Health Articles
Glycemic Control Questions on the Minds
of Practicing Retina Specialists
Dr Heier: Dr Peters, is there a general target for
early glycemic control? If a patient presents to an
ophthalmologist with an HbA1c of 9%, but no
Figure 2: Case 1 fluorescein
retinopathy, how aggressive should we be in initiating
angiogram and OCT.
a referral to an endocrinologist?
Photos Courtesy of
Dr Peters: Certainly an HbA
Diana V. Do, MD
1c of 9% is always
concerning, and that patient should be seen by an
endocrinologist. That being said, it is still important to
establish what the individual patient's target is. It is
also important for the patient and for all the medical
providers involved with the patient's care to establish
which provider is setting the patient's target.
Dr Nguyen: Do you believe that all patients with
diabetes should be managed by an endocrinologist?
Dr Peters: I think that all patients with type 1 diabetes,
if possible, should be monitored by an endocrinologist
because of the technical complexity of ongoing
but I would want to know if it was lower in the previous
management. I think that the vast majority of patients
assessments. I have had patients who averaged 6.0%,
with type 2 diabetes have to be managed in a primary
lost that level of control for a little bit, and subsequently
care setting. There are relatively few endocrinologists
developed fluid. Unless patients are very symptomatic, I
who focus primarily on the management of diabetes.
might try a short period of attempting to restore glycemic
If a patient with type 2 diabetes is complicated or
control (3-6 months often allows an adequate period for
having difficulty getting into a target range, then that
improvement) and managing other factors such as poorly
patient should be seen by an endocrinologist. Other
controlled hypertension, rather than essentially committing
providers, including Certified Diabetes Educators and
them to a series of injections. If they are very symptomatic,
dietitians, also have an important role. If you can
if their control has been excellent, and if their blood
connect your patients with the diabetes community,
pressure is under good control, I will discuss anti-VEGF
that can be very empowering for the patient.
therapy with them; and then if I am going to treat, anti-
Dr Nguyen: Do you have a morning glucose target in
VEGF would be my treatment of choice.
mind for most patients?
Dr Do: Dr Nguyen, if you were going to choose an anti-
Dr Peters: The ADA target is between 70 and 130, but if I
VEGF agent, which one would you choose for this patient?
have a patient who has difficulties with hypoglycemia, I
Let us assume patient insurance coverage and finances
would increase the fasting target to 100 to 130. I generally
are not factors.
aim for between 90 and 130 before meals, but it might be
Dr Nguyen: In a case such as this, if finances are not
lower or higher, depending on the individual patient.
a factor, I would choose either ranibizumab or
Dr Nguyen: How does the rate of glycemic reduction
aflibercept because both have been US Food and Drug
potentially worsen retinopathy?
Administration (FDA) approved for the indication of DME.
I am comfortable using either drug, but I may prefer
Dr Peters: In the DCCT, 13.1% of patients randomized to
ranibizumab because it has a longer record of safety
the intensive control arm had worsening of retinopathy
since it was approved several years before aflibercept.33,34
within the first year of treatment, compared with 7.6% of
the patients assigned to conventional treatment.1 Some
Dr Heier: I think most ophthalmologists would choose
of the risk factors for early worsening that were identified
bevacizumab as first-line therapy because cost cannot be
included higher HbA1c levels at screening and
ignored. I have gone on record a number of times stating
reduction of these levels within the first 6 months of
that I always use bevacizumab as my first-line therapy.
treatment. The DCCT authors did not find any evidence
I think that patients do well with it, and almost 90% of my
supporting the concept that more gradual glycemic
patients get bevacizumab. That being said, if cost was not
control might be associated with a lower risk for early
an issue, I would never use it because of the availability
worsening. That being said, they did recommend
of FDA-approved drugs that may be more efficacious in
ophthalmologic monitoring before initiation of intensive
some patients.35 Some information has recently been
treatment and at 3-month intervals for the first 6 to 12
released regarding the Diabetic Retinopathy Clinical
months of treatment.1 They also recommended delaying
Research Network (DRCR.net) Protocol T study, which
the initiation of intensive glycemic treatment until the
compared the safety and efficacy of 2.0-mg aflibercept,
retinopathy was treated, particularly for patients with
1.25-mg bevacizumab, and 0.5-mg ranibizumab in the
poorly controlled diabetes.1 The outcomes for those
treatment of patients with DME. These data have not
patients who were intensively controlled who had early
been peer reviewed. They indicate that there may be
worsening of retinopathy were the same or better than
differences among aflibercept, bevacizumab, and
for those in the conventional group who did not have
ranibizumab with respect to gains in visual acuity and
early worsening.
rates of cardiovascular events.36
1. Early worsening of diabetic retinopathy in the Diabetes Control and
Complications Trial. Arch Ophthalmol. 1998;116(7):874-886.
Dr Do: Many ophthalmologists are aware of the clinical
trial data showing that center-involved DME is best treated
20 RIDE RISE Pooled
with an intravitreal anti-VEGF agent. One of our first
landmark studies was from DRCR.net, which looked at
ranibizumab, given with either prompt or deferred laser,
and it showed that either dosing regimen of ranibizumab
was superior to preservative-free triamcinolone with laser
and also superior to focal/grid laser.37
A change, ETDRS letters
Regarding bevacizumab, which is the most popular choice
among the American Society of Retina Specialists
membership, the BOLT clinical trial that was conducted
4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
in the United Kingdom additionally provides us some
prospective clinical trial data to suggest that bevacizumab
Ranibizumab 0.3 mg
Ranibizumab 0.5 mg
is also an effective option for center-involved DME.38
ETDRS=Early Treatment Diabetic Retinopathy Study.
Aflibercept was recently approved by the FDA for the
Figure 4: Mean change in best corrected visual acuity over time,
treatment of DME, based on the 1-year data from the
RISE and RIDE 3-year pooled data.33
phase 3 VISTA and VIVID studies.39 Aflibercept treatment,
whether dosed every 8 weeks or every 4 weeks, was
Returning to our case, the patient's visual acuity remained
superior to focal/grid laser, and eyes gained an average of
stable after a 1-month period of observation, but his edema
10.5 to 12.5 letters of visual acuity (Figure 3).39 Both dosing
increased on OCT, so I elected to treat him with the only
regimens of aflibercept had similar efficacy. We also have
on-label anti-VEGF treatment available at the time,
some of the 2-year data from VISTA, and both dosing
ranibizumab. I gave him 1 dose, but his visual acuity did
regimens resulted in sustained visual acuity with similar
not improve significantly, and his edema persisted.
Anti-Platelet Trialists' Collaboration-defined arterial
I administered a second ranibizumab injection, and his
thromboembolic events across all groups.40
visual acuity improved to 20/25 with some decrease in
central retinal thickness. After a third
ranibizumab injection, his visual acuity
improved to 20/20 and the center-involved
Another FDA-approved treatment option
that exists for patients with DME is the
A (letters) 15
dexamethasone delivery device.* The
MEAD study looked at the safety and
efficacy of this option, and in a recent
subanalysis of the study, dexamethasone
was found to be more effective than sham
therapy in all subgroups, regardless of
duration of DME, type of DME, duration of
Mean change from Baseline BCV
diabetes, patient age, or perfusion status.41
12 16 20 24 28 32 36 40 44 48 52
12 16 20 24 28 32 36 40 44 48 52
Patients who were pseudophakic at
Time (weeks)
Time (weeks)
baseline showed benefit from
dexamethasone at each chronological
BCVA=best corrected visual acuity; IAI=intravitreal aflibercept injection.
point that was evaluated, while patients
who were phakic at baseline did not show
Figure 3: Mean standard deviation change in best corrected
continued benefit from dexamethasone
visual acuity from baseline through week 52 with censoring of
after the first year of treatment because of the emergence
values after additional treatment was given (last observation
of cataracts. However, when these patients had their
carried forward).39
cataracts removed, their visual acuity results were
comparable to those patients who were pseudophakic
at baseline. We do not know the optimal dosing strategy
When we further probe our armamentarium, we see that
for this implant; in recent phase 3 clinical trials,
the RISE and RIDE studies demonstrated the superiority of
dexamethasone was given every 6 months.42 Most
ranibizumab to sham treatment.33 Looking at the extension
of us would say that it needs to be dosed every 3 to 4
study, patients who were initially randomized to sham
months, according to our clinical experience with the
treatment and crossed over to treatment with ranibizumab
dexamethasone implant for retinal vein occlusion.
2 years later never matched the gains in visual acuity
Dr Nguyen, when would you recommend the
seen in patients who were initially treated with
dexamethasone implant for DME?
ranibizumab (Figure 4).33
Dr Nguyen: I would tend to select anti-VEGF therapy as an
This suggests that a long delay in beginning anti-VEGF
initial treatment based on the clinical outcomes data. If
therapy for DME causes some level of irreversible damage
you compare the overall gains in vision and percentage
to the retina, and those eyes will not catch up to eyes that
of patients who gained more than 3 lines of vision in
began anti-VEGF therapy much earlier. Maybe you could
RISE/RIDE and VISTA/VIVID against the gains in the recent
delay for a few months, but certainly do not delay for a
dexamethasone study, the anti-VEGF therapies had an
period of years.
* A fluocinolone delivery device also has been approved by the FDA recently for the treatment of DME in patients who have been previously treated with a course of
corticosteroids and did not have a clinically significant rise in intraocular pressure. It is expected to be available early 2015.
Dr Do: Dr Heier, if we are concerned about the treatment
Metabolic Parameters and the Response
burden to the patient and the patient's family, then the
to Pharmacotherapy in DME
dexamethasone delivery device may be an attractive
treatment option because it can be given every 3 to 4
Given the prominent role of anti-VEGF therapy and
months. For some patients, this interval might even be
steroid therapy in the armamentarium for the treatment
stretched out further. What is your perspective on the
of DME, it is important to assess parameters that may
influence their efficacy. Although no double-masked
prospective studies have been conducted to assess
Dr Heier: I am happy that the dexamethasone implant
the relationship between glycemic control and
was approved, and I do think that it will help some of our
responsiveness to pharmacotherapy for patients with
patients. But I still think that anti-VEGF therapy is the best
DME, the question has been addressed with other
first line of therapy, largely for its safety profile. Although
investigations. The limitations of investigation designs
cataracts would not be an issue for the pseudophakic
and variation in results have hindered the ability to
patient, the problem of treatment-induced glaucoma
draw any definitive conclusions.
remains,42 and patients with diabetes are already more
likely to have elevations in intraocular pressure than
A recent subanalysis of the MEAD data, which looked at
the role of intravitreal dexamethasone implant therapy
patients without diabetes.43 As you mentioned, I believe
in the treatment of DME, found that there was a trend
that the number of patients who will be able to get to
toward greater influence of dexamethasone in patients
6 months with 1 implant will be relatively low. Three to
who had better control of their diabetes.1
4 months seems a more likely interval.
A retrospective study conducted by Ozturk and
Dr Nguyen: Dr Peters, if a patient's HbA1c is between 7%
colleagues was designed to assess the effects of glucose
and 7.5%, and he or she continues to have problems with
regulation on visual outcomes for patients with DME
recurrent macular edema, is there any utility to lowering
who were treated with ranibizumab. In this study, the
the patient's HbA1c further?
patients' HbA1c values negatively correlated with
Dr Peters: I think that there is a benefit regarding the
the change in central subfield macular thickness
retinopathy issue. I am not sure there is always a benefit in
(coefficient = –0.50, P<.001).2
terms of the entire person, and that is where we providers
Another recent retrospective case analysis conducted
have to collaborate. Some patients are quite fragile, and
by Matsuda and colleagues enrolled 124 consecutive
the risks for hypoglycemia are too great.
patients with DME to determine the role of systemic
factors on functional and anatomic outcomes of anti-
VEGF therapy (bevacizumab).3 Patients with a serum
Dr Heier: This case features a 36-year-old woman with a 25-
HbA1c of ≤7.0% had a more robust response with respect to best corrected visual acuity and central subfield
year history of type 1 diabetes who presented with a 5-day
macular thickness than those whose HbA
history of "black blobs" in the central vision of her right eye.
>7.0%. Patients whose glycemic control improved during
Her most recent HbA1c was 8%. She received panretinal
the study had lower retinal thickness than patients
photocoagulation in her right eye and focal treatment in
her left eye in 2011 (the laser was performed prior to our
1c was stable or had deteriorated.3
care of her). Her visual acuity at the time of presentation
1. Loewenstein A. MEAD: Diabetic Macular Edema Trial Subanalysis. Presented
was 20/25 in her right eye and 20/20 in the left.
at: Retina Subspecialty Day, American Academy of Ophthalmology. October
17-18, 2014; Chicago, IL.
The patient's imaging shows some preretinal hemorrhage
2. Ozturk BT, Kerimoglu H, Adam M, Gunduz K, Okudan S. Glucose regulation
influences treatment outcome in ranibizumab treatment for diabetic macular
inferiorly in the right eye; there is evidence of previous
edema. J Diabetes Complications. 2011;25(5):298-302.
laser. The left eye looks good. Dr Do, how would you
3. Matsuda S, Tam T, Singh RP, et al. The impact of metabolic parameters on
suggest this patient be managed?
clinical response to VEGF inhibitors for diabetic macular edema. J Diabetes
Dr Do: I would recommend obtaining a fluorescein
angiogram to evaluate the retinal vasculature.29 I suspect
that there will be significant capillary nonperfusion and
multiple areas of neovascularization in her right eye. She
may have more retinopathy problems with her left eye as
well. If this patient has poor glycemic control, retinopathy
is likely to be fairly symmetric in both eyes.
Dr Heier: You are correct. There are some areas of
neovascularization and perhaps some capillary
nonperfusion. Her widefield angiogram shows that there
are a number of areas of neovascularization and extensive
capillary nonperfusion (Figure 5). Dr Nguyen, how would
you approach this patient?
Dr Nguyen: This patient has PDR that seems to be laser
deficient at the time of this imaging. I would perform
additional panretinal photocoagulation, because there
is evidence to support its efficacy in controlling the
progression of the PDR.29,44 Because there is no macular
Figure 5: Case 2 widefield angiogram (OD).
edema, I would delay pharmacologic therapy at this time.
Photo Courtesy of Jeffrey S. Heier, MD
Dr Heier: Dr Do, if there was macular edema, would you
a much greater extent of disease pathology than does
approach this patient differently?
7 standard field imaging, and may, in fact, alter the
classification of DR in as many as 10% of eyes evaluated
Dr Do: I would recommend anti-VEGF injection to treat the
by the 7 standard field imaging technique.32,48
macular edema, and panretinal photocoagulation laser to
control the proliferative aspect.
I get baseline widefield imaging on every patient with
diabetes, as well as on patients with retinal vein occlusion.
Dr Heier: Would you administer these 2 treatment
For this particular patient, we were amazed by the extent
modalities at the same time or would you do the anti-VEGF
of disease in her left eye.
first and then the laser?
Dr Do, when treating a patient with DR with anti-VEGF
Dr Do: I tend to do both procedures at the same visit to
therapy, do you follow the patient with angiography?
avoid the need for the patient to come back multiple
times. I also try to do all the panretinal photocoagulation
Dr Do: I think that when treating DME, an angiogram at
baseline is helpful. For routine follow-up and ongoing
management decisions, OCT is more practical. In my
Dr Peters: This young woman is the perfect example of a
opinion, you need to repeat the angiogram only if
patient who should be referred to an endocrinologist, if she
something changes or if the patient does not respond as
is not already under the care of one. Given the fact that
you would expect.
she is of reproductive age, any attempts to treat her
ophthalmic problems would be significantly complicated
Dr Heier: We have recently conducted a study looking at
by a pregnancy.45 Contraception should be discussed. You
just such an issue, and we are currently evaluating the
do not want a patient with poor glycemic control or
results.49 We treated patients who had PDR with either 12
unstable vision becoming pregnant.
monthly injections of aflibercept or 6 monthly injections
followed by a period of 6 months during which the
Dr Do: Yes, I agree completely. We do not know the effects
injections were given every other month. We then followed
of anti-VEGF therapy on pregnant women, so we certainly
the patients with widefield angiography, with the intent of
do not advocate using it in patients who are pregnant. We
examining the degree of nonperfusion and how the anti-
always counsel our young female patients to use a reliable
VEGF therapy affected it.49 I expect to have those results
birth control method, as you have advised.
If this patient with progressive eye disease was to become
pregnant, I would attempt focal/grid laser first for DME,
because that is the safest option.46 If the edema does not
Dr Do: We next have a case of a 62-year-old woman with
respond, and her vision is being further compromised,
a 5-year history of type 2 diabetes who presented with a
then an intravitreal steroid injection may be the next
complaint of decreased vision in her left eye. Her diabetes
best option. The safety of intravitreal anti-VEGF agents
was initially treated with oral antiglycemic agents, but she
in pregnancy is unclear, and we do not recommend
subsequently required insulin. Her most recent HbA1c was
anti-VEGF injections in this population.47 In my opinion,
8.5%. At the time of presentation, she was noted to have
anti-VEGF would be a first-line agent for women of
center-involved DME in her left eye with a visual acuity of
reproductive age who have diabetes and DME, if they are
20/80 (Figure 7).
able to be reliable with contraception. If not, then laser or
intravitreal steroids might be other options to consider.
Dr Heier: Let us move on to the patient's left eye; her OCT
shows a few cysts but a nice contour.
There is some evidence of neovascularization on her
7 standard field imaging, and on her widefield imaging
(Figure 6) gross nonperfusion is evident.
Figure 7: Case 3 baseline OCT OS (20/80–1).
Photo Courtesy of Retina Consultants of Houston
Her retina specialist elected to treat her with ranibizumab,
and after 1 injection, her visual acuity improved to 20/60.
Her edema was still persistent, and her ophthalmologist
administered a second injection. Her vision then was
20/60+2, and her foveal contour returned. Dr Heier, in this
patient, would you continue treatment or begin a period of
observation at this point?
Figure 6: Case 2 widefield angiogram (OS).
Photo Courtesy of Jeffrey S. Heier, MD
Dr Heier: I would continue treatment here. As in RISE and
RIDE, we often see slow recovery of vision in patients with
Recent studies, such as those conducted at the Joslin
diabetes.33 There are still some exudates and fluid
Diabetes Center and Weill Cornell Medical Center, have
temporarily, so I would continue until I was absolutely
shown that ultra-widefield angiography potentially reveals
convinced that she had maximized visual gain.
Dr Do: Dr Nguyen, do you ever consider combining anti-
Dr Do: That is what her specialist did. He administered
VEGF with laser, and if so, when do you add the laser?
another ranibizumab injection. Her macula looked great,
with no edema. Her visual acuity improved to 20/40.
Dr Nguyen: I usually start with anti-VEGF injections alone.
If the eye has a suboptimal response to the intravitreal
Subsequently, her provider decided to administer yet
VEGF blockers, I may switch anti-VEGF agents or add
another injection, and her vision improved by 1 line to
focal/grid laser to the injections.
20/30. Dr Nguyen, what would you do now? Do you think
that the eye will go to 20/20 if you give 1 more injection?
Dr Heier: While I am not yet convinced that subthreshold
Should we continue?
micropulse diode laser50 will work, if the problem is
recurrent, as it is in this scenario, I would be interested
Dr Nguyen: She continues to improve, so I would say to
to see if such an approach would help.
continue monthly therapy.
Dr Do: I know many of our colleagues like to combine
Dr Do: When you look at the visual acuity response curves
the effects of anti-VEGF therapy with focal/grid laser.
from the randomized clinical trials pertaining to the
Interestingly, the DRCR.net Protocol I demonstrated that
treatment of wet macular degeneration and DME, you can
in year 3, eyes randomized to ranibizumab with deferred
see that visual gains rise quickly in age-related macular
laser (laser given at month 6 or later) had gained almost
degeneration (AMD) and may also plateau more quickly
3 letters more compared with eyes randomized to
in AMD than they do in DME (Figure 8).33,52
ranibizumab with prompt laser. These data suggested that
anti-VEGF treatment with deferred laser may be more
We do not know why this slight difference occurs. One
beneficial than when laser is used at the beginning.51
study looking at bevacizumab for the treatment of
DME found that although anti-VEGF therapy did lower
In this case, the patient's retina specialist provided another
intraocular VEGF levels dramatically, the effect on other
anti-VEGF treatment, and her vision improved to 20/40.
cytokines involved in disease progression was not as great
Dr Nguyen, what would you do at this time? Would you
as it is in AMD.53,54
observe, or continue the anti-VEGF therapy? When would
your end point be?
Dr Nguyen: The patient has continued to show
Dr Nguyen: I think that there are several key messages to
improvement in vision, so I would like to make sure that
highlight. First, we need to be patient with our treatment
we have maximized her potential gain in visual acuity.
choices with DME, because it appears that the time to
I would continue to treat her at this point, because there
maximal effect of anti-VEGF therapy may be longer for DME
may yet be some level of edema that we could eliminate.
than it is for some other retinal vascular diseases. Anti-VEGF
therapy does appear to be a therapeutic cornerstone for
DME, particularly for those patients with central involvement.
Second, an individualized approach to glycemic control may
benefit patients with diabetes more than trying to treat to a
specific HbA1c goal. Third, DR and DME are quite complex
and variable in their presentations, and it may be
worthwhile to consider widefield angiography as a means of
detecting and assessing the true scope of these diseases.
My appreciation to our panelists for a lively discussion of
some essential management strategies for our complex
ean Change in Visual Acuity (no. of letters)
patients with DR and DME. An individualized approach
can provide great improvements in glycemic control as
well as in visual outcomes.
Trial Abbreviations Used
Action to Control Cardiovascular Risk in Diabetes
Action in Diabetes and Vascular Disease: Preterax
and Diamicron MR Controlled Evaluation
A prospective randomized trial of intravitreal
bevacizumab or laser therapy in the management
of diabetic macular edema
Macular Edema: Assessment of Implantable
Dexamethasone in Diabetes
ean BCVA Change, ETDRS letters
A study of ranibizumab injection in subjects with
clinically significant macular edema with center
involvement secondary to diabetes mellitus
Ranibizumab 0.3 mg
Ranibizumab 0.5 mg
Veterans Affairs Diabetes Trial
Figure 8: Visual acuity response curves from ANCHOR (AMD)52
A study of intravitreal administration of aflibercept
and RISE/RIDE (DME).33
in patients with diabetic macular edema
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CME Post Test Questions
To obtain AMA PRA Category 1 Credit ™, please see detailed instructions on page 2.
1. Which of the following factors would tend to favor more
6. Which of the following statements regarding the
stringent management of hyperglycemia for a patient
relationship between type 1 diabetes and patient age
with type 2 diabetes?
a. High level of risk potentially associated with
a. Older patients are less successful with glycemic
control than adolescent patients
b. Low patient motivation
b. Approximately 30% of adult patients are at
c. Long-standing duration of disease
d. Lack of established vascular complications
c. The frequency of severe hypoglycemia decreases
2. Which of the following statements regarding the
d. Pediatric glycemic goals have been made less
management of hyperglycemia in type 1 diabetes
stringent because of validated concerns regarding
a. Adult glycemic targets are more stringent now
than they have ever been
7. A patient with evidence of clinically significant diabetic
b. Early problems with hyperglycemia do not
macular edema should have an HbA1c target value:
predispose children to complications as adults
c. Ophthalmologic monitoring should take place
before and during the first year of increased
glycemic control efforts
d. That takes into account multiple individual patient
d. Patients with long-standing diabetes should
factors, including risk for hypoglycemia
always aim for an HbA1c value of ≤6%
8. All the following statements regarding the use of OCT in
3. The use of ultra-widefield angiography for patients with
the management of DME are true, except:
diabetic macular edema:
a. OCT imagery has a high level of correlation with
a. Has been mandated as a means of following
anatomic outcomes in clinical trials
b. OCT is a highly reproducible method of measuring
b. Has revealed a correlation between the degree of
pathological features of DME
retinal ischemia and macular thickness
c. OCT can monitor response to therapies such as
c. Has the potential to change the classification of a
surgical intervention and intravitreal
patient's ophthalmic disease
d. Has been shown to be less efficacious than
d. OCT may be performed in conjunction with
7 standard field imaging as a means of detecting
fluorescein angiography
diabetic pathology
9. All the following factors may adversely influence visual
4. Dexamethasone implant use for the treatment of
health for patients with diabetes, except:
diabetic macular edema:
a. Is currently FDA approved for pseudophakic adult
c. Poor glycemic control
b. Provides up to 2 years of medication per implant
d. Low serum triglyceride levels
c. Carries no appreciable risk for elevations in
intraocular pressure
10. When assessing the response of patients with DME to
d. Is a Pregnancy Category X treatment
anti-VEGF therapy, it is important to consider that:
a. Visual gains plateau more quickly in DME than
5. Anti-VEGF therapy for clinically significant diabetic
b. Glycemic control influences the efficacy of all
a. Is regarded as a first-line choice for this condition
when it involves the foveal center
c. Prolonged delays in anti-VEGF therapy may limit
b. Has worse functional and visual outcomes than
the magnitude of visual gains for patients who are
laser photocoagulation
candidates for it
c. Has only 1 FDA-approved option
d. Anti-VEGF therapy should be combined with laser
d. Typically achieves maximum functional gains
therapy within the first month of pharmacologic
by 2 months of treatment
Activity Evaluation/Credit Request
Original Release: January 2, 2015 • Last Review: December 9, 2014 • Expiration: January 31, 2016
Current Management of Diabetic Macular Edema and Diabetic Retinopathy:
A Multidisciplinary Discussion of Clinical Cases
PARTICIPANT INFORMATION (Please Print)
❏ Home ❏ Office
Last Name _ First Name Birth Month/Day (mm/dd)
Specialty Degree ❏ MD ❏ DO ❏ OD ❏ PharmD ❏ RPh ❏ NP ❏ RN ❏ PA ❏ Other
City State _ ZIP Code Country
E-mail Phone Fax _
The objectives were achieved.
Upon completion of this activity, participants will be better able to:
Recognize the importance of individualized glycemic control in optimizing outcomes for patients with DR/DME
Discuss the utility of different diagnostic imaging techniques in guiding the management of patients with DR/DME
Describe the efficacy, dosing, and safety profiles of current and emerging treatment options for DME
Confidently tailor diagnostic and treatment strategies for various patients with DR/DME
Communicate effectively with referring physicians regarding the relevant systemic and ophthalmic health issues of their mutual patients with DR/DME
FINANCIAL INTEREST AND BIAS
Disclosure of relevant financial interests of presenters and planners was stated. ❏ Yes ❏ No
This educational activity was free of commercial bias. ❏ Yes ❏ No
If no, please explain.
IMPLEMENTING INTO PRACTICE
Do you intend to make changes or to apply new knowledge as a result of this educational activity?
I intend to make changes to improve my effectiveness. ❏ Yes ❏ No
This experience will not change my practice, as my current behavior is already consistent with the information provided. ❏ Yes ❏ No
If no, please explain.
What strategies for improvement or changes do you plan to implement following this educational activity?
Please indicate all barriers you perceive in implementing these changes. (check all that apply)
❏ Lack of professional guidelines or consensus
❏ Patient compliance issues
❏ Opportunity to practice
❏ Lack of resources
❏ Lack of health system support
❏ Further training is needed
❏ Cost/Reimbursement/Insurance issues
❏ Other, please specify _
How do you think your changes will affect patient outcomes?
POST TEST ANSWER BOX
Source: http://www.oftalmo.epm.br/no/diabetic.pdf
INSTALLATION AND MAINTENANCE MANUAL Original instructions MAN3300010 rel. 03 dated 27.09.2011 www.rheavendors.com Caffè Europa by this manual is intended to describe the Caffè Europa vending machine in its three versions: basic, multimedia and multitouch; by using the same basic components, the three machines differ from each other in components and in the
Private experience and observational learning in pharmaceutical demand Tanja Saxell∗† February 13, 2014 I quantify the roles of the physician's own experience and the past choices of other doctorsin pharmaceutical demand. I develop a model of medical decision-making under uncer-tainty about the quality of the match between the patient and drug treatment. Unlikeprevious demand models, I take into account both private and social learning, and allowheterogeneity in product quality across individuals. I test whether information on thepast choices of other doctors improves drug choices. Using rich data from the market forcholesterol drugs, I show that treatment patterns relying heavily on the past choices ofother doctors can lead to over-prescribing in terms of e ciency. My results suggest thatcontinuity of care, where a patient is repeatedly consulting the same doctor, is an e cientpolicy to limit such behavior.
