Older age, worse diabetic retinopathy may predict vision loss in DME
Older age and more severe diabetic retinopathy were linked to vision loss in eyes with diabetic macular edema and good starting visual acuity, according to a retrospective cohort study in Retina.
“Although some real-world studies suggest that anti-vascular endothelial growth factor therapy for DME with good visual acuity [does] not improve visual outcomes after 1.7 years of follow-up, delayed treatment in these types of patients after a median follow-up of 3 years [was] linked to poor visual outcomes, with worse visual acuity at the time of treatment initiation associated with poorer long-term visual outcomes,” Daniella Lent-Schochet, BS, of the department of ophthalmology and vision science, University of California Davis, and California Northstate University College of Medicine, and colleagues wrote. “These studies highlight the importance of close monitoring and the value of identifying factors that may predict the risk of vision loss when observing patients with DME and good initial visual acuity.”
Lent-Schochet and colleagues set out to determine what factors are most important to monitor in these patients. Demographic and clinical characteristics were recorded, with vision loss defined by the DRCR Protocol V study. The study included 56 eyes of 48 patients (mean age, 63.1 years) with center-involving DME seen at University of California Davis Eye Center between March 8, 2007, and March 8, 2018.
Inclusion criteria were visual acuity of at least 20/25 at baseline, no prior DME treatment, at least 1 year of follow-up with spectral-domain OCT imaging and no treatment of any kind in the study eye during the study period.
During an average follow-up period of 4.9 years, 42 eyes (75%) had visual acuity loss, which occurred mainly in men (70.8%) and people with type 2 diabetes (89.6%).
Visual acuity declined from logMAR 0.05 ± 0.05 at baseline to logMAR 0.125 ± 0.194 at 1 year, logMAR 0.209 ± 0.165 at 2 years, logMAR 0.234 ± 0.201 at 3 years, and logMAR 0.260 ± 0.207 at 4 years. Median time to vision loss was 442 days in the 42 eyes that had vision loss.
Vision loss was associated with older age (P = .075) and higher HbA1c (P = .031); eyes with severe nonproliferative diabetic retinopathy (NPDR) (P = .020) and non-high-risk or inactive PDR (P = .025) were at higher risk for vision loss than those with mild or moderate NPDR.
Among SD-OCT biomarkers evaluated, only central subfield thickness (P = .0470) and cyst diameter (P = .0094) were associated with vision loss.
“In summary, we found that older age and worse DR severity were associated with risk of vision loss in eyes with DME and good initial visual acuity. Outside of the context of strict adherence to the Protocol V regimen, these features are important factors when deciding on the optimal frequency of follow-up visits,” the study authors wrote.
Perspective
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It is important for eye care providers to be knowledgeable regarding which eyes with DME will likely be treated and which are at greatest risk for vision loss and require closer monitoring.
There remains some debate regarding what management strategy is best for eyes with center-involved DME (CI-DME) and good vision. The 2-year results of the landmark DRCR Network Protocol V study showed that there was no significant visual benefit from treating eyes with CI-DME and ETDRS acuity of 20/25 or better immediately with intravitreal aflibercept compared with withholding injections until acuity worsened. The authors therefore concluded that the latter may be a reasonable management strategy for eyes with treatment-naive CI-DME and good vision. But how does this strategy fare in real-world settings where follow-up may be less frequent, and can we predict which patients will experience vision loss?
This study by Lent-Schochet and colleagues found that among patients with untreated CI-DME and good vision, those with severe NPDR or worse and those of older age had the greatest risk for vision loss. In fact, eyes with severe NPDR were three times more likely to lose vision (median time to vision loss was approximately 11 months) and require anti-VEGF therapy compared with eyes with milder-stage disease.
Foremost, this study highlights the importance of screening all eyes with retinopathy, regardless of acuity, for DME using OCT. Eyes with excellent acuity can still have CI-DME that may be amenable to early anti-VEGF therapy, especially if coexisting risk factors are present. In eyes with CI-DME and severe-stage NPDR, anti-VEGF therapy may not only benefit DME but also stabilize or improve the stage of retinopathy and decrease the risk for developing vision-threatening complications.
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