Plants convert electromagnetic energy directed from the sun into biochemical energy and store it into sugar. Your body converts this chemically stored energy back into electrical power at a cellular level. You can stretch your hand to the sun to capture it, but from the first day of your life, you already have the solar energy in yourself. You are connected to the sun, your body is nothing more or less than a sun storage. In diabetes, the use and flow of this energy storage is disturbed. Yours Peter Maloca, MD.
What to do in diabetic retinopathy? by Martin K. Schmid, MD
The strategies change, new knowledge has to be evaluated and proofed. The findings of today may already be obsolete tomorrow. We can only show a snapshot of the current knowledge about diabetes. General recommendations must always be placed in the context of the affected patient. There is no standard diabetes patient, each person is different, everybody needs a customized procedure.
It sounds simple but first of all: the basic frame of all diabetic problems, is the diabetes itself. Diabetic retinopathy represents “only” the complication of the underlying disease, called diabetes. Good interdisciplinary management of the underlying disease means control and treatment of the most important paramaters. Responsible for the treatment and control of the underlying disease are the internist and the patient together.
How should we monitor patients with diabetes?
It is important to know that after 20 years, more than 80 percent of affected patient develop a diabetic retinopathy. There are mainly the situations:
Pregnancy can be a source of danger in diabetes. Pregnancy can lead to a diabetes decompensation. A baseline checkup should already occur if a desire for pregnancy exists. During pregnancy the patient should be checked every three months, even monthly in special cases.
2. Type 1 diabetes:
Currently it is recommended in type 1 diabetes: annual check from the fifth year of manifestation, or from the age of eleven. In the presence of type 1 diabetes without retinopathy annual inspection should be performed. In the presence of type 1 diabetes with retinopathy, the procedure corresponds to the severity.
3. Type 2 diabetes:
In type 2 diabetes, it is different because at diagnosis 36 percent already show a retinopathy. If the retina is healthy in diabetes type 2, nevertheless the retina should be examined annually.
In diabetes with a healthy retina or only a few microaneurysms an annual inspection is recommended.
A moderate diabetic retinopathy means only a few hemorrhages, microaneurysms, beaded veines. In question of an ischemia a fluorescence angiography is worthwhile. An OCT may be helpful in a decrease of visual acuity with looking for a macular edema.
The checks are carried out every 6 to 12 months depending on the situation.
An advanced diabetic retinopathy is characterized by the 4-2-1 – rule
-Presence of more than 20 microaneurysms in the four quadrants
-or venous beading in two quadrants and/or one quadrant with IRMA
Currently, the treatment of a macular edema is a most discussed topic. A proposal for control and treatment in diabetic macular edema is presented in this video.
A proposal for control and treatment:
In severe diabetic retinopathy a fluorescence angiography (FA) and OCT are performed. These two methods are the basis for the indication of a therapy. The laser is still an important tool, especially for the treatment of ischemia. After treatment, frequent monitoring is necessary.
Consider the morphology and function of the macula:
In a dry macula, good visual acuity and inconspicuous biomicroscopy, checks are carried out every year.
In borderline cases an OCT or fluorescence angiography (FA) should be performed, followed by an appropriate therapy.
In a clinically significant macular edeme, OCT and/or fluorescence angiography (FA) are the basis, followed by Laser and/or anti VEGF therapy. After treatment, a frequent monitoring is necessary in every case.
In cases with a thickened foveola a proposal may be:
If the edema is not located quite centrally, a focal laser may be sufficient. When this laser is not successful, we go back again in the proposed scheme.
If the foveola is thickened centrally, the anti-VEGF therapy is then possible.
If no stabilization occurs, the vision rises an additional laser treatment may be useful.
If therapy stabilized the situation, a break and a close monitoring follows. If everything remains stable, the patient remains in the small control loop.
If the situation worsens, the patient returns to the top level of control.
This is not a fixed regimen, but must be customized and changed over time.
Diabetes damages the blood vessels and if untreated, can lead to blindness. The newest discoveries with anti-VEGF therapy in diabetes have their own requirements. One question is when should a macular edema be treated and when not?
So far, a clinically significant macular edema was the main criterion for therapy. There has been a shift from clinically significant macular edema towards the concept of “center involving or central subfiled thickening”. With OCT, the course over time can now be controlled much more accurately.
View video strategies in diabetes GETOCT 4 Youtube channel:
The question is, which concept is better: “clinically significant macular edema” versus “center involving”. In the label (package leaflet) of Lucentis is nothing written about retinal thickness. The single most important criterion is the visual acuity loss due to macular edema in diabetes. Monthly injections of Lucentis for three consecutive months until visual acuity is stable. Re-treatment, if the visual acuity is worse again. It is to discuss whether the visual acuity alone is a good parameter for treatment. What is a “clinically significant macular edema”?
A GETOCT memory aid: important are two circles and a line (cross section papilla):
1. First inner circle with 500 microns around foveola
2. Second circle with one disc diameter around the the foveola
3. A line represents the disc diameter
The definition of clinically significant macular edema is important:
1.Retinal thickening within 500 microns of the center (foveola)
2.Hard exudates within 500 microns around the foveola with adjacent retinal thickening
3. Retinal thickening greater than one disc diameter in order to one disc area around foveola
The disadvantage of this arrangement is that the findings are not always clear.
Diabetes is a vascular disease
Diabetes affects vessels. Therefore, the assessment of the ischemic component is very important. Diabetes on the retina leads to a thinning of the peri foveolar capillary network. The normal fovelar avascular zone (FAZ) increases in size. Almost always, the lesions are irreversible. The capillary network is so badly damaged that swelling can not longer be caused, no edema is visible in advanced cases. In an avascular retina, OCT of the foveola shows completely thinner layers. The normal fine retinal layers are destroyed, but a few crumbs are visible. In very far-advanced stage, anti-VEGF and laser have no great benefit anymore for the visual acuity. The goal of therapy in very advanced situations is no longer the visual acuity, but to prevent vascular proliferations, thus bleeding and a secondary glaucoma or even blindness.
Thanks OCT, we obtain information to the third dimension. Flurescence angiography allows only limited statements about the spatial extent of processes
The retinal thickness is measured precisely with OCT and an objective quantification is possible. The fourth dimension means a precise control over the course of years at exactly the same place.
The measurements are comparable with each other really well. With OCT is a synchronous mapping and comparison over time is possible and changes are shown. In some OCT devices the scanning area is permanently adjusted, no matter where the patient looks. This is advantageous because the patient can’t fix very well in advanced diseases. From these cross sections thicknesses maps can be produced, even differences over time can be calculated.
Anti-VEGF for diabetic macular edema?
Anti-VEGF for diabetic macular edema has been investigated in many studies.
The combination with ranibizumab turns to an increase in visual acuity. the sole laser therapy worsened the situation at the beginning rather. The number of injections in the combined group with a laser can be reduced.
Immediate or delayed laser?
Another study on laser: what impact does an immediate or delayed laser? If successful, the strategy with immediate laser, a significant gain is produced. When laser was carried out somewhat later, however, a similarly good progress is produced. So it’s not a big difference whether immediate or slightly delayed laser is done.
The results with triamcinolone and laser show in the first 6 months of a profit, then drop due to cataract formation. The number of injections in this study is also at eight to nine injections per year.
Diabetes is well known and you can hear it everywhere. Still, diabetes is an insidious disease, especially on the eye. The affected patient often feels very healthy and he is supposedly doing well. If restrictions occur diabetes shows its evil side. Diabetes is like a ball, which was triggered and the direction and speed, one can only guess. Life will never be the way it once was. Therefore it is best to give diabetes not a chance. Eye doctors in collaboration with other physicians and the diabetes specialists are very important partners of the patient. The main goal is an indepedent living and to enable a high quality of life.
Our esteemed colleague, Dr. Martin K. Schmid, Co-Medical Chief at Eye Clinic Lucerne, Switzerland, proved to us the honor on 7th GETOCT meeting in Lucerne. He lectured in close collaboration with the public on diabetes and OCT.
Interpretation of OCT is awareness!
Interpretation of an OCT image means brightening of something, explaining and laying out the findings. OCT images are some kind of a transmitter, the interpreter is the receiver of an hidden information. Your answers to an OCT image are linked to your experiences, your interest and willingness to lay down the blinders and your prejudices. The answer to a question also affects the other answers. Put nothing into the image what is not there!
It’s a challenge to record a good OCT image. The even greater challenge is the correct interpretation! A major risk ist the danger of subjectivity and a rapid satisfaction. Search the challenge of OCT images! Nothing is more boring in your career as an eye doctor when you do the same every day.
As a source of enlightenment: getoct.com database
A big help is to consider as many OCT images as possible to achieve a “cerebral calibration “. Hundreds of annotated OCT images and videos are waiting to be discovered, through you.
Don’t miss anything really occurring
Dr. Hasler says at the getoct academy 2011, that a perfect instruction of the patient leads to good OCT images. You have first to prepare a good timing to start the recording at the right moment. It is of advantage to get both: OCT scan and corresponding infrared image of the fundus. These images are linked to each other and improve the orientation. If the scans are not perfect, it is worthwhile to start again. Immediately delete useless images to keep your computer clean.
Dr. Hasler: the algorithme (red line) follows the wrong way and leads to an erroneous measurement.
Algorithme makes mistakes (red/white line): OCT mapping and thickness imaging is nonsense (X) by Dr. Hasler.
Highly myopic eyes are difficult
OCT scanners are designed for normal-sighted eyes and sometimes have a button for highly myopic eyes. An oblique cut makes the algorithm work hard and leads more frequently to errors. Thus one has to check only the individual cross-sections of whether the algorithm has done his work satisfactorily.
The quality of an individual OCT cut influences the construction and the representation of the three-dimensional volume. If the cross section is poor in quality, the 3D representation is useless.
3D images are a summary of cross-sections and if they look strange you have to switch back and look at the cross section level. The OCT scanner analyzes the samples using an algorithm, so a „ simple calculation method“. The 3D OCT has the advantage that you can quickly scroll through a lesion, to detect and to estimate the dimensions and to identify mistakes easier.
In addition, 3D OCT is a good training to discover the anatomy of the eye and the problem is explained in an impressive way to the patient. Interpretation of OCT
The most difficult task is the correct interpretation of the OCT images. There is an enormous achievement to get a good OCT image. Good interpretation is a real challenge.
Dr.med.PeterMaloca recommends a multi-stage procedure for an accurate diagnosis: Checklist OCT pre-interpretation:
1. OCT practice:
Only practice makes perfect! Who does not look exactly on OCT images, will never learn it. 2. OCT network – calibration
Get in touch with experienced OCT users. Visit an OCT congress, for example the annual getoct academy in Lucerne (in German) and join the community at getoct.com. Upload your pictures to getoct.com, ask the community.
OCT interpretation in 5 getoct steps by Dr. med. Peter Maloca: 1. Orientation: where are you? For a proper assessment of OCT images you have to orient yourself first. Say nothing of what you can not prove or show on the OCT images! 2. Findings: describe only what you really see in simple words. 3. Summarize the findings 4. Link the findings to a diagnosis (interpretation) 5. Be honest: self-criticism/what else? Be honest! Say nothing what you have not checked for alternatives! Don’t skip lesions! Twist nothing! There are no stupid questions. Only someone who has no questions is stupid. Serve the OCT scans and do not abuse it for your self-expression! 6. Explain: explain to the patient the diagnostic findings. If he understood it, you have understood it.
Steps of interpretation OCT by Dr Maloca
OCT-Interpretation von Dr. med. Peter Maloca:
1. Orientierung auf dem OCT- Bild: wo bist Du? Für eine angemessene Bewertung der OCT-Bilder müssen Sie sich zuerst orientieren. Sagen Sie nichts, was Sie nicht beweisen können, zeigen Sie es auf den OCT-Bildern! 2. Befunde: beschreiben Sie in einfachen Worten nur, was Sie wirklich sehen. 3. Zusammenfassung der Befunde 4. Verknüpfen Sie die Befunde zu einer Diagnose (Interpretation) 5. Seien Sie ehrlich, Selbstkritik, was könnte es sonst noch sein?
Seien Sie ehrlich! Sagen Sie nichts, was sie nicht nach Alternativen geprüft haben! Lassen Sie keine Läsionen aus! Verdrehen Sie nichts! Es gibt keine dummen Fragen. Nur jemand, der keine Fragen hat, ist dumm. Missbrauchen Sie die OCT scans nicht zu Ihrer Selbstdarstellung!
6. Erkläre! Erklären Sie dem Patienten die Befunde. Wenn er es verstanden hat, haben Sie es auch verstanden.
Main problem in OCT (optical coherence tomography) is that things are interpreted in the pictures, they really do not exist. Pitfalls with OCT, technical aspect, case presentation, view video from getoct academy 2011.
It’s a great honor to welcome Dr. med. Pascal Hasler, Basel, at the 6th getoct academy in Lucerne/Switzerland. The problem with OCT congresses is, that everything looks wonderful. Everyone seems to know everything and no one dares to admit mistakes. Therefore, Dr. Pascal Hasler will show you in this video pitfalls using OCT. In the first part technical aspects are discussed. In the second part pitfalls of interpretation are shown. Therefore it is important that there are such courses as the practice-oriented getoct academy in Lucerne!
getoct academy 2011 Dr. Maloca and Dr. Hasler
Dr Hasler says that there are four main sources of error using OCT: patient dependent, cooperation between patient and examiner, wrong scanner settings and above all interpretation of OCT images, which is an extraordinary challenge.
Here is a summary of Dr. Hasler speech, held at the 6. getoct academy 3 December 2011:
Pitfalls with OCT, technical aspect, case presentation
1. Sources of error in patient
miosis: OCT in miosis is possible, but difficult due to lower signal strength, no accurate centering of laser beam
small interpalpebral space/ptosis
in dry eye use of moisturizing eyedrops before scanning
wrong indications for OCT: with vitreous hemorrhage OCT is practically impossible 2. Cooperation between patient and examiner:
poor visual acuity is equally to poor fixation: expand inner fixation target, use external fixation light
restless patients: shorten scanning, ask for assistance to fix the head
alternatively use the quick scan mode even when you loose image quality
scan rather an individual, low qualitiy cross scan than a fullrange measurement 3. Wrong settings on OCT scanner:
choose corresponding diopters, may be set automatically
the centering should be focused on the hot spot orthogonally if possible
measurement on correct eye and correctly stored
choose the right scan protocol: in children, one must often use protocols others than in adults
observe the quality of the scan signal observing the intensity chart
OCT is also useful for advanced cataract to evaluate the retina because the wavelength of the laser light is not so impeded by the cloudiness oft he cataract.
4. Interpretation of OCT
The most difficult task is the correct interpretation of the OCT images. There is an enormous challenge to get a good OCT image. Still, good interpretation of OCT iamges is an extraordinary challenge!
Dr. med. Peter Maloca recommends a multi-stage procedure for an accurate diagnosis: 1. First patient data
Is it the right patient (name, age)? Is it the right eye? 2. Anatomy
Where are normal, healthy structures?
Where are different structures?
Signs of activity (thickening, accumulation)?
3. Descriptive diagnosis
Try to describe the nature of the different structures first without trying to make a diagnosis: “I see a fine line that runs to the center of the retina, where spaces are present and there is a gap in the center of the retina” 4. Working diagnosis – differential diagnosis
Count for possible diagnoses. Which is less? What is rare is rare. Ask your colleagues. Upload some images to getoct.com and ask your getoct friends. 5. Diagnosis, synopsis
Which diagnosis is best suited to clinical picture and the other results? 6. Follow-up
What happens during the next time?
The biggest mistake in OCT is to ask: does the OCT suits my diagnosis instead of matches my diagnosis to the OCT?
Dr. med. Peter Maloca empfiehlt ein mehrstufiges Verfahren zur korrekten OCT-Diagnose:
OCT-Checkliste von Dr. med. Peter Maloca:
Ist es der richtige Patient (Name, Alter)? Ist es das richtige Auge? 2. Anatomie
Wo sind normale, gesunde Strukturen?
Wo sind abweichende Strukturen?
Aktivitätszeichen (Verdickungen, Einlagerungen)? 3. Deskriptive Diagnose
Beschreibe die Art der abweichenden Strukturen zuerst ohne eine Diagnose erzielen zu wollen: “Ich sehe eine feine Linie, die zur Netzhautmitte zieht, wo rundliche Räume vorhanden sind und die Netzhaut eine Lücke aufweist” 4. Arbeits Diagnose- Differential-Diagnose
Zähle mögliche Diagnosen auf, die Dir einfallen. Welche weniger? Was selten ist, ist selten. Frage Deine Kollegen. Lade Bilder auf getoct.com hoch und frage Deine getoct friends. 5. Diagnose, Synopsis
Welche Diagnose passt am besten zum klinischen Bild und den anderen Resultaten? 6. Verlauf
Was passiert während der nächsten Zeit?
Der grösste OCT-Fehler ist die Frage, ob das OCT zur Diagnose passt anstelle von “passt die Diagnose zum OCT?”
Dr. med. M.K. Schmid, PD Dr. med. Christoph Kniestedt, PD Dr. med. Claude Kaufmann, PD Dr. med. Johannes Fleischhauer, Martin Zurmühle, Prof. Dr. med. Klara Landau, Dr. med. Pascal Hasler, PD Dr. med. Hannes Wildberger, Dr. med. Sandrine Zweifel, Gastgeber Dr. med. Peter Maloca.
Programm 2011: Prof. Dr. med. KlaraLandau, Zürich: OCT jenseits der Retina, PD Dr. med. ChristophKniestedt, Zürich: OCT und Glaukom: wie weiter?, PD Dr. med. ClaudeKaufmann, Luzern: OCT und Vordersegment, PD Dr. med. Johannes Fleischhauer: OCT und Makula: , Unerwartetes und Exotisches , Dr. med. Martin K.Schmid, Luzern: OCT und Diabetes: wann und wohin?, Herr MartinZurmühle, Fotograf & Architekt: Sehen in einer wunderbaren Bilderwelt, Dr. med. PascalHasler, Basel: Was man mit OCT alles falsch machen kann, PD Dr. med. HannesWildberger/Dr. med. Sandrine Zweifel, Zürich: Cases(UpdatePlaquenil, MEWDS), Dr. med. PeterMaloca, Luzern: OCT-Knacknüsse aus der Praxis für die Praxis.