eMedicine Specialties > Ophthalmology > Retina

Macular Edema, Diabetic: Differential Diagnoses & Workup

Author: Emmanouil Mavrikakis, MD, PhD, Consultant Vitreoretinal Surgeon, Ophthalmology Department, Athens Medical Centre, Greece
Coauthor(s): Wai-Ching Lam, MD, FRCS(C), Associate Professor, Department of Ophthalmology and Vision Sciences, University of Toronto; Baseer U Khan, MD, Staff Physician, Department of Ophthalmology, University of Toronto, Canada
Contributor Information and Disclosures

Updated: Sep 29, 2009

Differential Diagnoses

ARMD, Exudative
Branch Retinal Vein Occlusion
Central Retinal Vein Occlusion
Hypertension
Macular Edema, Irvine-Gass
Uveitis, Evaluation and Treatment

Other Problems to Be Considered

Cystoid macular edema
Hypotonic retinopathy
Macular pucker
Epinephrine use in aphakia

Workup

Imaging Studies

  • Fluorescein angiography
    • Fluorescein angiography is not relevant in aiding in the diagnosis of CSME but should be performed if treatment of CSME is being considered.
    • Fluorescein angiography distinguishes and localizes areas of focal versus diffuse leakage, thereby guiding the placement of laser photocoagulation.
    • The proximity of the leakage to the foveal avascular zone should be noted.
  • Color stereo fundus photographs provide an opportunity to evaluate long-term changes in the retina.
  • Optical coherence tomography
    • Optical coherence tomography (OCT) captures reflected light from retinal structures to create a cross-sectional image of the retina, which is comparable to histologic sections as seen with a light microscope.
    • It has been able to demonstrate a moderate correlation between retinal thickness and best-corrected visual acuity, and it has been able to demonstrate 3 basic structural changes of the retina from diabetic macular edema (DME), that is, retinal swelling, cystoid edema, and serous retinal detachment.
    • OCT is not currently required to establish a diagnosis and is not prescribed by current practice guideline; however, OCT has gained widespread acceptance as an additional modality to help identify and evaluate macular pathology.4
    • Quantitative measurement of macular thickness and subjective analysis of the foveal architecture allow a precise and reproducible way to monitor macular edema.

Histologic Findings

One study has demonstrated vascular endothelial growth factor (VEGF) to be strongly positive in cells and extracellular matrix taken from retinas exhibiting diabetic retinopathy and diabetic macular edema.

Staging

See Physical for the differentiation between clinically significant and nonclinically significant diabetic macular edema.

More on Macular Edema, Diabetic

Overview: Macular Edema, Diabetic
Differential Diagnoses & Workup: Macular Edema, Diabetic
Treatment & Medication: Macular Edema, Diabetic
Follow-up: Macular Edema, Diabetic
References
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References

  1. Early Treatment Diabetic Retinopathy Study Research Group. Treatment techniques and clinical guidelines for photocoagulation of diabetic macular edema. Early Treatment Diabetic Retinopathy Study Report Number 2. Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology. Jul 1987;94(7):761-74. [Medline].

  2. Albert DM, Jakobiec FA. Principles and Practice of Ophthalmology. 2nd ed. Philadelphia: WB Saunders Co; 2000.

  3. Aiello LP, Avery RL, Arrigg PG, et al. Vascular endothelial growth factor in ocular fluid of patients with diabetic retinopathy and other retinal disorders. N Engl J Med. Dec 1 1994;331(22):1480-7. [Medline].

  4. Otani T, Kishi S, Maruyama Y. Patterns of diabetic macular edema with optical coherence tomography. Am J Ophthalmol. Jun 1999;127(6):688-93. [Medline].

  5. Chew EY, Klein ML, Ferris FL 3rd, et al. Association of elevated serum lipid levels with retinal hard exudate in diabetic retinopathy. Early Treatment Diabetic Retinopathy Study (ETDRS) Report 22. Arch Ophthalmol. Sep 1996;114(9):1079-84. [Medline].

  6. Bonini-Filho MA, Jorge R, Barbosa JC, Calucci D, Cardillo JA, Costa RA. Intravitreal injection versus sub-Tenon's infusion of triamcinolone acetonide for refractory diabetic macular edema: a randomized clinical trial. Invest Ophthalmol Vis Sci. Oct 2005;46(10):3845-9. [Medline].

  7. Jonas JB, Martus P, Degenring RF, Kreissig I, Akkoyun I. Predictive factors for visual acuity after intravitreal triamcinolone treatment for diabetic macular edema. Arch Ophthalmol. Oct 2005;123(10):1338-43. [Medline].

  8. Patelli F, Fasolino G, Radice P, et al. Time course of changes in retinal thickness and visual acuity after intravitreal triamcinolone acetonide for diffuse diabetic macular edema with and without previous macular laser treatment. Retina. Oct-Nov 2005;25(7):840-5. [Medline].

  9. Avitabile T, Longo A, Reibaldi A. Intravitreal triamcinolone compared with macular laser grid photocoagulation for the treatment of cystoid macular edema. Am J Ophthalmol. Oct 2005;140(4):695-702. [Medline].

  10. Cunningham ET Jr, Adamis AP, Altaweel M, et al. A phase II randomized double-masked trial of pegaptanib, an anti-vascular endothelial growth factor aptamer, for diabetic macular edema. Ophthalmology. Oct 2005;112(10):1747-57. [Medline].

  11. Scott IU, Edwards AR, Beck RW, et al. A phase II randomized clinical trial of intravitreal bevacizumab for diabetic macular edema. Ophthalmology. Oct 2007;114(10):1860-7. [Medline].

  12. Hsu J. Drug delivery methods for posterior segment disease. Curr Opin Ophthalmol. May 2007;18(3):235-9. [Medline].

  13. Diabetic Retinopathy Clinical Research Network. A randomized trial comparing intravitreal triamcinolone acetonide and focal/grid photocoagulation for diabetic macular edema. Ophthalmology. Sep 2008;115(9):1447-9, 1449.e1-10. [Medline].

  14. Lewis H, Abrams GW, Blumenkranz MS, Campo RV. Vitrectomy for diabetic macular traction and edema associated with posterior hyaloidal traction. Ophthalmology. May 1992;99(5):753-9. [Medline].

  15. Tachi N, Ogino N. Vitrectomy for diffuse macular edema in cases of diabetic retinopathy. Am J Ophthalmol. Aug 1996;122(2):258-60. [Medline].

  16. Fong DS, Segal PP, Myers F, Ferris FL, Hubbard LD, Davis MD. Subretinal fibrosis in diabetic macular edema. ETDRS report 23. Early Treatment Diabetic Retinopathy Study Research Group. Arch Ophthalmol. Jul 1997;115(7):873-7. [Medline].

  17. Takagi H, Otani A, Kiryu J, Ogura Y. New surgical approach for removing massive foveal hard exudates in diabetic macular edema. Ophthalmology. Feb 1999;106(2):249-56; discussion 256-7. [Medline].

  18. Kertes. Clinical Trials in Ophthalmology: Summary and Practice Guide. Lippincott Williams & Wilkins; 1998:15-35.

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Further Reading

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Keywords

diabetic macular edema, DME, diabetes, diabetic eye disease, diabetic eye complications, diabetic retinopathy, DR, retinal edema, macula

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Contributor Information and Disclosures

Author

Emmanouil Mavrikakis, MD, PhD, Consultant Vitreoretinal Surgeon, Ophthalmology Department, Athens Medical Centre, Greece
Emmanouil Mavrikakis, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology and American Society of Retina Specialists
Disclosure: Nothing to disclose.

Coauthor(s)

Wai-Ching Lam, MD, FRCS(C), Associate Professor, Department of Ophthalmology and Vision Sciences, University of Toronto
Wai-Ching Lam, MD, FRCS(C) is a member of the following medical societies: American Academy of Ophthalmology, Canadian Ophthalmological Society, and Royal College of Physicians and Surgeons of Canada
Disclosure: Pfizer Grant/research funds Primary investigator; Novartis Honoraria Speaking and teaching; Novartis Honoraria Review panel membership

Baseer U Khan, MD, Staff Physician, Department of Ophthalmology, University of Toronto, Canada
Baseer U Khan, MD is a member of the following medical societies: Canadian Ophthalmological Society
Disclosure: Nothing to disclose.

Medical Editor

V Al Pakalnis, MD, PhD, Professor of Ophthalmology, University of South Carolina School of Medicine; Chief of Ophthalmology, Dorn Veterans Affairs Medical Center
V Al Pakalnis, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and South Carolina Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Steve Charles, MD, Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine; Adjunct Professor of Ophthalmology, Columbia College of Physicians & Surgeons; Clinical Professor Ophthalmology, Chinese University of Hong Kong
Steve Charles, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Club Jules Gonin, Macula Society, and Retina Society
Disclosure: Alcon Laboratories Consulting fee Consulting; OptiMedica Ownership interest Consulting

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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