Laser treatment of diabetic macular edema,psychological first aid training red cross 5k,erectile dysfunction topical treatment definition,letter for financial help for education - 2016 Feature

I prefer treating and controlling the macular swelling first, before treating the neovascular disease (PDR).
When possible, I’ll treat the macular edema with focal and wait several weeks, or months, to treat with scatter laser. Avastin, however, has improved my ability to treat those patients with both macular and proliferative disease.
Diabetes is a disease that affects the ability of the body to produce or respond to insulin. Diabetic retinopathy, which damages the small blood vessels of the retina, is the leading cause of blindness among patients younger than 65. The risk of diabetic retinopathy, which causes leakage of the small blood vessels, increases with duration and control of blood sugar levels.
Diabetic retinopathy is a term used to describe the changes in the blood vessels of the retina.
Fluorescein angiography is a dye test often used to assess the damage to the retina and it's blood vessels from diabetes. These angiograms show areas of leakage, areas of oxygen-starved retinas, and weak, fragile new vessels.
The most important treatment for diabetes and its complications including diabetic retinopathy is control of the diabetes.
Laser treatment for diabetic macular edema stabilizes vision by stopping blood vessels from leaking fluid into the retina. Laser photocoagulation has been shown to reduce the risk of both moderate and severe permanent vision loss by 50-75%. In the less common proliferative diabetic retinopathy (PDR) new blood vessels grow onto the retina in response to need of nourishment and oxygen which is deprived by the diabetic process. Recently drugs known as vascular endothelial growth factor (VEGF) have been used to block the signal causing growth of abnormal retinal blood vessels which occurs in proliferative diabetic retinopathy (PDR), venous occlusion, wet age related macular degeneration and ocular histoplasmosis.
Octreotide (SandostatinTM) is another drug that may prove beneficial in the treatment of proliferative retinopathy; it is currently used to treat certain endocrine tumors by suppressing blood vessel growth. A non-prescription, fat-soluble form of Vitamin B1 (thiamine) that has been shown to prevent diabetic retinopathy in laboratory animals and is currently in human trials. While pan retinal photocoagulation is usually successful in halting the proliferative process, some patients progress despite laser treatment. The goal of any treatment, laser, steroid injections or anti-VEGF injections is to reduce the swelling. Usually, a fluorescein angiogram is performed to demonstrate where the normal retinal blood vessels are leaking. Treatment can involve anywhere from a few to dozens of burns…all depending upon the number leaks. Laser treatment to the center of the macula could lead to a permanent blind spot in the vision and, therefore, is not always the best treatment for every patient.
After 4-6 months, I can usually tell if the laser treatment is effective or needs to be augmented (ie.
There are a variety of treatments for diabetic macular edema.   Laser treatment is still the standard of care for treating this common condition seen with diabetic retinopathy. Diabetic retinopathy can not be cured, but we are often successful maintaining status quo…provided regular checkups occur.
After complete dilated exam, I was happy to report to him that he needed cataract surgery and, most importantly, there were no signs of diabetic macular edema nor active proliferative disease. I noted his weight was stable, hinting AB is very disciplined and, unlike me, has been able to control his weight over the years. My point is that the disease is not certain to cause blindness or even severe loss of vision and I wanted to share a good story of seeing well despite chronic disease…and a trusting friendship. Iluvien advances in the regulatory process for use in the treatment of diabetic macular edema in Europe. Alimera Sciences’s efforts for FDA approval of Iluvien in the United States were stymied in 2011 citing concerns over safety and requesting additional clinical trials. One of the more common symptoms of diabetic retinopathy is loss of vision due to swelling in the retina, more specifically, in the macula.  This is called Diabetic Macular Edema (DME). The macula gives us central vision.   When fluid accumulates within the macula, the vision worsens.



Alternative include intravitreal injections of steroid or anti-VEGF (such as Avastin or Lucentis). Iluvien, similar to its cousin Ozurdex (already FDA approved, but for the use of retinal vascular occlusions), is an injectable sustained release device that will release steroid for up to 36 months!  Iluvien has hopes of being the first sustained release delivery system for the treatment of diabetic retinopathy. Iluvien represents an emerging treatment for diabetic macular edema, a disease that clearly needs to be treated in a variety of ways.  Ophthalmologists are limited in our ability to treat these patients as not all patients with this sight threatening complication are candidates for laser treatment. While we may not see Iluvien available here in the US, perhaps its approval and use in another country will be enough for a company such as Alimera Sciences to sustain them as a business and allow them to continue their research and development of newer technologies. Iluvien was to be indicated for the treatment of diabetic macular edema, a very common complication of patients with diabetic retinopathy.  Typically, patients receive laser treatment as a first line treatment, but alternative treatments have been long needed as laser can not be performed in everyone. The sustained release device is injected into the eye and will release a steroid, fluocinolone, for up to 36 months.  Shorter acting steroid injections have demonstrated favorable results and it was anticipated that a sustained release system might offer a realistic benefit of better drug levels and little need for reinjection.
Moreover, Iluvien would have validated sustained release drug delivery systems.  Ozurdex was first and Iluvien would have been the second delivery system designed for injection into the vitreous. A second approved product, regardless of indication, would have been a significant endorsement for injectable sustained release systems.  Sustained release devices for macular degeneration (sustained release drug delivery of anti-VEGF), post-operative medications and glaucoma seem logical. Such safety and efficacy data were presented recently to the public at a large ophthalmic meeting in FL last month.  The company has also submitted this data to the FDA (Food and Drug Administration).
In short, the company performed two large clinical trials, the so-called FAME study showed that about 33% of patients  receiving the implant noted an improvement in vision.  Of significance is that this improvement, according to the company, was present after 3 years. Last year, the FDA also asked for a review of the manufacturing process of Iluvien, but I am not aware of any specific elements that were made public.  These, too, have been addressed. About a year ago, Alimera Sciences submitted the new drug application (NDA) for it’s proprietary intraocular drug delivery system for the treatment of diabetic macular edema (DME). Last December, the FDA failed to approve the NDA, but, instead requested more data about the efficacy (how well a drug works) of Iluvien.  This was provided this Spring.
If you remember, Ozurdex, the first sustained release intraocular drug delivery system was approved for treatment of retinal edema caused by retinal vascular diseases. It may be that a second such device may be shortly approved for the treatment of diabetic retinopathy.  While this further endorsed the sustained release technology, it will be a breakthrough that allows significantly more people to be helped that presently have few options. Treating diabetic retinopathy with both laser and anti-VEGF injections may be the best way to treat patients with diabetic macular edema. The results of a large, multicenter, randomized clinical trial compared several permutations of laser and the anti-VEGF drug, Lucentis.
To date, standard treatment, or the standard of care, includes treating the retina with laser photocoagulation to retard the loss of vision. This new study not only validates the use of anti-VEGF medications, but also hints that anti-VEGF may be superior to steroids.
Most importantly, however, the study describes a treatment regimen that leads to improvement, stabilization and reduction in the number of treatments!
As with it’s predecessors, Macugen and Lucentis, the company must prove to the FDA that the drug is effective and safe. Regeneron has also started Phase III clinical trials for VEGF-Trap for the treatment of diabetic macular edema.
Diabetic macular edema is the leading cause of decreased vision in patients with diabetes under the age of 50. On the other hand, using VEGF-Trap for the treatment of diabetic retinopathy will be the first drug to gain FDA approval. Diabetic macular edema (DME) is swelling in the retina caused by diabetic retinopathy.  More specifically, the swelling is located in the macula, the functional center of the retina.
Diabetes can be considered a disease of blood vessels, caused in some way by high sugar levels.  For reasons that are not completely known, the blood vessels in the retina start to leak, both blood and the fluid component of blood. Regardless, fear not, the treatment for the disease is quite successful in preventing further vision loss. The Food and Drug administration fails to approve Iluvien for the treatment of diabetic retinopathy and cites the need for more safety information in addition to concerns about the safety of the manufacturing process of Iluvien.   Alimera Sciences had hoped to gain approval by the end of December 2010, instead, it was told by the FDA that more information was needed. There were also concerns regarding the manufacturing, packaging and sterilization of Iluvien, though no specifics were noted.
Iluvien may be the second drug approved that is based on technology to offer sustained drug delivery into the eye.  Ozurdex, a similar product, has been in use since the summer of 2009 and is used for retinal vein occlusions. Had the product been rejected, or requests for additional clinical trials, this would have been a clearer signal of failure.


In the end, though disappointing, the company hopes to have a marketable product by the end of 2011.
When the retina becomes ischemic, it releases a protein called Vascular Endothelial Growth Factor (VEGF).  The vascular endothelial growth factor (VEGF) causes abnormal blood vessels (neovascularization) to develop on the surface of the retina and on other parts of the inside of the eye such as the optic nerve and iris.
Blindness may develop from massive proliferation of the neovascularization (aka abnormal blood vessels) causing either retinal detachment or, a rare type of painful glaucoma (neovascular glaucoma – NOT the regular glaucoma). So far, ischemia has caused vascular endothelial growth factor (VEGF) to be liberated.  The VEGF has caused neovascularization to develop.
If we laser the peripheral retina, the portion of the retina away from the macula, we can stop the production of VEGF in most cases and arrest the proliferative phase of the diabetic retinopathy. After 5 years, approximately one-quarter of patients with IDDM will demonstrate damage to the retinal blood vessels. There may be bleeding within the layers of the retina (hemorrhages); leakage of serum into the retina causing protein deposits in the retina called exudates.
Dilatation, is like opening the door of closet, so that we can see what is inside to properly evaluate the retina. Tight control of both blood sugar, weight and blood pressure control are important in preventing the ocular complications of diabetes and slowing the progression of the disease.
Either focal treatment for small discreet areas of leakage or a grid pattern is used when the leakage is diffuse in nature. Laser therapy is destructive by design; some retinal tissue is intentionally destroyed in order to preserve the function of other, more visually important areas of retina. Ruboxistaurin (ArxxantTM) is the first drug shown to prevent vision loss from macular edema in patients with moderate to severe non-proliferative diabetic retinopathy, it’s FDA approval remains in question. Genestein, a soy isoflavone that blocks VEGF receptors, has been shown to ameliorate retinal vascular permeability in diabetic animals and is currently available in an OTC eye supplement called Ocuvite DF. As a result, patients often experience a loss of peripheral vision, abnormal blind spots , and reduced ability to see at night . The most common type of diabetes is non-insulin-dependent diabetes mellitus (NIDDM) whereby control of blood sugar is with oral medications or diet. Pan-retinal laser photocoagulation for treatment proliferative diabetic retinopathy results in a loss of vision in approximtately 11% of treated patients.
The main indications for vitrectomy are persistent vitreous hemorrhage and tractional retinal detachment. Eventually, I operated to remove a vitreous hemorrhage resulting from his proliferative diabetic retinopathy.
Glaucoma, cataract, and corneal disease are more common in people with diabetes and contribute to the high rate of blindness. These abnormal neo-vascular vessels (new blood vessels) found in proliferative diabetic retinopathy are treated with pan retinal (scatter) laser photocoagulation or PRP. The other more severe type of diabetes is called insulin-dependent diabetes mellitus (IDDM); insulin injections are used to regulate blood sugar levels. In addition, high blood pressure or pregnancy increases the risk of retinopathy in diabetics. Laser surgery is used to treat both diabetic macular edema and proliferative diabetic retinopathy. Laser treatment is given to the peripheral retina which is not receiving an adequate blood supply. These statistics demonstrate the risk for diabetic patients; the need for regular eye check-ups and treatment,which will reduce the risk of blindness. It is believed that by treating the areas of retina deprived of normal vasculature, the reduction in demand for nutrients and oxygen by damaging retina will halt the development of new blood vessels. Frequently, the retina has to be reattached by surgically separating the scar tissue from the surface of the retina. In some cases, a gas bubble is left in the eye following surgery to keep the retina flat against the back of the eye.
Smaller bleeding episodes may clear up on their own but larger, repeated or bleeding lasting more than 6 mos.



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