Four ways to discuss diabetic treatment with patients

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In my practice, I see a large population of younger, working diabetic patients with retinal vascular complications. These individuals have complex and chronic eye disease. Therefore, I take the time at the outset of treatment to explain that their therapy will also need to be similarly long-term and multifaceted. Setting expectations will ensure that patients stay committed and engaged over the full course of their long-term treatment regimen. Here are four pearls you can follow: 

1. Every picture tells a story
A picture-or optical coherence tomography (OCT) scan or a fluorescein angiogram (FA)-speaks a thousand words. It is amazing how powerful and educational images are to patients when describing their condition.

With color-coded OCT maps, for example, patients can see that green and yellow indicates normal tissue thickness with red and white representing “sick” thickened tissue. As they come back for their follow-up, patients begin to monitor their OCT scans with me to track their retinal thickness.

When patients merely note what their HbA1C numbers are without observing the consequences of their lack of blood sugar control, it is easy for them to dismiss the seriousness of their condition. When I show patients an angiogram of their retinas, however, they can see evidence of damaged blood vessels in their body.

I explain that black areas on FA indicate tissue that has suffocated from a lack of oxygen. The small white dots indicate “balloons” in the vessels that are breaking down, I tell them, and I say that the large white areas are leaking areas and abnormal harmful growth of vessels over the retina.

When patients see compelling OCT and FA images, they tend to more fully grasp the severity of their diabetes and its implications.

2. Chronic means forever
I emphasize that, just as diabetes is a chronic disease that requires ongoing treatment, the same holds true for their eye disease. I might say, thankfully, I do not have to inject you or perform laser treatment every day-I can see you once every 4 weeks. It is important that they understand their role in committing to the treatment regimen and have the correct mindset.

3. The five-year delay
I educate patients to the delay between A1C control and vascular damage. The Diabetes Control and Complication Trial revealed that in patients with type 1 diabetes, microvascular disease is occurring five years after the onset of the disease.

There is at least a five-year delay between the glycemic dysfunction and microvascular disease. Reciprocally, there is five-year delay between glycemic control and microvascular healing. If a patient says his or her blood sugar is in control now, I say that we are dealing with damage that has been happening during the past five years and now we have to treat it and “catch up.”

4. Complex disease requires multipronged therapy
When it comes to discussing treatment options with patients, the key concept I try to communicate is that complex diseases require combination therapy.

I explain that my goal is to use multiple modalities because it has been shown that the combined benefits are superior and longer lasting to single approaches, and ultimately, we want to be able to reduce the frequency of office visits.

I tell patients that, in general, we like to start with treatments that have the lowest risk of side effects, the least amount of complications, and are the most convenient. From there, we progress to more advanced techniques. Eye drops if applicable would be first line, for example, then injections, followed by laser, in-office surgery, and other surgical interventions.

Treatment approach
My usual treatment in retinal vascular disease-whether it is proliferative diabetic retinopathy or diabetic macular edema-is first to inject with bevacizumab. After the initial injection, which is also the patient’s first-ever intravitreal injection, I see the patient back after one week.

I check for any adverse reaction, make myself available to counsel the patient and answer questions, and address concerns after a first-time invasive procedure to their eyes. I am not looking for any major visual benefit associated with the treatment at this point, instead, I use this short office visit to provide patients with peace of mind and repeat the OCT to look for any trends in decreasing central macular thickness.

I inject patients on a four- to five-week interval with bevacizumab. I stress to patients the need for them to committing to their treatment schedule so as not to lose the benefit gained. It is important to note the burden on patients with bilateral disease who must return every two weeks.

I try to make sure, however, that they understand that studies show the more aggressive we are with treatment early in the disease, the better the outcomes are over the long term. For patients receiving the loading injections, I have my staff dilate only the treatment eye so that they can be on a “fast-pass” through clinic to receive their injections only.

Follow-up
After two or three injections, I reassess the patient via OCT to identify a trend toward improvement, i.e., drying. Once I do see a trend, I add laser therapy. If there is capillary nonperfusion or neovascularization, I treat with a laser (PASCAL Endpoint Management, Topcon) to target these areas, as well as for macular edema.

Conditions that are associated with severe vision loss such as vitreous hemorrhage, neovascular glaucoma or neovascularization of the retina with a tractional component, are more serious than DME in terms of the severity of associated vision loss. The combination of anti-VEGF and panretinal photocoagulation laser with close monitoring is an effective treatment for these patients.

My laser treatment is not “one size fits all.” I can be very conservative with peripheral treatment at first, waiting at least 30 days after the treatment session. It may take two to three sessions to achieve complete resolution of all neovascularization on the angiogram. At the same time, I continue with anti-VEGF while I try to reach the final balance between retinal oxygen demand and supply.

Conclusion
Do not shy away from showing patients what you see on OCT and FA. Use chair time educating patients about their disease and the treatment strategy, their role-and commitment-in the process, and set their expectations. Consider not starting treatment on that very first visit.

Instead, focus on ensuring your patients must have the mindset that their eye disease, like their diabetes, is a chronic condition that will require ongoing treatment.

Disclosures:

Ragui Sedeek, MD, is in practice at Elite Eye Care, Santa Maria, CA. He can be reached at Dr.Sedeek@shepardeye.com.
This information is Dr. Sedeek’s opinion and experience and not that of Topcon.

References:

1. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin dependent diabetes mellitus. N Engl J Med. 1993;329:977-986.