment if you choose anti Jeff. Another strategy that I'll take is I'll give the 3 to 4 anti Jeff injections. But I'll do lasers. And while they're getting those injections, because the laser effect as much because it takes a longer time, takes weeks to months to have effect. But it also could be permanent. So I'll do is I'll put in those three injections, put a laser on, then four months later to a florist to see if there's more proliferation. There's a few different strategies to do, but yes, sir, A sort of caveat. So that nuances of it. There is another thing we can inject in the eye. They're extremely effectively inflammatory. Component in some patients where you just can't were anti. Jeff just is not clearing the macular oedema. Uh, they do really well with steroids. Um, when we inject, try essence. It's a white powder, so patients have floaters for about 3 to 5 days. There also are implants. They're not this big. It's just in the foreground in this picture. But it's a little implant that goes in the I caused the floater for a couple of days until it sinks to the bottom of the eye. They're very, very effective. In some cases, problems of steroids is they can induce, um, ocular hypertension, which means glaucoma. And when you use them long term, they can also induce cataracts. Some retina specialist feel that an ophthalmologist feel that, you know, diabetes causes cataracts. So you know it. Za wash. I don't really feel that way. I think you know you're still using a drug you know, causes cataracts. I've actually heard that a meeting one time I called diabetes cataract, a genetic disease. So with steroid affected matter took some offense to that, Um, but it s Oh, yes. So these to be very effective, I use them sparingly because I don't like glaucoma. I don't like giving a person called coma, so I'll see with Anti Jeff for 68 months before trying one of these other retina specialists. You know, like that. It's so effective in certain cases, and so we use a little more quickly and really, it z kind of up to your experience. Um, Bolivian is a great I've used it. A few patients with great success. It's an implant that releases a low amount of stereo for about three years. The any of the problem is implants. We know that about 60% of patients will need to go a coma dropped by the Internet three years. About 15% might need glaucoma surgery and 90% of cataract surgery. They don't. So we do know that it caused problems. But in patients who have a frat who have macular oedema are losing vision from that could be an effective treatment. Surgery is always carries guarded. Prognosis is the same before you can operate a patient and everything could go great, and then they still somehow vision after surgery. Eso were very cautious. Diabetes. Most read a specialist do not like to do surgery unless there's a track for traction. All membrane for the very, very most of your diabetes unless it's pulling up in attaching central vision because they can. Sometimes they stable. Or you can use laser to stabilize them without doing surgery. There are other indications for surgery and non print vitreous hemorrhage that some people are finding might be beneficial. And there's a few reasons for that. If you have just the vitreous hemorrhage with very early prefer of diabetic retinopathy, Sometimes you can clear that hemorrhage put in PRP during the surgery. Given a vast injection, you have effectively treated their political diabetic retinopathy in one surgery. Also, some people think that getting rid of the vitreous maybe allows the that you have to sort of flow through the eye faster so that it's not causing as much of a problem, and you don't have that victory is pulling on the retina, causing traction of attachments. So there is some you know there is some rationale for doing earlier surgery. If someone has a vitreous hemorrhage, I don't think I mean, there might be some people who have written about it, but there's not really. It's not the status quo to just juice. Patients have retinopathy like that, but if someone has an oncoming hemorrhage or hemorrhage, I usually wait about a month for hemorrhage to clear. And if it doesn't, then I'll offer surgery used to be going up to six months. But now, with smaller gauge surgery and safer surgery with a little more aggressive, this is the sort of thing you this is the sort of attachment you might do surgery on. This is severe traction, retinal detachment and again, you know if you've got a band of traction here, but it's not affecting the central vision, you might try. Treat this with laser because you can stabilize it rather than causing the risk of risks of surgery. But this is This is why the prognosis is poor because they've already had attraction and attachment threaten is really, really sick. You're trying to get anatomical repositioning of the retina, but it's it's just very risky. Any questions about that? Hope it was informative. So a make a regulation versus teacher therapy on your so they're they're similar. Clinically, they have a similar effect, but they're not the same thing. So it z what? That one child show that either one will get the vessels to regress to a safe level. The benefit. I had this conversation patients a lot because I'll offer both and we'll talk about different things in different places, like ST in different ways, but can run a photo regulation eyes more painful will take 2 to 4 treatments. Andi, Uh, on. But it's also more permanent. So once you get through those treatments, you may not need injections anymore. It doesn't treat macular oedema at all. In fact, 10% of patients that can cause macular oedema or we just see one line dropping vision after panel on a photo regulations. So it's there. I I think it's very, very effective for long term management, but there are some other caveats to it. Interventional injections are almost miraculous. I mean, they get blood us to shrink almost every situation. Uh, the problem is that will last about a month. You gotta keep injecting them and you get out to ST Extend, where you could do one injection every three months. But once you stop those injections, you gotta start monitoring very closely again, using fluorescent angiography or or seeing, seeing if those places come back. So there's a little bit less security in the long term with the advent of protection. So they have the same effect through different mechanisms. Um, anti by Jeff blocks the signal that's causing proliferation of blood vessels. Pattern of political regulation kills the cells that are releasing that signal, so they're having the same. They're cutting off the pathway at the same point, Um, but just through different different means. The other problem with ends it with Prp. And like I said, my typical strategy is to give anti just to clear up the hemorrhage, clear up the vascular ization and then use Prp is more permanent treatment. Um, you know, diabetes. As you all know, patients were lost to follow up. It's awful in ophthalmology loss to follow for a year because someone who has a little bit of new vascular ization come back a year later with attraction attached. Eso That's That's one of the reasons in our literature it says, You know you wanted Do Prp for patients who are high risk for being lost to follow up. But I use it. There's a little more of a general strategy because we have You can do whiter laser. You could do more peripheral laser on. We've got safety. That's like the injections we could fall back on. It fails. You can do a lighter laser that hopefully will treat the patient without causing other side effects. One big one for panel folk regulation like this, You know, when it's that close to a person like that's also a decrease night vision and a constricted visual field. So I actually had a patient who was who had proliferate disease, but he was in his job, a transport company. So E was giving. It became in every two months for anti Jeff injections because we didn't want to take the risk of them losing visual field or night vision because he had a career service between Buffalo and Rochester, sometimes driving at 10 o'clock. So it z why I think you know, there's nuances that required knowing the patient a little bit with situations. It's like reason. Oh, you know That's a little question I wouldn't that more in trauma and for sympathetic found me off rate with trauma. The rate is really, really sympathetic family or something. That is something always on a boy. But the rate is so low we don't worry about much for trauma. The rate is about half a percent from a severe rupture globe Andi for attracting me when it was recorded a recent study a while. But record is about 10 times less than trauma. We now smaller games attracting these. We're making smaller wounds. I don't I personally don't see the cases from from attracted me. But I think that I would say that with smaller decisions that we're making now in a less invasive surgery just now, the rate is much lower. That used to be oh, all service, which might change. It is it's a good question. I don't more about trauma, but you want trauma. I don't worry about it too much. Yeah, mostly steroids. Uh, nice to this is probably the number needed to treat one of the reasons I e o brush it off anyway. But I did Look, it is a lot of a terrific way look this periodically on. Then there was a study to show the number needed to treat to prevent legal climate. Sympathetic value would be by treatment. Is a new creation of the globe is what, 900? So it z rare it out even for trauma, we'll talk to patients about preserving a problem is a eyes. There's sort of this arbitrary rule that you've gotta remove the I within two weeks of the trauma that prevented. But that's that. There's no study that showed that you think you're basically taking out the I before the chance for a few reaction. Thio being sensitization, of course. No way. Don't know as much about it. Listen, Thank you, everybody.