Managing Diabetic Macular Edema: Pearls and Pitfalls
Targeted audience and level.
Retina specialists /comprehensive ophthalmologists
Medium and Advanced Level
Background: Diabetic macular edema (DME) is the leading cause of legal blindness in diabetic patients, occurring at any stage of diabetic retinopathy, although more likely as the disease progresses. DME can be asymptomatic until severe and irreversible visual loss is present. Therefore its early diagnosis (with proper imaging modalities) is fundamental to obtain a better identification of different DME phenotypes, which need a tailored treatment in order to obtain the best functional result.
Precise outline: This course will cover, clinically relevant aspects of DME, from main biochemical mechanisms involved in its multifactorial pathogenesis to the most appropriate clinical assessment and choice of treatment. Moreover, screening challenges and margins of improvement delivered around the world, will be also discussed.
Course Objectives: At the conclusion of this course the attendees will be able to critically manage and treat patients with DME.
Diabetic macular edema (DME) is the leading cause of impaired visual acuity in patients affected by diabetes mellitus (DM). The pathophysiology of DME involves many interconnected pathways with specific contributions, thus determining different DME phenotypes. Diabetic retinopathy (DR), together with DME, is not only a vascular, but also a neuroinflammatory disease. Slit-lamp biomicroscopy, fluorescein angiography (FA), optical coherence tomography (OCT), fundus autofluorescence (FAF), microperimetry (MP) and retromode scanning laser ophthalmoscope (RM-SLO), have all been used for diagnosis and follow-up of DME and also for better identifying different DME characteristics and phenotypes.
In particular the use of non-invasive imaging modalities has significantly increased lately. Spectral Domain (SD-OCT) has been recently used for the evaluation: of intraretinal hyperreflective spots (foci/dots), choroidal thickness, reflectivity of intra/subretinal fluid and outer retina integrity. Even though laser photocoagulation has still an important role in the treatment of DME, intravitreal treatments, in particular anti-vascular endothelial growth factor (anti-VEGF) drugs and steroids, have been established as the first-line treatment in center-involving DME. Knowledge of ocular and systemic safety of these drugs, is fundamental in choosing the right treatment for each patient. Moreover, the panelists will try to give an algorithm for treatment, and especially how to identify responders vs non-rsponders as well as suggestions on what to do in non-responder DME patients.
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Title:: Optimising Injection Clinics
Course Director: Martin Zinkernagel, MD, PhD
Targeted audience and level
Retina specialists: Intermediate to advanced Level
Background: Service providers specializing in intravitreal treatment of macular diseases dif-fer in their structure, size, and patient population. In addition differing healthcare systems with varying reimbursment schemes lead to a myriad of different approaches to organize in-jection clinics.
Precise outline: This course will provide retina specialists with a comprehensive overview of clinical practices and organization of intravitreal injection clinics. The aim is to bring together retina specialists from different countries and clinical settings to report on the difficulties and advantages of their system they are confronted with during injection clinics.
Objectives: The following outcomes will be discussed in detail:
- Administration of injection clinics; different countries different models
- Management of patient flow with different treatment regimens
- Choice of intravitreal agent to optimize injection clinics
- Advantages and disadvantages of separating patients under treatment with intravitreal agents from regular outpatients
- The role of non-consultant staff (nurse practitioners and optometrists) to maintain monthly follow-up of patients
- The role of medical records to monitor outcomes and the advantages or disadvantages of electronical devices to optimize injection clinics
Outline: Given the increase of patient numbers receiving intravitreal injections for various macular diseases, pressures on clinical capacity in injection clinics are likely to increase in the next decade. Usually the number of follow up appointments is the main bottle neck during in-jections clinics. Compromises in follow up appointment intervals may have negative effects on long term maintenance of visual acuity gain as close monitoring of the majority of patients is necessary. Whereas the indication for intravitreal treatment are fairly uniform throughout the world, differing healthcare systems, reimbursement schemes and staff resources have a profound impact on how injection clinics are run. The aim of this course is to teach fellow retinologists about the disadvantages and advantages of individual injection clinic systems. At the end of each presentation the audience will have the opportunity to discuss specific points.
Special consideration will be given to clinical premises and spatial organisation of injection clinics and injection procedures. Here the advantages and disadvantages of one-stop versus a two-stop model and the challenges of organizing a rapid access clinic for intravitreal injections will be taught to the attendees. Furthermore issues considering staffing such as the role of non-consultant staff in administrating injection clinics but also in the (re-)treatment decision making process, preparation of patient and injection process itself will be discussed and disadvantages and advantages of each system will be debated.
Furthermore, equipment consideration such as availability of several OCTs or fluorescein an-giographs will be discussed as well as which follow up examination should be done in what intervals during injection clinic follow ups, such as visual acuity/OCT/IOP measure-ments/fluorescein angiography. Advantages or disadvantages of separation of different macu-lar diseases (AMD, RVO, DME) in regards to follow up examination will be discussed with the attendees. In addition, the advantages and disadvantages of using different visual acuity readouts such as ETDRS or snellen will be discussed.
The role of patient education in optimizing follow up compliance and work flow during injec-tion clinics will be shown. The influence of different treatment regimens on clinic capacity will be discussed. Here, special consideration will be given to fixed, PRN or treat and extend regimens with detailed discussion about the benefits of these regimens in regards to organiz-ing injection clinics, patient compliance and optimizing Cost: s.
Taken together, at the conclusion of this course the attendee will have gained a insight into how injection clinics can be organized and optimized.
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Title:: Autologous choroidal transplantation in AMD: toward the RPE-transplantation era
Abstract: The Submacular Surgery Trials (SST) study demonstrated that sole removal of choroidal neovascularization (CNV) and/or blood did not significantly improve or stabilize the visual function. The damage of submacular retinal pigment epithelium (RPE) during surgery was considered to play a key role in the lack of visual improvement.
From then on, different techniques have been studied to replace the diseased RPE, ranging from transplantation of stem cells derived RPE cells to full thickness choroidal grafts.
Transplantation of an autologous RPE-choroid graft as described by Peyman et al and van Meurs et al, is a surgery in which healthy RPE and choroid are harvested from the midperiphery and inserted under the macula through a parafoveal retinotomy after CNV removal. Postoperative fixation and retinal sensitivity in the area of the patch have been demonstrated. In certain patients an RPE-choroid graft is able to improve visual function and improvement can be maintained in the long term. Overall long-term results, however, are rather modest with a relatively high risk of proliferative vitreoretinopathy (PVR) of 10%.
In a variation of the surgery described by van Meurs et al, a large peripheral retinotomy at the ora serrata can be performed. Using this technique, the surgeon has a better accessibility of the subretinal space and there is less manipulation of the parafoveal retina and the graft. For these reasons, his technique has the potential to improve the outcome.
One of the most frequent observed complications is the development of atrophic changes of the transplanted RPE. The study of the evolution of the disease can shed some light on the pathogenesis of the atrophy in AMD and anticipate what we can expect, for example, after stem cells derived RPE transplantation.
Title:: Fluorescein, ICG and OCT-angiography in macular diseases – interpretation and comparison with other imaging modalities
Course Leader: D. Pauleikhoff, G. Staurenghi
Audience Level: Retina specialists/Comprehensive ophthalmologists/ Beginner / Intermediate / Advanced
Didactic presentations with scheduled questions and answers managed by the course director
Abstract and outline
Course Description: The course will present the role of fluorescein and ICG but new also OCT - angiography as diagnostic tools in different macular diseases. The concept is to demonstrate its general potential in respect to and combination with other diagnostic tools (p.e. SD-OCT, autofluorescence) and to describe specific diagnostic strategies including these diagnostic tools in defined macular dieseases (AMD, MacTel type 2, inherited macular degeneration)
To demonstrate the general potential of Fluorescein, ICG and OCT-angiography and to describe specific diagnostic strategies including these diagnostic tools in defined macular dieseases.
An overview about Fluorescein, ICG and OCT-angiography and its place in the multimodal diagnostic sttategies of macular dieseases
Participants will have a better understanding of the role of Fluorescein, ICG and OCT-angiography in the multimodal diagnostic sttategies of macular dieseases