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«Raj K. Maturi, M.D. Jonathan D. Walker, M.D. Robert B. Chambers, D.O., FAOCOO Diabetic Retinopathy for the Comprehensive Ophthalmologist SECOND ...»

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for the Comprehensive Ophthalmologist


Raj K. Maturi, M.D.

Jonathan D. Walker, M.D.

Robert B. Chambers, D.O., FAOCOO

Diabetic Retinopathy for the

Comprehensive Ophthalmologist


Raj K. Maturi, M.D.

Associate Clinical Professor

Department of Ophthalmology

Indiana University School of Medicine, Indianapolis Retina Service, Midwest Eye Institute Jonathan D. Walker, M.D.

Clinical Assistant Professor Indiana University School of Medicine Fort Wayne Robert B. Chambers, D.O., FAOCOO Associate Clinical Professor Havener Eye Institute Department of Ophthalmology & Visual Sciences The Ohio State University, Columbus, Ohio Deluma Medical Publishers 7900 West Jefferson Blvd.

Suite 300 Fort Wayne, IN 46804 retinopathytext@gmail.com Editor Steve Lenier editor@stevelenier.com Layout and Design Lauren Peacock lauren@canalstreetwinona.com Line Art Roberta J. Sandy-Shadle Publications Indiana University-Purdue University, Fort Wayne Financial Disclosures None of the authors have any proprietary interests in either the book or its subject matter. Dr. Maturi serves as a consultant to Eli Lilly and the Jaeb Center for Health Research. He is on the advisory board for Allergan and Regeneron, and is a principal or sub-investigator for Alcon, Alimera, Quark, Allergan, Sanofi, Eyegate, GlaxoSmithKline, Jaeb Center, Parexel and Santen.

Legal Disclaimer The author provides this material for educational purposes only. It is not intended to represent the only or best method or procedure in every case, nor to replace a physician’s own judgment or give specific advice for case management. Including all indications, contraindications, side effects, and alternative agents for each drug or treatment is beyond the scope of this material. All information and recommendations should be verified, prior to use, with current information included in the manufacturers’ package inserts or other independent sources, and considered in light of the patient’s condition and history. Reference to certain drugs, instruments, and other products in this publication is made for illustrative purposes only and is not intended to constitute an endorsement of such. Some material may include information on applications that are not considered commu- nity standard, that reflect indications not included in approved FDA labeling, or that are approved for use only in restricted research settings. The FDA has stated that it is the responsibility of the physician to determine the FDA status of each drug or device he or she wishes to use, and to use them with appropriate patient consent in compliance with applicable law.The author specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise from the use of, any recommendations or other information contained herein.

© 2015 by Jonathan D. Walker, M.D.

All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without the written permission of the author, except for the inclusion of brief quotations in a review.

ISBN-13: 978-0-9821472-2-1


My wife Dheepa R. Maturi, for her years of steadfast support, love and kindness; my children, Vikas and Jay, for their incredible humor, good nature and love. Each of you has made this lifetime so much more joyful.

–  –  –

To my wife DeAnne and my children Christopher and Megan with an equal measure of thanks for your support of me and pride in your own accomplishments.

Robert B. Chambers


There are many broad shoulders upon which this book stands. First of all, there are the pioneers of retinopathy treatment that have given us the tools that we have and the elegant studies that tell us how to use them. There are also the folks all around the world--like the members of the DRCR.net--that are trying to provide even better therapies. They intuitively grasp the infinity of things not covered in Chapter 2. On a more personal level, I owe a great debt to all the attending physicians and ancillary staff at the Ohio State University, the USC/Doheny Eye Institute, and the University of Iowa.

They are not only busy performing all the tasks mentioned above; they also had to suffer through training me.

I want to thank Dr. Sandeep Nakhate, Dr. Robert Goulet III, Lucius Walker and Dr. Alan “Patience is Your Most Valuable Surgical Tool” Kimura, who were willing to spend their time reviewing the first edition. And this book has been brought to a new level by my coauthors, Bob Chambers and Raj Maturi, who took on the thankless task of making right the things I wrote. They also have been invaluable friends and colleagues over decades of retinal practice. Of note, I was responsible for the final version, so anything that is wayward is totally my doing.

Thanks also to Drs. Giorgio Dorin, David Sorg, Valerie Purvin, James Schmidt, Dale Fath, Donald Reed, Thomas Wheeler, Taniya de Silva, Krishna Murthy, Lik Thai Lim and John Pajka, who contributed to individual chapters in various ways. Everyone’s advice has been invaluable and is reflected in anything in the book that is actually useful.

Thanks to Lauren Fath and M. Walt Keys; they made the first edition happen. And the second edition now exists thanks to the editing skills of Steve Lenier and the artistic skills of Lauren Peacock; their contact info is in the front matter if you have a book in you that is hankering to come out. The marvey line art was provided by Roberta Sandy-Shadle and the photos in Chapter 7 were done by James Whitcraft—both at Indiana-Purdue University, Fort Wayne. Mike Neeson helped out by confirming my memories of lasers of old, and Larry Hubbard of the Wisconsin Reading Center generously shared his Zen Master knowledge of retinopathy grading. Thanks to my partner—Matt Farber—who actually saw the patients while I was locked in my office Photoshopping laser spots, and thanks to my exemplary office staff for keeping everything going when I wasn’t. Of course, there are no words to thank my wife and kids for doing all the real work while I alternately napped and typed on the couch.

Finally, thanks to the referring doctors for entrusting me with their patients and especially thanks to the patients themselves, who extend the ultimate honor of entrusting us with their eyes.

–  –  –

Taniya de Silva, MD Associate Professor of Clinical Medicine Program Director, Endocrinology Fellowship Section of Endocrinology, Diabetes & Metabolism Louisiana State University School of Medicine New Orleans, LA Lik Thai Lim, MBBCh, BAO(UK), FRCOphth, FRCSEd, MFSTEd Consultant Ophthalmologist Malaysia Krishna R. Murthy, MRCOphth Prabha Eye Clinic & Research Centre Vittala International Institute of Ophthalmology Indira Gandhi Institute Of Child Health Sciences Bangalore, India

–  –  –


This book is designed to transfer useful skills for the clinical management of diabetic patients. It does not start with the fundamentals; instead, it is assumed that the reader has basic examination skills and is at least partially familiar with various tests, such as fluorescein angiography and optical coherence tomography.

Nor does this text offer an in-depth discussion of basic science or an exhaustive review of the available literature. If you want an in-depth look at the literature behind treating retinopathy, you are encouraged to review the sections on diabetes in any of the major

ophthalmology texts. Another excellent resource is the book Diabetic Retinopathy:

Evidence-Based Management by David J. Browning—it is a must read for anyone who wants to really understand the disease.

The goal of this book is simply to make the trenches where most of us live a bit more comfortable.

The voice of this text is different from standard texts—something done in hopes of conveying useful information without too much tedium. However, as a wise person once said, “There is a fine line between clever and stupid.” If anything offends or interferes with the smooth download of information, let us know.

Also, there are no absolutes here. Once you think you know the best way to do anything, you have lost the ability to learn. Try these suggestions and techniques, and if they don’t work, throw them out. Run them by your mentors and your friendly neighborhood retinal specialists—get other opinions and synthesize a style of your own. We welcome any comments and/or complaints. If the gods of retina smile on this book, then perhaps there will be further editions with plenty of input from people way smarter than us. Our contact info is below.

Mostly, we hope that you can peruse these pages and find something that will help you to help patients who have one of the most prevalent and vicious causes of blindness on this planet.

Robert B. Chambers, D.O.

Raj K. Maturi, M.D.

Jonathan Walker, M.D.

Contact info:

Deluma Medical Publishers 7900 West Jefferson Blvd. #300 Fort Wayne, IN 46804 260 436-2181 retinopathytext@gmail.com Drcobook.com 10 P.S. At various points in the text, there are unavoidable opportunities to harass our surgical colleagues who have mastered more refractively oriented procedures. Recognize that this is meant in good sport and, in truth, stems largely from professional jealousy— they can actually understand things like high order aberrations and apodized lenses and they have patients who hug them after surgery.

Retina specialists do not generally get hugged by their patients. Moreover, the only bit of optics we understand is The Retina Refraction: room lights on—better one; room lights off—better two.

–  –  –

First, some really big numbers: An estimated 20.2 million Americans have diabetes mellitus, and the number is expected to grow to over 30 million cases by the year 2025.

And, half of them may not even know that they have the disease! Thanks to exports like the Great Western Lifestyle, the number of worldwide cases is expected to increase by 72%—to 333 million—by the year 2025.1 That is a lot of microaneurysms. By contrast, currently the number of patients blind from cataracts worldwide is estimated to be 18 million people. In other words, although a lot of ophthalmic effort is (correctly) directed towards decreasing the worldwide cataract burden, the number of patients at risk for vision loss from diabetes will soon be almost 20 times greater. Moreover, once a cataract is popped out, the job is done. Treating diabetes goes on forever for both the patient and physician—it isn’t one-stop shopping.

Diabetic blindness also tends to occur at a time when people are younger and more active in society; it is the leading cause of new blindness in patients under the age of 65.

12 CH.1: A Tiny Bit of Statistics and a Big Pep Talk The rate of onset is variable, but after 20 years, about 60% of Type 2 and essentially all Type 1 diabetics will have some sort of retinopathy. You will spend a great deal of time caring for these patients. It may seem that the treatment of diabetic retinopathy has been well defined thanks to the large clinical trials with which you are no doubt familiar.

However, the reality is that each patient you see presents an incredibly complex array of variables—social, emotional, physical and retinal. Addressing all of these variables requires a lot more than the ability to memorize the definition of clinically significant macular edema. It is axiomatic that we all went into ophthalmology to avoid dealing with the morass of an entire patient. Unfortunately, when it comes to treating diabetic retinopathy, your results are going to suck if you don’t start by understanding the entire patient. At the very least, recognize that by the time a diabetic needs your help, they are usually facing the risk of irreversible vision loss—real, life-changing vision loss—not Nerf vision loss that can be fixed with Lasik.

–  –  –

And the battle is bigger than just honing your clinical skills and trying to deal with the entire patient. At the risk of sounding hyperbolic, you also have to look at the society in which you function. It has been said that if patients are examined in a timely fashion and the standard treatment guidelines are followed, less than 5% of diabetics will develop severe vision loss.2 A huge part of your job lies in recognizing the importance of the first clause of that sentence: if patients are examined in a timely fashion. Not only do you need to develop the ability to treat these people, but you also have to be aggressive about getting them in to be evaluated. Far too many diabetics show up only when they start having symptoms, and this is not the best way to keep people seeing.

Educate the patient and the patient’s physicians at every visit. Educate the patient’s family about the importance of getting everyone in the family routinely checked for diabetes and getting anyone who is diabetic in for an annual exam.

Educate society. Give talks to local diabetes support groups. Offer to provide information for the health desk editors at local newspapers, magazines or TV stations. Do the free clinic thing—or more ambitiously, get them a camera so they can send photos of all their diabetics and you can treat the ones with disease well before they fall apart. Make general information slides for the local cinema multiplex so they can be interspersed with all of those fascinating questions about which actor said what in which movie. Whatever.

Just get these people in.

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