Macular Edema in Diabetes 

  • Author: Emmanouil Mavrikakis, MD, PhD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Oct 10, 2011
 

Background

The Early Treatment Diabetic Retinopathy Study (ETDRS) set the guidelines for the treatment of diabetic macular edema (DME). Since that time, the standard of treatment for diabetic macular edema has been glycemic control as demonstrated by the Diabetes Control and Complications Trial (DCCT), optimal blood pressure control as demonstrated by the United Kingdom Prospective Diabetes Study (UKPDS), and macular focal/grid laser photocoagulation.

In ETDRS, laser photocoagulation reduced the risk of moderate visual loss from diabetic macular edema by 50% (from 24% to 12% 3 years after initiation of treatment).[1] Nevertheless, some patients suffer permanent visual loss even after intensive treatment.

Over the past few years, research has started to focus on the use of anti-vascular endothelial growth factor (VEGF) therapy to treat DME. As new and promising treatment options emerge, these treatments will need to be reevaluated.

It is imperative for patients with diabetes to understand that a healthy lifestyle and compliance with medical care can greatly reduce the development and progression of complications of their disease, in the eyes as well as other organs.

For patient education information, see the Diabetes Center, as well as Diabetic Eye Disease.

For further clinical information, see the Medscape Reference articles Diabetes Mellitus, Type 1, Diabetes Mellitus, Type 2, and Diabetic Retinopathy.

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Pathophysiology

Diabetic macular edema results from retinal microvascular changes. Thickening of the basement membrane and reduction in the number of pericytes are believed to lead to increased permeability and incompetence of the retinal vasculature. This compromise of the blood-retinal barrier leads to the leakage of plasma constituents into the surrounding retina, with subsequent retinal edema.[2] Hypoxia produced by this mechanism can also stimulate the production of vascular endothelial growth factor (VEGF). There is evidence that VEGF is up-regulated in diabetic macular edema and proliferative diabetic retinopathy.[3]

A study suggests that the pathogenesis of diabetic macular edema is not only related to VEGF dependency but also to other inflammatory and angiogenic cytokine levels that can be suppressed by corticosteroids.[4]

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Epidemiology

Diabetes is the leading cause of new blindness in the United States, and clinically significant macular edema (CSME) contributes greatly to this vision loss. In the absence of ophthalmologic treatment, persons with diabetes have a 25-30% risk of moderate vision loss. With treatment, the risk drops by 50%. According to 2007 data, 23.6 million people in the United States have diabetes, but only 17.9 million have been diagnosed.[5] . About 50% of those with diagnosed diabetes do not receive appropriate eye care. The World Health Organization estimates that worldwide, more than 150 million people have diabetes.

Although diabetes is more common in Hispanics, African Americans, and Native Americans than in whites, no data describe a greater risk of developing macular edema among diabetic patients of any one racial group. Likewise, no data describe a difference in risk of diabetic macular edema between the sexes.

Diabetic retinopathy, not specifically diabetic macular edema, generally occurs in persons older than 40 years. It rarely occurs before puberty.

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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)

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.

Wai-Ching Lam, MD, FRCS(C)  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: Novartis Honoraria Speaking and teaching; Novartis Honoraria Review panel membership; Allergan Honoraria Review panel membership; Alcon Honoraria Speaking and teaching

Specialty Editor Board

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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 and 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 Other; Topcon Medical Lasers Consulting fee Consulting

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.

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, Keyt BA, Jampel HD, Shah ST, 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. Sohn HJ, Han DH, Kim IT, et al. Changes in aqueous concentrations of various cytokines after intravitreal triamcinolone versus bevacizumab for diabetic macular edema. Am J Ophthalmol. Oct 2011;152(4):686-94. [Medline].

  5. National Diabetes Information Clearinghouse. National Diabetes Statistics, 2007. Accessed July 8, 2010. Available at http://diabetes.niddk.nih.gov/DM/PUBS/statistics/#allages.

  6. 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].

  7. Chew EY, Klein ML, Ferris FL 3rd, Remaley NA, Murphy RP, Chantry K, 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].

  8. 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].

  9. 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].

  10. Patelli F, Fasolino G, Radice P, Russo S, Zumbo G, DI Tizio FM, 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].

  11. 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].

  12. Cunningham ET Jr, Adamis AP, Altaweel M, Aiello LP, Bressler NM, D'Amico DJ, 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].

  13. Massin P, Bandello F, Garweg JG, et al. Safety and efficacy of ranibizumab in diabetic macular edema (RESOLVE Study): a 12-month, randomized, controlled, double-masked, multicenter phase II study. Diabetes Care. Nov 2010;33(11):2399-405. [Medline]. [Full Text].

  14. Nguyen QD, Shah SM, Heier JS, et al. Primary End Point (Six Months) Results of the Ranibizumab for Edema of the mAcula in diabetes (READ-2) study. Ophthalmology. Nov 2009;116(11):2175-81.e1. [Medline].

  15. Lang G, RESTORE study group. Safety and efficacy of ranibizumab as monotherapy or adjunctive to laser photocoagulation in diabetic macular edema: 12-month results of the RESTORE study. Late-breaker presentation at EASDec Meeting. May 22, 2010.

  16. Elman MJ, Aiello LP, Beck RW, et al. Randomized trial evaluating ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema. Ophthalmology. Jun 2010;117(6):1064-1077.e35. [Medline]. [Full Text].

  17. Elman MJ, Bressler NM, Qin H, et al. Expanded 2-Year Follow-up of Ranibizumab Plus Prompt or Deferred Laser or Triamcinolone Plus Prompt Laser for Diabetic Macular Edema. Ophthalmology. Apr 2011;118(4):609-14. [Medline].

  18. Michaelides M, Kaines A, Hamilton RD, et al. A prospective randomized trial of intravitreal bevacizumab or laser therapy in the management of diabetic macular edema (BOLT study) 12-month data: report 2. Ophthalmology. Jun 2010;117(6):1078-1086.e2. [Medline].

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

  20. 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]. [Full Text].

  21. 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].

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

  23. 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].

  24. 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].

  25. Scott IU, Edwards AR, Beck RW, Bressler NM, Chan CK, Elman MJ, et al. A phase II randomized clinical trial of intravitreal bevacizumab for diabetic macular edema. Ophthalmology. Oct 2007;114(10):1860-7. [Medline]. [Full Text].

 
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