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    Importance of adherence and follow-up in patients with diabetic retinopathy

    Communication between doctor and patient plays key role in proper treatment

    A 37-year-old male came to my office for the first time in 2014 for a diabetes eye examination at the insistence of his primary-care provider (PCP). He had been diagnosed with type 1 diabetes at age 11 and was using multiple daily doses of insulin aspart (Humalog, Lilly) along with insulin glargine (Lantus, Sanofi).

    His HbA1c was 7.9 percent (equivalent to an average blood glucose of 204 mg/dl), and he reported fluctuating vision over the last several months. He said his last eye examination was three to four years prior and had shown no problems. His best-corrected visual acuities were 20/20 in each eye, intraocular pressures were 19 mm Hg, pupils were somewhat sluggish without afferent defect, and the anterior segment showed a normal cornea, iris, and conjunctiva with peripheral cortical lens spoking after dilation.

    Posterior segment examination and recommended treatment

    His retinal examination was much more worrisome, with scattered intra-retinal hemorrhages in the macula and periphery, multiple microaneurysms in the macula without macular edema, and neovascularization of both optic nerves (Figure 1, right) and with fibrovascular scaffolding (Figure 1, left).

    I explained my findings to the patient and told him that without treatment, he had a high risk of permanent vision loss. I sent a report to his PCP, and he was referred for immediate consultation with a local retinal specialist who saw him two days later and initiated treatment with intravitreal bevacizumab (Avastin, Genentech).

    Though panretinal laser has been the gold standard for treatment of proliferative diabetic retinopathy for 40 years, I knew that anti-VEGF therapy was increasingly being used for proliferative diabetic retinopathy (PDR), especially when patients also had diabetic macular edema (DME). In fact, Diabetic Retinopathy Clinical Research Network (DRCR.net) protocol S has shown that anti-VEGF therapy up to every four weeks with ranibizumab (Lucentis, Genentech) is non-inferior to PRP for treatment of PDR over two years.1

    Related: How diabetes affects contact lens wear

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    Optometry Times A/V