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Diabetic retinopathy position statement promotes prevention, early detection, control
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A new position statement by the American Diabetes Association recommends intensive glycemic control and regular screening for prevention and early detection of diabetic retinopathy and highlighted the role of anti-VEGFs in the management of diabetic macular edema.
Diagnostic assessment and treatment options have greatly improved since the previous position statement in 2002, the authors noted. OCT, widefield fundus photography and anti-VEGFs have entered the scene, and new medications and devices have improved the ability of patients to effectively control the disease.
Several studies since then have demonstrated a close correlation between hyperglycemia and diabetic microvascular complications, including retinopathy. Consequently, early treatment with intensive therapy is key: A 10% reduction of hemoglobin A1c was shown to reduce the risk of retinopathy progression by 43%.
Regular eye examination was also recommended, within 5 years of diagnosis of type 1 diabetes and at the time of diagnosis of type 2. If retinopathy is progressing, more frequent examinations are required, while pregnant women should be monitored every trimester.
“Intravitreal injections of anti-VEGF were acknowledged as the standard of care for central-involved diabetic macular edema (DME), following numerous well-designed randomized phase 3 clinical trials that have shown benefit compared with monotherapy or even combination therapy with laser,” the authors wrote. DRCR.net data suggest that patients with lower level of acuity of 20/50 or worse respond better to aflibercept.
Due to the inferior results obtained in phase 3 trials and the increased adverse events of cataract and glaucoma, intravitreal steroids were not recommended as first-line therapy.
Finally, laser photocoagulation was confirmed to still be a viable option, but only in limited cases of patients with high-risk proliferative diabetic retinopathy and in some cases of nonproliferative diabetic retinopathy.
Regarding cost-effectiveness, “eye injections have been shown in numerous studies to be more cost-effective than laser monotherapy,” the authors wrote. – by Michela Cimberle
Disclosure: Solomon receives academic support through the Katharine M. Graham Professorship at Wilmer Eye Institute, Johns Hopkins School of Medicine. Please see the published paper for the other authors’ financial disclosures.
Perspective
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Kuniyoshi Kanai, OD, FAAO
The American Diabetes Association updated its position statement on diabetic retinopathy for the first time in 15 years. Fifteen years is long enough to change the landscape of the ever-changing field of medicine.
Historical perspectives of landmark studies, such as WESDR and DCCT, are still valid, and tight glycemic control remains at the forefront of prevention of blindness from retinopathy. However, we are now equipped with refined knowledge on risk management.
The more recent studies found a potential benefit of lipid-lowering therapy, particularly with fenofibrate. The ACCORD Eye Study found flooring effect of blood pressure control – tight blood pressure control had no additional benefit over the standard control.
In addition to retinopathy risk stratification, treatment strategy has dramatically changed in 15 years. As we are all familiar, anti-VEGF agents are the current mainstream of diabetic macular edema treatment. Treatment decision has been shifting from ETDRS criteria of “clinically significant macular edema” to OCT-based “center-involved” diabetic macular edema. Anti-VEGF agents are even implicated for proliferative diabetic retinopathy after successful work by the DRCR.net group.
Indeed, we are at a turning point of diabetic retinopathy management.
References:
ACCORD Study Group, et al. N Engl J Med. 2010;doi:10.1056/NEJMoa1001288.
DCCT Research Group. Diabetes Care. 1987;10(1):1-19.
Klein R, et al. Ophthalmology. 1987;94(11):1389-1400.
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