Treatment of retinopathy in diabetic zucchini,the role of education in diabetes mellitus type 2 management,type 2 diabetes eye problems 5th,diab?te de type 2 d?finition vulgaris 9ch - .


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.
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.
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.
The treatment for diabetic macular edema has changed.  The gold-standard for treatment of diabetic macular edema has long been laser treatment, but several types of injections have become approved.
Laser treatment works less well when there is diffuse thickening, but without obvious focal areas of leakage.  Laser treatment can not be performed when the areas requiring treatment are located in the central macula. Intraocular steroids, such as Kenalog, have been injected into the vitreous to help control diabetic macular edema. Ozurdex, a sustained release steroid delivery system, has also been FDA approved for the treatment of diabetic macular edema in those who have had cataract surgery or are planning to have cataract surgery.
The device is delivered into the vitreous as an injection and steroid is released into the eye for about 4 months. With the approval of these newer products, laser treatment is no longer the gold standard for treating macular edema from diabetes. There still is a role for each treatment modality.  No single treatment seems to be better than another.  It has become customary, at least in my practice, to usually combine treatments for the best outcomes!
Despite the array of treatments, it is still prudent to get early and regular dilated eye exams to limit the development of DME.
What is Diabetic Nephropathy?Diabetic nephropathy (''nephropatia diabetica''), also known as Kimmelstiel-Wilson syndrome and intercapillary glomerulonephritis, is a progressive kidney disease caused by angiopathy of capillaries in the kidney glomeruli. The DCCT was the pivotal trial that provided the link between A1C levels and the risk of diabetes-associated complications. The United Kingdom Prospective Diabetes Study (UKPDS) was a large-scale trial that investigated the effect of intensive blood glucose control versus conventional treatment in patients with type 2 diabetes, with a median follow-up of 10 years. Therefore, any improvement in A1C levels is likely to reduce the risk of diabetic complications.
Consistent high blood sugar level for a prolonged period damages almost every vital organ of the body.
Decreased sensation or numbness in the legs and feet is a common symptom of uncontrolled diabetes.
This condition known as peripheral diabetic neuropathy causes tingling, burning or stabbing pain and reduces sensation in the extremities. Nausea, vomiting, acid reflux, bloating, stomach pain and poor appetite are common digestive symptoms of uncontrolled diabetes.
These symptoms appear when the vagus nerve is damaged by diabetes causing gastroparesis, a digestive disorder characterized by delayed stomach emptying. Overactive bladder, urine leakage and urine retention are common urologic symptoms of uncontrolled diabetes. Uncontrolled diabetes damages the nerves and the blood vessels in the genitals, hindering proper sexual functions.
When diabetes persists for a prolonged period, you may experience dizziness, especially while standing up. Inability to maintain the blood pressure level while changing the posture is responsible for this condition. Excess sugar in the blood weakens the immune system and impairs the wound healing process, thereby slowing down healing of wounds.
A medical term ending in “itis” means that we are dealing with an inflammation, in this case an inflammation of the eye, and to be more specific the iris and connected tissue called the uvea. The iris is the part of the eye that surrounds the cornea and gives us the colour that makes our eyes different from one another, and contains the pupil at its centre, regulating the amount of light coming in. Anterior meaning “at the front” this category of inflammation is right at the iris itself, and makes up the most common of the three, up to 90% of the total, so much that it’s given its own name – Iritis. The renaming of the most common Uveitis as Iritis has led the medical fraternity to interchange the term frequently when diagnosing and treating, since they are of essentially the same thing. Anterior Uveitis can be further sub-divided into two groups according to the period of treatment required – a few weeks or a few months, a chronic condition. Dr Jim Kokkinakis (Optometrist) graduated in 1983 from the Optometry School University of NSW.
He has a specialist clinical practice in the Sydney CBD with interests in Eye Strain, Computer Vision problems, Treatment of Eye Diseases and complex Contact lens Fittings.
The results of the Diabetes Control and Complications Trial (DCCT) shown below are considered definitive for patients with type 1 diabetes.
This observational analysis of data from the UKPDS demonstrated a direct relationship between the risk of diabetic complications and glycemia over time.


National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2002. However, when a diabetic fails to get adequate treatment or ignores the condition for a long time, the blood sugar level rises to abnormally high levels. Exposure to excess glucose circulating in the blood affects the functioning of the heart, kidneys, eyes, nerves and gums. Decreased sensation in the legs may even occur when the large blood vessels in the legs are damaged by diabetes. In men, erectile dysfunction and retrograde ejaculation are frequently associated with diabetes. Damage to the blood vessels and nerves that control the heart function causes postural dizziness.
Relative risk increased with A1C for retinopathy, nephropathy, and microalbuminuria, and the risk of retinopathy and nephropathy accelerated at the highest levels of A1C.
Each 1% absolute reduction in mean A1C levels was associated with a 37% decrease in the risk of microvascular complications and a 21% reduction in the risk of any diabetes-related complication or death.
Poorly controlled diabetes or uncontrolled diabetes is associated with a number of serious health complications. If you cannot keep your blood sugar level under control, the excess sugar circulating in the blood for a prolonged period damages the nerves in the hands and feet. Appearance of dark spots or empty areas in the vision and loss of eyesight occurs when the blood sugar levels remain higher than normal for several years. Diabetic women may experience vaginal dryness, painful sexual intercourse and poor sexual response. Eventually, I operated to remove a vitreous hemorrhage resulting from his proliferative diabetic retinopathy. The disease is progressive and may cause death two or three years after the initial lesions, and is more frequent in men. In this study, improved glycemic control following intensive diabetes therapy delayed the onset and slowed the progression of diabetic retinopathy, nephropathy and neuropathy in patients with type 1 diabetes.
Diabetic nephropathy is the most common cause of chronic kidney failure and end-stage kidney disease in the United States. Further, once nephropathy develops, the greatest rate of progression is seen in patients with poor control of their blood pressure. Also people with high cholesterol level in their blood have much more risk than others.The earliest detectable change in the course of diabetic nephropathy is a thickening in the glomerulus. At this stage, the kidney may start allowing more serum albumin (plasma protein) than normal in the urine (albuminuria), and this can be detected by sensitive medical tests for albumin.
As diabetic nephropathy progresses, increasing numbers of glomeruli are destroyed by nodular glomerulosclerosis. Now the amounts of albumin being excreted in the urine increases, and may be detected by ordinary urinalysis techniques. At this stage, a kidney biopsy clearly shows diabetic nephropathy.Diabetic nephropathy continues to get gradually worse. Complications of chronic kidney failure are more likely to occur earlier, and progress more rapidly, when it is caused by diabetes than other causes. The main treatment, once proteinuria is established, is ACE inhibitor drugs, which usually reduces proteinuria levels and slows the progression of diabetic nephropathy. Several effects of the ACEIs that may contribute to renal protection have been related to the association of rise in Kinins which is also responsible for some of the side effects associated with ACEIs therapy such as dry cough. The renal protection effect is related to the antihypertensive effects in normal and hypertensive patients, renal vasodilatation resulting in increased renal blood flow and dilatation of the efferent arterioles. Many studies have shown that related drugs, angiotensin receptor blockers (ARBs), have a similar benefit. However, combination therapy, according to the ONTARGET study, is known to worsen major renal outcomes, such as increasing serum creatinine and causing a greater decline in estimated glomerular filtration rate (eGFR).Blood-glucose levels should be closely monitored and controlled. As kidney failure progresses, less insulin is excreted, so smaller doses may be needed to control glucose levels.Diet may be modified to help control blood-sugar levels.
Modification of protein intake can effect hemodynamic and nonhemodynamic injury.High blood pressure should be aggressively treated with antihypertensive medications, in order to reduce the risks of kidney, eye, and blood vessel damage in the body.
Urinary tract and other infections are common and can be treated with appropriate antibiotics.Dialysis may be necessary once end-stage renal disease develops.
These include, but are not limited to, bardoxolone methyl, olmesartan medoxomil, sulodexide, and avosentan This article is licensed under the Creative Commons Attribution-ShareAlike License.
There is an increase in blood pressure (hypertension) and fluid retention in the body plus a reduced plasma oncotic pressure causes oedema. Other complications may be arteriosclerosis of the renal artery and proteinuria.Throughout its early course, diabetic nephropathy has no symptoms. Most often, the diagnosis is suspected when a routine urinalysis of a person with diabetes shows too much protein in the urine (proteinuria). The urinalysis may also show glucose in the urine, especially if blood glucose is poorly controlled. Serum creatinine and BUN may increase as kidney damage progresses.A kidney biopsy confirms the diagnosis, although it is not always necessary if the case is straightforward, with a documented progression of proteinuria over time and presence of diabetic retinopathy on examination of the retina of the eyes.



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