A weekly e-newsletter to help increase awareness and support patient education. This week features Szilárd Kiss, MD, discussing the diabetic risk factors and key conversations to have with patients. This week’s edition features Charles C. Wykoff, MD, PhD, discussing types of diabetes and shifting treatment options resulting from new data and studies. David Eichenbaum, MD, discussing tips to help physicians motivate their patients to adhere to therapy for their diabetic eye disease. Geeta Lalwani, MD; and A. Paul Chous, OD, CDE, discussing comanagement tips for diabetic eye disease.
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We know disease duration is the leading risk factor for vision loss from diabetes.1
Elevated levels of blood sugar, blood pressure, and blood lipids are all associated with disease progression and the onset of DR.1,2
Regular eye examinations along with good control of blood sugar, blood pressure, and blood lipids are the primary steps patients can take to minimize their risk of diabetic eye disease.
1. Pregnancy. Pregnancy can cause changes to diabetic eye disease, almost independent of blood sugar levels. In the setting of abnormal blood sugars, the retinopathy can progress.3 Women with diabetes should be examined as the family planning process progresses, during the first and second trimesters of pregnancy, and after giving birth.
2. Sleep Apnea. Sleep apnea has been linked to worsening diabetic eye disease, owing to intermittent hypoxia,4 but eye care providers and primary care physicians often do not associate this condition with vision loss. If your patient is obese, has some difficulty breathing, and seems tired most of the time, ask about sleep apnea, particularly if his or her DR seems out of proportion to what you think it should be. Treating sleep apnea may help a patient’s diabetic eye disease.
3. Denial. Some patients, for many reasons, do not visit their doctors, even when they suspect something may be wrong. Educating patients on the risk factors associated with diabetes and the consequences of nonadherence is vital to preventing tragic results.
Diabetes is an incurable disease; however, it can be controlled. It is important for eye care providers to counsel patients about lifestyle changes and medications that will help them control risk factors associated with diabetes.
We are all a part of the education solution to teach our patients about the risks associated with this disease. We also need to make the consequences of untreated diabetes tangible. Taking the time to bring the picture together for patients can make a big difference in how they interpret these consequences.
1. Jau JW, Rogers SL, Kawasaki R, et al.; Meta-Analysis for Eye Disease (META-EYE) Study Group. Global prevalence and major risk factors of diabetic retinopathy. Diabetes Care. 2012;35:556-564.
2. Yun JS, Lim TS, Cha SA, et al. Lipoprotein(a) predicts the development of diabetic retinopathy in people with type 2 diabetes mellitus. J Clin Lipidol. 2016;10:426-433.
3. Morrison JL, Hodgson LA, Lim LL, Al-Qureshi S. Diabetic retinopathy in pregnancy: a review. Clin Exp Ophthalmol. 2016;44:321-334.
4. Nashimura A, Kasai T, Tamura H, et al. Relationship between sleep disordered breathing and diabetic retinopathy: Analysis of 136 patients with diabetes. Diabetes Res Clin Pract. 2015;109:306-311.
Diabetic retinopathy (DR) is a blinding disease, but in a majority of cases today, it is treatable, and blindness can be prevented if patients are diligent about compliance (See last week’s article).
Positive outcomes over the last decade stem from advances in pharmacotherapy — both anti-VEGF agents and steroids — that built on the value of retinal lasers. New data and ongoing studies are expanding our indications. By initiating treatment earlier in the disease course, you can attempt to preserve vision, improve quality of life, and ultimately reduce the treatment burden for your patients.
Here is a snapshot of where we stand now, with a look at the most recent FDA approval and ongoing trials that may trigger future paradigm shifts.
The two most common causes of blindness in diabetes are proliferative diabetic retinopathy (PDR) and diabetic macular edema (DME).
The data from these trials are shifting treatment patterns. Many cases of PDR are now managed with anti-VEGF therapy, often in combination with more limited peripheral laser application.
Optimal management of patients with nonproliferative diabetic retinopathy (NPDR) without DME, is in flux.
I believe we will find that the earlier we treat DR and DME, the fewer treatments patients will need and the better ultimate visual outcomes they will enjoy. I believe our treatment paradigms will continue to shift toward intervening earlier, giving our patients better long-term visual potential.
1. Beaulieu WT, Bressler NM, Melia M, et al.; Diabetic Retinopathy Clinical Research Network. Panretinal photocoagulation versus ranibizumab for proliferative diabetic retinopathy: patient-centered outcomes from a randomized clinical trial. Am J Ophthalmol. 2016;170:206-213.
2. Sivaprasad S, Prevost AT, Vasconcelos JC, et al.; CLARITY Study Group. Clinical efficacy of intravitreal aflibercept versus panretinal photocoagulation for best corrected visual acuity in patients with proliferative diabetic retinopathy at 52 weeks (CLARITY): a multicentre, single-blinded, randomised, controlled, phase 2b, non-inferiority trial. Lancet. 2017;389:2193-2203.
3. McKean-Cowdin R, Varma R, Hays RD, et al.; Los Angeles Latino Eye Study Group. Longitudinal changes in visual acuity and health-related quality of life: the Los Angeles Latino Eye study. Ophthalmology. 2010;117:1900-1907.
Physicians who care for patients with diabetes are challenged to keep their patients engaged and to encourage them to continually strive to achieve their health goals. This includes motivating them to adhere to therapy for diabetic eye disease.
The fact that we can effectively treat all stages of diabetic retinopathy (DR) — not just control it but actually improve the level of retinopathy — is tempered by the need for frequent treatments for at least the first 12 months to achieve optimal therapeutic effect.
How do we help prepare patients to adhere to this course of therapy? Communication is key. Here are five tactics I have found effective with my patients. I encourage referring ophthalmologists and optometrists to adapt these conversations for use in their offices, as well.
When I diagnose patients with DR, I start the conversation by telling them something they rarely hear from their other doctors: “I can make you better.” Then I follow up with “…but it requires a commitment to therapy.”
My favorite graphic teaching tool is ultra widefield angiography. I think these high-quality black-and-white pictures are even more impactful than lower-contrast color photos for our layperson patients.
Whatever evidence-guided treatment I recommend, I know the first year involves a fairly high burden of frequent office visits, so I tell patients, “We are going to get to know each other very well during this first year, but after that, I probably will not see you quite as often.”
This is how I segue into an explanation of the course of treatment — whether it involves anti-VEGF or steroid injections, laser, or a combination — and the importance of staying the course to achieve the optimal benefit.
When I sense that a patient is becoming fatigued, usually after a few injections, I tell him that diabetes is like a freight train that has been heading in the wrong direction for a long time. We are trying now to put it into full reverse by treating his local disease and by controlling his blood glucose going forward.
I explain that even though his diabetic “train” is now in reverse with treatment, momentum is going to keep it going down the track of disease for a while. I explain, “You are riding on that momentum. We are not battling the sugars from 5 months ago, we are battling the sugars from the last 5 years. If you can commit to a loading course of injections and keep your sugars under control now, we can keep this freight train from rolling further down the track of disease advancement. With your commitment, your diabetic disease will slow down or stop getting worse before you run out of track.”
I find that analogy helpful with both the commitment to frequent intravitreal therapy when initiating injection treatment for DR, as well as for encouraging patients to better control their sugars and affect their systemic disease progression.
Patients need to control their diabetes, and for many, this can be daunting. I want my patients to know that I am as interested in their progress as their diabetologist is.
Referring ophthalmologists and optometrists play an important role in managing and treating the stages of DR. Encouraging patients to adhere to therapy is a challenge, but with these five tactics, it should make the process smoother for both the physician and patient.
Diabetes is a chronic, life-long condition and calls for careful comanagement among a patient’s diabetic eye care team members. In honor of Diabetes Awareness Month, a retina specialist, Geeta Lalwani, MD, and an optometrist, A. Paul Chous, OD, CDE, offer insights on their individual roles and working together when caring for patients with diabetes. They share the following tips on developing and maintaining relationships for referring partners and key members of the diabetes care team.
In summary, communication remains key and is a team sport across eye care, as well as a patient’s other diabetes care physicians. The role of the general eye care provider is irreplaceable and needs to remain front and center in the routine care of all patients. Applying the latest retina clinical advances to provide patients the best opportunity for saving vision takes a village. Communication with patients is also a key element to managing diabetic eye disease. Eye care team partnerships and partnerships with patients themselves serve everyone well.
• Chief, Retina Service; Director, Clinical Research; Director, Tele-Ophthalmology; Director, Compliance; Associate Professor of Ophthalmology at Weill Cornell Medical College; and Associate Attending Physician at New York-Presbyterian Hospital, New York City
• Consult/Research Support: from Alcon, Alimera, Genentech/Roche, Optos, and Regeneron
• Director of Research at Retina Consultants of Houston; Deputy Chair of Ophthalmology for the Blanton Eye Institute, Houston Methodist Hospital
• Consultant/Grant Support from: Alimera, Allergan, Bayer, Clearside, Genentech, and Regeneron
• Partner in Retina Vitreous Associates of Florida, Clearwater; Clinical Assistant Professor of Ophthalmology at the University of South Florida, Tampa
• Consult/Research/Speaker support:
from Alimera, Allergan, Clearside, Genentech, Novartis, and Regeneron
• Editorial Advisor, Review of Optometry and Optometry Times; AOA Representative, National Diabetes Education Program; Primary Investigator, Diabetes Visual Function Supplement Study (DiVFuSS); and Adjunct Instructor, NOVA Southeastern University College of Optometry
• Consultant/Advisory/Speaker Support:
from Bausch & Lomb, Diabetes In Control, DiabetesSource, Genentech, GlaxoSmithKline, Kestrel, Optos, Regeneron, Risk Medical Solutions, VSP, ZeaVision, and Zeiss
• Founder, Rocky Mountain Retina Associates in Boulder, Colorado
• Consultant/Advisory/Speaker Support:
from Alcon, Bausch & Lomb, Dutch Ophthalmic Research Center, Genentech, and Regeneron
Retina Today is a publication that delivers the latest research and clinical developments from areas such as medical retina, retinal surgery, vitreous, diabetes, retinal imaging, posterior segment oncology and ocular trauma. Each issue provides insight from well-respected specialists on cutting-edge therapies and surgical techniques that are currently in use and on the horizon.