CME - dr AJAY dudani

CME MANAGEMENT

1. CYSTOID MACULAR
EDEMA
DR. AJAY I DUDANI
M.S.,DNB,FCPS,DOMS
DR. SHEENA BUCH
DOMS

2. CystoidMacular Edema-CME
Appearance of fluid filled cystic
spaces in the macular region

3. CystoidMacular Edema-CME

4. Most Common Cause
Macular edema after cataract surgery
(Irvine-GassSyndrome)

5. Other Causes
Other intraocular surgeries
Non-proliferative Diabetic Retinopathy
Exudative ARMD with CNVM –serous
detachment of overlying retina and CME

6. Other Causes
Retinal vein occlusions
Glaucoma treatment with LATANOPROST
Retinitis Pigmentosa

7. Other Causes
Chronic Uveitis
High doses of Niacin
(for Hypercholesterolemia)
EpiretinalMembranes

8. Other Causes
Choroidaltumors
CMV Retinitis

9. Pathophysiology
Irvine GassSyndrome
Inflammatory cause
Vascular instability and breakdown of blood
retinal barrier
Release of cytokines
Accumulation of fluid in outer plexiformand
inner nuclear layer

10. Pathophysiology
Diabetes and Vein Occlusions
Vascular damage directly (endothelial cell
damage)
In ARMD
Neovascularmembranes are inherently leaky

11. Pathophysiology
Epiretinalmembrane, Vitreo-macular traction
Direct mechanical forces

12. Clinical Features
GRADUAL PAINLESS VISION LOSS
UNIOCULAR OR BINOCULAR –
Depending on etiology
Vision is typically in the 20/40 to 20/200 range

13. Clinical Examination
Blunt/irregular retinal fovealreflex
Retinal thickening
And/or cysts

14. Additional Examination
To elicit cause
Uveitis–presence of ant. Chamber/vitreous
cells
Epiretinalmembrane/Pucker –in macular
region
Diabetes –Features of diabetic retinopathy
Irvine-GassSyndrome –Optic disc edema

15. Laboratory Inv.
Guided by suspected etiology
Fasting blood sugar
Blood pressure monitoring
Lipid Profile
Further work-up for hypercoaguablestate

16. Imaging Studies
Fundus FlouresceinAngiography (FFA)
Late phase showing
central macular leakage
in cystic spaces around
the fovea

17. Imaging Studies
Optical Coherence Tomography(OCT)
OCT showing central
macular cystic spaces in
cross -section

18. Treatment –Medical Care
Topical and systemic NSAID’s –Inhibit
cycloxygenase
Diclofenac, Ketorolac, Nepafenaceyedrops
Administered 3 times a day for 3-4 months
Steroids –Inhibit phospholipase
Topical/Oral/Intra-vitreal/Sub-tenon
However, many side-effects

19. Treatment-Medical Care
Carbonic AnhydraseInhibitors-enhance the
pumping action of RPE cells
Oral Acetazolamide250 mgs 3-4 times a day
Anti –VEGF Therapy –VEGF known mediator
of capillary leakage
Intra-vitrealBevacizumab

20. Treatment-Surgical Care
Pars Plana Vitrectomy
Indications
Remove vitreous strands stuck to pupil after
complicated cataract surgery/trauma
Peeling of Epiretinalmembrane
Peeling of posterior hyaloidface in vitreo-
macular traction syndrome
Unresponsive to medical treatment

21. Prevention
Avoid intra-ocular complications
Post. Capsule tear/Vitreous loss/Dislocated
lens fragments/ IOL capture/Iris prolapse

22. Prevention
Pre-operative NSAIDS decrease the incidence
of CME after Cataract Surgery

23. Course and Prognosis
Most cases resolve with treatment
PseudophakicCME has the best prognosis
However, if persistent or multiple remissions
or exacerbations, leads to irreversible
photoreceptor damage and vision loss