Diabetic macular edema

Usewith caution in older patients with CHF, CAD, NYHA Class 111 or IV, Hepatic impairment (avoid if ALT >2.5 times the upper li mit of normal), Diabetic macular edema... 

In recent years intraocular delivery of medication, including anti-vascular endothelial growth fector, corticosteroids and related compounds, and antiviral agents, has either been approved or is under study for treatment of macular degeneration, uveitis, cytomegalovirus, or diabetic macular edema (Table 2-5).This area of research and development is growing rapidly. 

Posurdex Dexamethasone implant Allergan Phase 111 Diabetic macular edema Biodegradable intravitreal rod-shaped implants... 

AMD = age-related macular degeneration DME = diabetic macular edema VEGF = vascular endothelial growth factor VEGER = VEGF receptor. From Duwuri S, et al.Advanced Drug Delivery Reviews 57 (2005) 2080-2091 Table 1, p 2082. 

Posterior snb-Tenon s injection of corticosteroids is most often nsed in the treatment of chronic eqnatorial and mid-zone posterior uveitis, including inflammation of the macnlar region. Cystoid macular edema after cataract extraction and diabetic macular edema are treated occasionally with snb-Tenon s repository steroids. 

Intravitreal triamcinolone has been used to treat diffuse diabetic macular edema. Also, an intravitreal implant delivering fluocinolone acetonide (Retisert) is effective in the treatment of patients with noninfectious posterior uveitis who have failed to respond to conventional treatment. 

Cardillo JA, Melo LA, Costa RA, et al. Comparison of intravitreal versus posterior sub-Tenon s capsule injection of triamcinolone acetonide for diffuse diabetic macular edema. Ophthalmology 2005 112 1557-1563. 

Clinical presentation involves a normal postoperative course for several weeks to 6 months, followed by vision loss that is often the only symptom but may be accompanied by photophobia, injection, anterior chamber reaction, or Amsler grid distortion. There is some evidence of an increased prevalence of early age-related macular degeneration in eyes that have imdergone cataract surgery. Also, diabetic retinopathy and clinically significant diabetic macular edema may both be exacerbated by CE. Therefore the differential diagnosis of postoperative vision loss must include these conditions. 

Diabetic macular edema (DME) is either focal or diffuse. As the severity of overall retinopathy increases, so does the proportion of eyes with macular edema. In a review, 3% of eyes with mild nonproliferative retinopathy had DME, 38% of eyes with moderate to severe non-prolif-erative retinopathy had DME, and 71% of eyes with proliferative changes had DME. In patients with diabetic retinopathy, CME usually occurs after long-standing DME. 

Bresnick GE Diabetic macular edema. A review. Ophthalmology 1986 93 989. 

Martidis A, Duker JS, Greenberg PB, et al. Intravitreal triamcinolone for refractory diabetic macular edema. Ophthalmology 2002 109 920-927. 

Treat other disorders of the retina associated with intraretinal or subretinal fluid build-up, including central serous retinopathy, central and branch retinal vein occlusion, and cystoid and diabetic macular edema. 

Thus, there exist a variety of predominantly acute edematous retinal disorders that may be amenable for treatment with an intravitreous injection of INS37217. For treatment of chronic conditions such as cystoid or diabetic macular edema, alternative means of intravitreous delivery, such as intravitreous insert or implant or a sustained-release formulation, will likely be required. 

While a number of animal models of diabetic macular edema exist, sustained delivery of steroids using a nondegradable device has not been tested in an animal model (14,15). Other nondegradable sustained-release drugs that have been investigated in vitro but not in animal models, include methotrexate and trimetrexate to treat intraocular lymphoma, and disease 2-methoxyestradiol to treat choroidal neovascularization (16 18). 

Early Treatment Diabetic Retinopathy Study Research Group. Photocoagulation for diabetic macular edema. Early Treatment Diabetic Retinopathy Study report number... 

Klein R, Klein BEK, Moss SE, et al. The Wisconsin Epidemiologic Study of Diabetic Retinopathy. IV. Diabetic macular edema. Ophthalmology 1984 91 1464-1474. 

Micelli-Ferrari T, Sborgia L, Furino C, et al. Intravitreal triamcinolone acetonide evaluation of retinal thickness changes measured by optical coherence tomography in diffuse diabetic macular edema. Eur J Ophthalmol 2004 14(4) 321—334. 

Jonas JB, Kreissig I, Sofker A, et al. Intravitreal injection of triamcinolone for diffuse diabetic macular edema. Arch Ophthalmol 2003 121 (1) 57—61. 

Pollack JS. ISIS-DME a randomized dose-escalation study of intravitreal steroid injection for diabetic macular edema. Presented at Vail Vitrectomy 2004, Vail, Colorado, March 6, 2004. 

Jonas JB, Degenring RF, Kamppeter BA, et al. Duration of the effect of intravitreal triamcinolone acetonide as treatment for diffuse diabetic macular edema. Am J Ophthalmol 2004 138(1) 158—160. 

Pearson PA, Baker C, Elliott D, IP M, Morse L, Callanan D. Fluocinolone acetonide intravitreal implant for diabetic macular edema 2 year results. Presented at the Annual Association for Research in Vision and Ophthalmology Meeting, Fort Lauderdale, FL, April 25-29, 2004. 

Campochiaro PA, C99-PKC412-003 Study Group. Reduction of diabetic macular edema by oral administration of the kinase inhibitor PKC412. Invest Ophthalmol Vis Sci 2004 45(3) 922-931. 

Aiello LP, Davis MD, Miton RC, Sheetz MJ, Arora V, Vignati L. Initial results of the protein kinase C beta inhibitor diabetic macular edema study (PKC-DMES). Diabetologia 2003 46 A42. 

Macugen (pegaptanib sodium injection) shows positive visual and anatomical outcomes in a Phase II trial for patients with diabetic macular edema. Eyetech Pharmaceuticals Press Release, May 3, 2004 http //www.eyetk.com/investors/press releases.asp. 

Recently, intravitreal triamcinolone acetonide has been used clinically to treat retinal vascular disease (Fig. 4). A case report by Jonas and Sofker (32) described a patient with nonproliferative diabetic retinopathy and a six-month history of persistent, diffuse macular edema despite grid photocoagulation. Following one intravitreal injection of triamcinolone acetonide, the visual acuity of this patient improved from 20/200 to 20/50 over a five-month follow-up period. It was also noted that there was marked regression of macular edema on clinical examination. Martidis et al. (33,34) reported on the use of intravitreal triamcinolone for refractory diabetic macular edema. Sixteen eyes with a macular thickness of at least 300 pm despite prior photocoagulation were treated with 4 mg injections of triamcinolone. At three-month follow-up the mean decrease in central retinal thickness was 57.5%, with a visual acuity increase of 2.4 Snellen lines. Those with six-month follow-up demonstrated some recurrence of edema and visual acuity improvement was reduced to 1.3 lines. 

Jonas JB, Sofker A. Intraocular injection of crystalline cortisone as adjunctive treatment of diabetic macular edema. Am J Ophthalmol 2001 132 425 -27. 

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