Ophthalmologists’ role key to mitigating burden of diabetic eye disease

Take-home message: Preserving vision in patients with diabetes requires ophthalmologists to be aware of the importance of reinforcing preventive strategies, maintaining communication with internists/diabetologists, and keeping up to date with current treatment approaches.

By Cheryl Guttman Krader; Reviewed by Paul Sternberg Jr., MD

Nashville, TN-Though much progress has been made in helping patients with diabetes to preserve their vision, ophthalmologists must continue to give high priority to delivery of eye care for these patients, according to Paul Sternberg Jr., MD.

Diabetic retinopathy and diabetic macular edema (DME) remain leading causes of vision loss in adult populations, and an increasing prevalence of diabetes is compounding the burden.

Advocating and communicating

Annual screening for diabetic eye disease, along with good glycemic and blood pressure control, help to prevent diabetic retinopathy-related vision loss. However, available data show poor patient adherence to those strategies.

“At best, only about 60% of patients have yearly screenings for diabetic retinopathy, and perhaps only 12% of patients present for their eye exam, have good blood pressure control, and are meeting their HBA1c target,” said Dr. Sternberg, G.W. Hale Professor and chairman, Vanderbilt University, Nashville, TN.

“In speaking to patients, ophthalmologists need to reinforce these goals and their importance,” he said.

In discussing metabolic control, ophthalmologists should remind patients that controlling blood pressure, hyperglycemia, and hyperlipidemia are critical to their overall health, as well as to their risk for diabetic retinopathy development and progression.

Though tighter glycemic control is better globally and in terms of diabetic retinopathy risk, ophthalmologists need to be sensitive to the fact that glycemic targets are individualized for patients based on a variety of features.

“Ophthalmologists should be ensuring that patients are aware of their HbA1c target and recognize the importance of being compliant with that goal,” Dr. Sternberg said.

In addition to having proper communication with patients, ophthalmologists need to be communicating with the primary-care physician and diabetologist who can reinforce the importance of appropriate ophthalmologic follow-up and strategies for preventing onset or progression of diabetic retinopathy.

“It is not just enough to do the eye exam,” Dr. Sternberg said. “Ophthalmologists need to make sure the information is communicated back to the providers who are managing the diabetes and its related comorbidities.”

Current strategies for intervention

The 2014 American Academy of Ophthalmology Preferred Practice Pattern on diabetic retinopathy states that laser photocoagulation remains the preferred treatment for non-center-involving DME, Dr. Sternberg observed.

However, ophthalmologists should be careful to note that this recommendation is specifically for non-center-involving disease. Based on clinical trial evidence, anti-vascular endothelial growth factor (VEGF) injection has become the primary intervention for treatment of clinically significant macular edema, regardless of whether the center is involved.

“There is even evidence that laser treatment should be deferred until we see what effect anti-VEGF treatment has,” Dr. Sternberg said.

Panretinal photocoagulation remains the appropriate treatment for proliferative diabetic retinopathy (PDR). However, an ongoing trial being conducted by the DRCR network is investigating anti-VEGF therapy for PDR.

“The results of this study may impact how we treat PDR in the future,” Dr. Sternberg said.

Paul Sternberg Jr., MD

E: paul.sternberg@vanderbilt.edu

This article was adapted from the 2014 meeting of the American Academy of Ophthalmology. Dr. Sternberg has no relevant financial interests to disclose.