Diabetic macular edema (DME) is a serious complication of diabetes that affects the eyes. It occurs when the blood vessels in the retina, the part of the eye that senses light and sends images to the brain, become damaged due to high blood sugar levels. This damage can cause fluid to leak into the macula, the central part of the retina responsible for sharp, detailed vision.DME can cause vision loss and can make it difficult to read, drive, or recognize faces. It is a common cause of vision loss in people with diabetes and can occur at any stage of the disease, although it is more common in people with advanced stages of diabetic retinopathy.Early detection and treatment are important in managing DME and preventing vision loss

1. DIABETIC MACULAR
EDEMA & ITS
MANAGEMENT
PRESENTED BY: NIGAR MEHTIYEVA, 10TH SEMESTER,
FACULTY OF MEDICINE.
UNIVERSITY: TBILISI STATE MEDICAL UNIVERSITY,
GEORGIA.
Guided by Nino Karanadze, Lions Eye Diabetes Clinic

2. INTRODUCTION
• Diabetic macular edema (DME) is a serious complication of
diabetes that affects the eyes.
• It occurs when the blood vessels in the retina, the part of the eye
that senses light and sends images to the brain, become damaged
due to high blood sugar levels.
• This damage can cause fluid to leak into the macula, the central
part of the retina responsible for sharp, detailed vision.
• DME can cause vision loss and can make it difficult to read, drive,
or recognize faces.
• It is a common cause of vision loss in people with diabetes and
can occur at any stage of the disease, although it is more common
in people with advanced stages of diabetic retinopathy
• Early detection and treatment are important in managing DME and
preventing vision loss

3. DIABETES PREVALENCE in UAE
• The UAE has a high prevalence of diabetes, with
rates of 16.3% for adults aged 20-79 years according
to IDF statistics in 2019.
• A survey from 1999-2000 found a similar rate of
20.0% for those aged 20-64 years using OGTT.
• More recent data from the Weqaya screening
program in Abu Dhabi for 2008-2010 found age-
standardized prevalence rates of 17.6% for diabetes
and 27.1% for pre-diabetes.
• However, there have been few studies on diabetes
prevalence in the UAE since then.

4. • A recent research conducted in the Northern Emirates of the
UAE discovered that the rate of diabetes was 25.1% among its
citizens.
• The prevalence of diabetes was found to be higher in UAE
citizens, ranging from 25% as compared to 13-19% in
expatriates.
• The study also revealed that the rate of diabetes increased with
age and reached a maximum of 40% in people over 55 years of
age.
• The prevalence of impaired fasting glycemia was observed to
be 5% in men and 7% in women.
• Shockingly, the survey also found that 41% of individuals with
diabetes were previously undiagnosed.
• Obesity was also found to be common in all ethnic groups in
the study

5. RISK FACTORS FOR OBESITY/DIABETES IN
UAE
• The swift urbanization and socioeconomic advancement
in the UAE have resulted in the local population's
extensive adoption of a sedentary lifestyle and
Westernized diet, contributing to the risk factors for
obesity and diabetes.
• These risk factors are also linked with increasing waist-
hip ratio (WHR), age, systolic blood pressure, and
ethnicity.
• Additionally, the survey found that co-morbidity with
glucose intolerance occurred in 8% of individuals with
obesity and with hypertension in 5%

6. OCULAR COMPLICATIONS OF DIABETES:
• These conditions include
• diabetic retinopathy,
• diabetic macular edema,
• cataracts,
• glaucoma,
• poor vision,
• diabetes

7. PREVALENCE..
• Diabetic eye diseases make up 2 of the top 5 eye
problems affecting UAE patients
• Diabetic retinopathy and Diabetic Macular Edema (DME)
are two of the top five eye problems affecting UAE
patients
• One study found prevalence of retinopathy to be 19 per
cent in the UAE and was more likely to occur in older
males

8. • A collaboration between the Emirates Society of
Ophthalmology and a committee consisting of
specialized ophthalmologists in Retina, SEHA, Dubai
Health Authority, Ministry of Health, and private hospitals
in the UAE was formed to work on the Diabetic Macular
Edema Management Consensus

9. SCREENING
• Bayer ME & Emirates Ophthalmology Society launched "Eyes
On" campaign to tackle Diabetic Macular Edema in UAE.
• Campaign aims to raise awareness among diabetic patients
about the serious implications of DME.
• Retinal department at SEHA focuses on conditions at the
back of the eye, including diabetic eye screening.
• Primary care facilities in UAE offer screening programs for
DME.
• Patients urged to have their eyes examined as soon as they
are diagnosed with diabetes, as Diabetic Retinopathy can
already be present in some cases.

10. Introduction on ESO
• ESO has taken on the responsibility of overseeing and
organizing scientific training, conferences, and events while
also collaborating with health organizations.
• It is considered the leading Society for Ophthalmology in the
GCC area, not just in the UAE.
• The society aims to promote Continuous Professional
Development, facilitate the exchange of scientific information,
and encourage research and development in Ophthalmology.

11. • ESO has developed these guidelines with the objective
of offering clinical recommendations that are based on
evidence, for the optimal management of various
aspects of diabetic eye disease.
• The guidelines have been created with a specific focus
on the management of Diabetic Macular Edema, and
have been designed to address cases of retinopathy that
pose a serious risk to vision.

12. Treatment Pre-requisites
• It is recommended to check Visual Acuity (VA) before
initiation of treatment
• recommended to check intraocular pressure (IOP)
before initiation of treatment
• OCT is recommended before the initiation of treatment,
• Ocular fundus exam is recommended
• Fundus Fluorescein Angiography (FFA)

13. WHEN SHOULD WE TREAT?
• The purpose of treating DME is to enhance vision when it
is impaired, preserve existing vision, and prevent any
structural harm to the macula.
• It is essential to conduct a thorough evaluation of the
macula's structure and function to achieve this goal
• Conditions which are needed to initiate treatment:
• Best Corrected Visual Acuity (BCVA) of 20/30 or below, and/or
the presence of DME features as observed on OCT, with a
Central Retinal Thickness (CRT) of 300 microns or more
(≥300 μm).
• Patients experiencing symptoms with vision better than
20/25(13) and /or CRT<300 μm(12,13) with OCT features
indicative of center-involving macular edema should be
treated.

14. General Guidance in DME Management
• Good control of Diabetes Mellitus and HbA1c, arterial
hypertension, dyslipidemia, and quitting smoking is crucial for
managing DME.
• Achieving a normal BMI through weight loss is important
• Manage renal impairment, sleep apnea, and other relevant
conditions in consultation with a diabetologist
• Fenofibrate and statin can be recommended to the family
physicians / endocrinologists as anti-dyslipidemia medication
• Investigate other potential ocular causes of decreased vision.
• Monitor for any new medications or changes in medication that
could exacerbate macular edema, such as Glitazones

15. • Conduct FFA/OCTA to evaluate macular ischemia in
case of no improvement in visual acuity
• Use anti-VEGF injections or Dexamethasone Implant to
reduce macular thickness
• Discuss all ophthalmic treatment options with the patient
• Improve compliance and set realistic expectations
• All ophthalmic treatment options should be discussed
with the patient for better compliance and expectations

16. Tx Recommendation for Non-Centre Involving DME
• Observation may be the initial approach for Non-Center Involving
DME
• Anti-VEGF therapy or FFA-guided focal laser may be recommended
if there is progression towards the center
• Avoid treatment closer than 300-500 μm from the center of the
macula
• Focal Laser should only be performed by a retina specialist in
special circumstances

17. Treatment Recommendation for Centre Involving DME
• Anti-VEGF therapy is the first-line treatment
option for Centre-Involving DME (CI-DME)
• Steroid implant (Dexamethasone implant) may be
used as a first-line treatment if anti-VEGF therapy
is not recommended or if the patient is poorly
compliant
• Regular follow-up is required to monitor
intraocular pressure (IOP)
• Dexamethasone implant may be suggested for
vitrectomized, pseudophakic, or chronic DME
patients
• Treatment algorithms may vary based on patient
and physician preferences.

18. • Fixed, pro re nata (PRN), and treat-and-extend dosing
strategies can be considered for treating DME
• All patients treated with anti-VEGF should have a
loading dose of 3-5 injections
• Estimated number of injections is 8-9 in the first year and
5-6 in the second year, including the loading dose
• Dosing strategies based on VA and OCT response

19. Anti-VEGF Contraindications
• Avoid anti-VEGF treatment for at least 3 months after
myocardial infarction or stroke
• Anti-VEGF treatment is not recommended during
pregnancy or breastfeeding
• Steroid can be considered as first-line treatment in
pregnancy or breastfeeding
• Intravitreal therapy for DME should be deferred in cases
of active infection

20. Relapsing DME(Edema After
1Year)
• If a patient experiences relapsing DME and there is clear
evidence of a response to a previous treatment, the
same treatment can be repeated.
• However, if there is no response, the patient should be
treated as a new case and any available treatment
option, such as anti-VEGF or a Dexamethasone implant,
should be considered.

21. Refractory DME
• Refractory DME is defined as DME not responding to a
full course of anti- VEGF agents and steroid implants.
• In such cases, we can consider ;
•
a combination therapy with anti-VEGF and steroids
• or
• referral to a retina surgeon for vitrectomy if OCT
confirms ERM or VMT.

22. Steroid Implant
• Dexamethasone implant injections recommended: 3-4 within 12
months
• If good response and infrequent recurrence, continue with
Dexamethasone implant
• Effect of Dexamethasone implant peaks at 6-8 weeks and lasts up
to 4 months
• If frequent fluid recurrence, switch to Anti-VEGF after discussing
with patient
• If patient prefers not to receive implant every 4 months, consider
switching to Fluocinolone implant.

23. Contraindications of Dexamethasone and
fluocinolone acetonide intravitreal implants
• patients with active or suspected ocular or periocular
infection,
• advanced glaucoma requiring more than three
medications,
• non-intact posterior capsule (excluding YAG
capsulotomy),
• aphakia,
• or hypersensitivity to Dexamethasone implant
• or fluocinolone acetonide intravitreal implant should not
receive these treatments.

24. DME and PDR
• Initially assess VA, and do a fully dilated fundus exam.
• Anti-VEGF agents are the first-line treatment for centre-
involving DME.
• Anti-VEGF treatment or pan retinal photocoagulation (PRP)
can be considered for non-centre involving DME and PDR
• Combination of both treatments can be used for PDR
• Anti-VEGF injections can be continued for DME after PDR
treatment.

25. Diabetic Macular Edema and Pregnancy
• Control blood glucose and use laser treatment as first-line options for managing
DME during pregnancy
• Avoid anti-VEGF treatment for DME during pregnancy
• Intravitreal Dexamethasone implant can be considered for severe DME
• Laser treatment is a viable option for non-centre-involving Macular edema
• Treatment can be postponed until after delivery if feasible
• If treatment is offered during pregnancy, it should be done only in the second or
third trimesters
• Discuss potential risks of treatment with the patient, including elevated
intraocular pressure, cataract development, and rare risk of fetal harm.

26. reference
• https://www.ema.ae/chop/multimedia/userfiles/file/ICON
%20Publication.pdf
• https://insights.omnia-health.com/medical-
specialities/diabetic-eye-diseases-make-2-top-5-eye-
problems-affecting-uae-patients