Results are generally satisfactory, though injections may need to be repeated Among NSAIDs, ketorolac tromethamine has proved effective in treating chronic CME 42 , in a literature review 5 and in double-blind placebo-controlled trials 43 , This drug has also proved effective in treating acute CME There is not enough evidence about subclinical CME treatment, that is, without loss of visual acuity 5.
Diclofenac results were comparable to ketorolac in reducing the duration and severity of acute cystoid edema There are also reports showing nepafenac effectiveness in CME treatment, both acute and chronic 16 , despite the fact that there are no comparative studies to other drugs specifically regarding CME The duration of topical treatment is still disputed, and it is usually prescribed from 4 to 12 weeks 5 , However, treatment effectiveness is questioned in treatments less than one month long Relapses may occur when treatment is suspended Antiantiogenic agents are becoming more popular, with several new indications.
One such application is the treatment of chronic CME, aiming to reduce vascular permeability caused by the inflammatory process. Results were favorable, with at least partial recovery of visual acuity and decrease in macular thickness 47 - The use of systemic carbonic anhydrase inhibitors acetazolamide has been suggested, and good results were documented 17 , 51 , despite known systemic side effects A possible alternative is the use of topical carbonic anhydrase inhibitors, suggested for treating edema in several other retina diseases 52 , but not yet studied.
Intravitreal octreotide has been used in slow release formulation 34 for patients with chronic CME. It is difficult to compare chronic edema treatments, since beyond the low incidence of the edema itself, only a small portion of patients do not respond to the usual treatments with corticosteroids and topical nonhormonal anti-inflammatory drugs Several other treatments have been suggested as alternatives in case of resistance to drug-based treatment, but there are only reports of series of cases with no control groups.
Laser grid treatment 53 , 54 , intravitreal pegaptanib 49, 55 and intravitreal infliximab 56 are examples of treatments that have been attempted with some benefit. Vitreous implication in the edema pathogenesis is disputed, but in selected cases its removal by vitrectomy may be an effective alternative 7 , 20 , 41 , In summary, treatment should be applied when there is loss of visual acuity, and evidences point to a combination of corticosteroids and topical nonsteroidal anti-inflammatory drugs as the most effective way to solve the edema 33 , maintaining the NSAID for a long period.
In chronic cases and those unresponsive to usual treatment, intravitreal corticosteroid injections or antiantiogenic agents have proved useful in a significant number of reports. Pseudophakic cystoid macular edema. Curr Opin Ophthalmol. The incidence, pathogenesis and treatment of cystoid macular edema following cataract surgery.
Trans Am Ophthalmol Soc. Incidence of cystoid macular edema after cataract surgery in patients with and without uveitis using optical coherence tomography. Am J Ophthalmol. Evaluation of macular changes after uncomplicated phacoemulsification surgery by optical coherence tomography. Curr Eye Res. Clinical pseudophakic cystoid macular edema. Risk factors for development and duration after treatment.
J Cataract Refract Surg. Int Ophtalmol Clin. Cystoid macular edema after pars plana vitrectomy for retained lens fragments. Macular edema after cataract surgery in eyes without preoperative central-involved diabetic macular edema. JAMA Ophthalmol. Progression of diabetic retinopathy and maculopathy after phacoemulsification surgery. Int Ophtahlmol Clin. Phacoemulsification with intraocular lens implantation in patients with uveitis.
Bloodaqueous barrier changes after the use of prostaglandin analogues in patients with pseudophakia and aphakia: a 6-month randomized trial. Arch Ophtahlmol. Evaluation of cystoid macular edema using optical coherence tomography and fundus fluorescein angiography after uncomplicated phacoemulsification surgery. Retinal thickness assessed by optical coherence tomography OCT in pseudophakic macular edema.
Arq Bras Oftalmol. Correlation between morphologic features on spectral-domain optical coherence tomography and angiographic leakage patterns in macular edema. Medical prophylaxis and treatment of cystoid macular edema after cataract surgery. The results of a meta-analysis. Cystoid and diabetic macular edema treated with nepafenac 0. J Ocul Pharmacol Ther. Ophthalmologica Journal international d'ophtalmologie. Int J Ophthalmol. Aqueous flare is increased in patients with clinically significant cystoid macular oedema after cataract surgery.
Br J Ophthalmol.
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A method of reporting macular edema after cataract surgery using optical coherence tomography. Cystoid macular edema following cataract surgery. Prophylactic nepafenac and ketorolac versus placebo in preventing postoperative macular edema after uneventful phacoemulsification.
A randomized, masked comparison of topical ketorolac 0. Macular alterations after small-incision cataract surgery. Analysis of macular edema after cataract surgery in patients with diabetes using optical coherence tomography. Effect of prophylactic nonsteroidal antiinflammatory drugs on cystoid macular edema assessed using optical coherence tomography quantification of total macular volume after cataract surgery.
Cystoid macular edema in a pseudophakic patient after switching from latanoprost to BAK-free travoprost. Clinical cystoid macular edema after cataract surgery in glaucoma patients. J Glaucoma. Glaucoma as a possible risk factor for the development of pseudophakic cystoid macular edema. Curr Med Res Opin.
Incidence of visually significant pseudophakic macular edema after uneventful phacoemulsification in patients treated with nepafenac. Impact of nepafenac 0. Invest Ophthalmol Vis Sci. Ketorolac versus prednisolone versus combination therapy in the treatment of acute pseudophakic cystoid macular edema. A randomized, double-masked controlled clinical trial of Sandostatin long-acting release depot in patients with postsurgical cystoid macular edema. Nonsteroidal anti-inflammatory agents in cataract intraocular lens surgery.
Chronic macular edema medical treatment in Irvine-Gass syndrome: case report. Eur J Ophthalmol. Cystoid macular edema after complicated cataract surgery resolved by an intravitreal dexamethasone 0. Case Rep Ophthalmol. Longstanding refractory pseudophakic cystoid macular edema resolved using intravitreal 0. Clin Ophthalmol. Intraocular triamcinolone acetonide for pseudophakic cystoid macular edema: optical coherence tomography and multifocal electroretinography study. Intravitreal triamcinolone acetonide for the treatment of chronic pseudophakic cystoid macular oedema.
Acta Ophthalmol Scand. Intravitreal triamcinolone acetonide versus pars plana vitrectomy for pseudophakic cystoid macular edema. Ketorolac treatment of pseudophakic cystoid macular edema identified more than 24 months after cataract extraction. Effectiveness of ketorolac tromethamine 0. Improvement in visual acuity in chronic aphakic and pseudophakic cystoid macular edema after treatment with topical 0. Treatment of acute pseudophakic cystoid macular edema: Diclofenac versus ketorolac.
Ketorolac tromethamine LS 0. Prospective randomized double-masked clinical trial. Intravitreal bevacizumab for refractory pseudophakic cystoid macular edema: the Pan-American Collaborative Retina Study Group results. Arch Soc Esp Oftalmol. Intravitreal pegaptanib sodium for refractory pseudophakic macular oedema. Eye Lond. Intravitreal ranibizumab for the treatment of cystoid macular edema in Irvine-Gass syndrome. In diabetes management, commitment of patients can deteriorate over time.
People generally are more willing to consider behavioural change at the time of diabetes diagnosis. But enthusiasm typically wanes, with condition fatigue emerging with therapy escalation. Poor glucose control is often explained by clinical inertia, which limits or delays intensification of treatment when needed in the management of diabetes. Diabetic retinopathy and DMO are the two major retinal complications that account for most diabetes-related vision loss. For optimal clinical care of patients with visual impairment due to DMO, several practice-based principles merit consideration in NHS ophthalmic service provision and care pathway redesign.
Foster closer working relationships between diabetes management, general practitioners, and ophthalmology specialties. Closer clinical collaboration between diabetology, primary care, and ophthalmology services may enhance patient experience. Much of the clinical focus in diabetes management is to limit the burden of diabetes-related complications.
A structured approach to education concerning health behaviours and health promotion is beneficial and higher uptake should be encouraged. Multiple risk factor intervention is required to reduce disease burden and improve clinical outcomes, generating value at the individual, clinical and health system level. The diabetes management team should be aware of the main prognostic factors for increased risk of development and progression of sight-threatening DMO.
This would enable the diabetes care team to identify high-risk patients at an early stage, for example, obesity, sleep apnoea, and elevated risk of progression of DR. Consider the benefits of establishing a dedicated clinic service for the management and follow-up of patients with DMO. More time during consultation is needed for patients, to educate them about their diagnosis, treatment, outcomes, and diabetes control. Dedicated service provision for DMO would also facilitate integration of a DSN-led review service thus enhancing efficiency of diabetes care.
The English Diabetic Retinopathy Screening Programme and guidance on retinal screening from the Royal College of Ophthalmologists have for a long time recommended dedicated assessment clinics in the NHS Hospital Eye Service for people with diabetic eye disease referred for ophthalmologist review. Multidisciplinary working and engagement with other healthcare professionals working with diabetes patients;. While many centres choose to treat all eligible patients with retinal disease during a combined medical retina injection treatment service for example, other clinical centres prefer to maintain separate assessment and injection clinics for patients with DMO.
Protocols for assessment and monitoring, as well as the recommended treatment posology with intravitreal anti-VEGF therapy, vary for different retinal disease entities. Specialist input from a diabetes expert is required when dealing with DMO patients coping with established diabetes-related complications and who may be at risk of mild or moderate vision impairment and of other later macrovascular complications because of poor metabolic control.
Diabetes experts urge ophthalmologists to make better use of the specialist diabetes services available. Commissioners investing in local services should also support expansion and strengthen DSN recruitment so they may logistically be in a position to provide further coverage within hospital eye departments. Tailor clinical practice and follow-up initiatives to improve treatment adherence in DMO.
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A wide range of appointment times should be available for patients with diabetes. Afternoon, evening or weekend appointments for working diabetic patients are often preferred, with experience suggesting only minor non-attendance rates for evening DMO clinics. Messaging beyond letter notification could be considered to reinforce the importance of a scheduled clinic appointment, for instance with follow-up text messaging. Text messaging can be quite effective for younger adults for example.
For DR screening programmes, the regular non-attenders need to be vigorously chased. Set realistic patient expectations when initiating treatment of DMO. Adequate support should be provided to ensure that patients understand the treatment they are being given and why that particular treatment is right for them, the treatment response they might expect, the most common side effects and the options that might be available if the initial treatment does not work well or does not suit them.
Where the treatment choice for DMO is intravitreal ant-VEGF therapy, patients should understand the goal of treatment, the need for regular repeat therapy, the treatment plan including follow-up regimen and be aware also that the frequency of injections may diminish after the first year of treatment.
Inadequate or delayed treatment may result in irreversible vision loss. The potential need for additional or substitute treatments should be discussed at the outset as there may be some cases of refractory macular oedema. Patients are reminded of the need to be proactive in optimising control of modifiable systemic risk factors. Several online sources of patient information and resources are outlined in Table 7. Perform a regular audit of practice outcomes and benchmark performance, preferably using an electronic medical record EMR system.
Audit and benchmark the key performance indicators of efficacy, safety, and treatment burden in the management and treatment of DMO. Development of a nationally agreed DMO outcome data set for EMR reporting will facilitate national audit data collection and shared learning. Best practice models illustrate progress in strengthening service capacity and referral refinement of DR, including the use of OCT imaging as a second-line surveillance tool for evaluating referrals of screen-positive maculopathy.
Illustrative examples include:. Refinement of screening referrals. Evening technician-led imaging clinics. Evening technician-led OCT imaging clinics for DMO patients being treated with intravitreal anti-VEGF therapy have been introduced successfully within ophthalmology departments, uplifting capacity and allowing high-speed decision-making based on ophthalmologist review of acquired OCT scans. This frees up additional time for direct ophthalmologist review of more complex cases and for patient cases that may benefit from a treatment switch.
DSN-led reviews of initial referrals of background DR or diabetic maculopathy after brief medical history and fundoscopy carried out by the eye clinic ophthalmologist, covering key baseline diabetes investigations and onward referral to the eye care service or discharge to primary care diabetes care. Virtual review clinics utilising OCT imaging combined with fundus photography. For patients with established DMO on regular intravitreal treatment and follow-up, a virtual OCT review clinic allows for separate assessment and grading of OCT images and fundus photographs by trained hospital technicians and nurses.
Patients with stable disease are taken out of the existing DMO clinic service, releasing additional front-line treatment capacity. Greater collaboration between eye health professionals and general practitioners, practice nurses and community-based diabetes care providers is recommended in order to ensure better coordinated follow-up and timely assessment of diabetes patients with related eye disease. Broader utilisation of and access to community-based diabetes care regimens can be expected to improve standards of patient care, and contribute to greater awareness of the need for improved glycaemic control to reduce diabetes-related complications and morbidity.
Evidence from randomised controlled trials supports treatment of proliferative DR and DMO to prevent progressive vision loss and imaging plays a valuable role in surveillance. Consider the benefits of establishing a dedicated DMO eye clinic service for management and follow-up of patients with diabetic eye disease, for example, facilitate integration of a DSN-led review service and enhance efficiency of diabetes care. Perform a regular audit of practice outcomes and benchmark performance, preferably using an EMR system.
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Pseudophakic Cystoid Macular Edema
Is it a risk factor for diabetic retinopathy? J Fr Ophtalmol ; 39 2 : — Retinal imaging techniques for diabetic retinopathy screening. J Diabetes Sci Technol ; 10 2 : — Assessing the effect of personalized diabetes risk assessments during ophthalmologic visits on glycaemic control: a randomized clinical trial. JAMA Ophthalmol ; 8 : — Download references. This publication and the expert advisory group meeting on which the paper is based were sponsored by Bayer. An expert clinical advisory group named Action on DMO met on 2 September in London to explore and discuss multidisciplinary practice initiatives and developments in the management of diabetic eye disease.
A meeting report was subsequently prepared, which formed the basis of the final approved manuscript. Development of this publication was sponsored by Bayer UK plc. All authors except J Napier received honoraria and all authors contributed to the development and finalisation of the manuscript and retained full control of the editorial content. Bayer checked that the content was factually accurate, balanced and compliant with the Association of the British Pharmaceutical Industry Code of Practice.
The views expressed are those of the author s and are not necessarily those of Bayer or the NHS. PHS: Consulting fees or speaking honoraria from Bayer; Allergan paid advisory board; educational grant support from Bayer to his employer. Correspondence to R Gale. This work is licensed under a Creative Commons Attribution 4. Article metrics. Advanced search. Skip to main content. Subjects Diabetes complications Eye diseases Health services Oedema. Abstract This paper identifies best practice recommendations for managing diabetes and sight-threatening diabetic eye disease.
Diabetes is an escalating global health challenge The World Health Organization WHO estimates that the global age-standardised adult prevalence of diabetes has nearly doubled since , rising from a prevalence rate of 4. Table 2: Estimates of diabetes prevalence in the United Kingdom a Full size table. Figure 1 Expected diabetes prevalence diagnosed and undiagnosed for England in by gender, ethnicity, and age group. Full size image. Table 3: Recommended approach to the management of hyperglycaemia in patients with type 2 diabetes: modulation of the intensiveness of glucose lowering based on patient and disease features, a broad construct to guide clinical decision-making a Full size table.
Table 5: Criteria utilising spectral domain optical coherence tomography OCT as an adjunct to colour fundus photography in diabetic eye screening surveillance clinic Full size table. Figure 4 Characteristic psychological profiles of diabetes patients, covering attitudes to diabetes and its treatment.