(Remember, this book is not just for decadent docs in developed countries.)
What if you only have the option of doing laser—no intravitreal treatment or vitrectomy? One might hope a race of thoughtful aliens will take over our planet and equalize the distribution of healthcare, so that no human being is treated worse than another. Until then, however, here are some suggestions.
First of all, if you really are the only one around, then it would be great if you could get some extra training, because your local population would benefit. Can you spend a week at a specialty center and learn some tricks and tips? Can you get a local service club (like the Lions or Rotarians) to help with cost? Some of the resources mentioned in Chapter 6 can help with additional education and training.
Second, it is likely that you are also in a situation where the medical control of your patients is dismal. As mentioned numerous times in this book, anything you do will not work as well if the patients are not well controlled. If there is anything that can be done to help with this, it will make your life a lot easier.
Third, if you are in this situation it is likely that patients are showing up late in their disease course, which only makes your job more impossible. Try to do anything to get them in sooner—patient and doctor education, assistance from service and religious organizations, telemedicine screening—whatever.
As for treating the patient with laser alone, there are not a lot of options beyond adding more spots as patients get worse. You need to do this parsimoniously, though. It has been suggested that once you put about 300 to 400 small spots into a posterior pole, you have done about as much as you can hope for with laser. Numbers like this came from the bad old days—before there were other treatments. Try not to go this high if possible, because this many spots will definitely expand and start to cause problems if the patient lives for many years (although you may not need to worry about this as much in developing countries, where diabetics tend to die sooner). If you are using very small light spots, though, it may be possible to perform multiple treatments, especially if you are just doing focal treatment directed at new microaneurysms.
Sadly, if you really are in this boat you are probably just barely staying ahead of your patient load, and you are also likely seeing lots of really bad, puffed-up maculas. In this situation, you are simply trying to keep eyes in the 20/400 range and not let patients go all the way to hand motions from macular disease. You also need conserve your resources—if you do gentle, staged treatment on everyone, you can get so backlogged with following them that you can't take care of anyone else. This situation may be the one time when your best option is to do a grid of 100 to 150 spots and hope for the best, and then repeat as needed until you have put in about 300 to 400 spots total. Again, this is not ideal at all, but if there are no other solutions, this approach at least gets enough scarring in to help keep the retina from totally swelling up. Patient expectations are also crucial if you are forced to do this. They must understand that they will get worse no matter what you do—it is just that by treating them, you will hopefully hold on to as much vision as possible. (The last part of Chapter 6 reviews this in more detail.)
It may be tempting to treat patients with intravitreal steroids in this situation, but you need to give serious thought to the potential complications. What are your options if a patient gets into trouble? If there is no way to treat it, a case of endophthalmitis or retinal detachment or refractory glaucoma is far worse than count-fingers vision from macular edema. This is not to say that one should never try intravitreal therapy but rather that you need to carefully balance all the risks if you have limited resources.
Unfortunately, there are some doctors in developed countries who do have access to specialists but act like they don't—until a patient's retina is far gone. The approach for such folks seems to be: "How can I extract the maximum amount of money from a patient before I refer them out and don't get a chance to bill them again?" One hopes that they are not really thinking this, and that they are simply deluding themselves into thinking they know what is best for the patient without paying attention to the literature (not that thinking this is much of an improvement over greed). If you know someone like this, we can send them a free copy of this book (with anonymous return address) if you wish. Here is the point: Do the best you can but if you think you are getting in over your head don't hesitate to ask for help. You—and your patient—will sleep better.
1. Diabetic Retinopathy Clinical Research Network. A Randomized Trial Comparing Intravitreal Triamcinolone Acetonide and Focal/Grid Photocoagulation for Diabetic Macular Edema. Ophthalmology. 2008 Sep;115(9):1447-9.
2. Ryan EH, Jr., Han DP, Ramsay RC, et al. Diabetic macular edema associated with glitazone use. Retina 2006;26:562-70.
3. Polito A, Del Borrello M, Polini G, Furlan F, Isola M, Bandello F. Diurnal variation in clinically significant diabetic macular edema measured by the Stratus OCT. Retina 2006;26:14-20.
Folk JC, Pulido JS. Laser photocoagulation of the retina and choroid. San Francisco: American Academy of Ophthalmology, 1997.
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 1987;94:761-74.
Intravitreal Therapy and How It Fits Into Your Armamentarium. Or Not.
Although laser has historically been the mainstay of treatment of diabetic retin-opathy, there is now tremendous interest in the use of intravitreal therapy to help control the damage. As of this writing, there is no single proven approach for using intravitreal drugs, so it is hard to provide firm guidelines. Furthermore, intravitreal treatment can significantly change the risk-benefit ratio given the potential complications, especially if you are practicing in an area where there may be limited resources to address such complications. For instance, if you are at an academic center where you can walk your patient with steroid-induced glaucoma down the hall to a world expert on glaucoma, your risk-benefit ratio may be very different than if you are practicing in a smaller town where the same patient may be operated on by someone who does only 10 filters a year. Finally, it is likely that some readers will not have access to specialty care at all.
As a result, this chapter will simply give an overview of these drugs with some suggestions about how they might fit in to the treatment of diabetic retinopathy. A complete discussion of the rationale, pharmacology, techniques and risks is beyond the scope of this book, but if you are going to use intravitreal therapy, you have to become more familiar with all of these issues—do not stop with the information here. Ultimately, you will need to decide whether you want to use these medications; this will be determined by their availability, your level of comfort, and your ability to identify and deal with complications. The philosophy of your local retinal community is also very important, and you will need to figure this out on your own—especially in terms of when to refer if you do not use these techniques. Hopefully, there will be studies over the next few years that will give us all a definite idea of the best way to use these drugs, in the same way the Diabetic Retinopathy Study and the Early Treatment of Diabetic Retin-opathy Study have helped to define the use of lasers.
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Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...