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    New strategies to assess the risk of diabetes-related vision loss

    ODs must go outside the lines of traditional eye care

     

    Current algorithm

    Landmark clinical trials inform the current algorithm for preventing diabetes and STR. The Diabetes Prevention Program (DPP) showed that walking 150 minutes per week lowered the risk of developing type 2 diabetes by 58 percent at 4 years and by 38 percent at 10 years in high-risk patients with prediabetes.6

    The Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR) have shown that a majority of patients with diabetes will develop some degree of DR over time. This study informs recommendations about how often dilated retinal examinations should be performed and at what length of disease duration such exams should begin.7

    In terms of preventing microvascular complications, The Diabetes Control and Complication Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS) showed that tighter blood glucose (both studies) and blood pressure control (UKPDS) lowers the risk of DR and its progression.8

    Related: Fasting regimens may be key in treating type 2 diabetes

    As for preventing vision loss, the Diabetic Retinopathy Study (DRS) and Early Treatment Diabetic Retinopathy Study (ETDRS) showed that laser therapy significantly lowers the chance of severe vision loss from PDR and clinically significant DME (CSME), respectively.9

    More recently, results from the Diabetic Retinopathy Clinical Research Network (DRCR.net) have shown that anti-VEGF therapy is superior to laser for ”center-involved” DME and equally effective as pan-retinal photocoagulation for PDR.10 Moreover, spectral domain optical coherence tomography (SD-OCT) has become the recognized standard for detecting DME and assessing response to therapy.11

    Collectively, these studies have shaped the current care algorithm:

    • Prevent diabetes by patient education to inspire behavioral change

    • Achieve good metabolic control via patient education, behavioral change, and drug therapy once diabetes is diagnosed

    • Monitor diagnosed patients routinely for the development of STR (and other complications)

    • Treat patients with STR when it develops

    More succinctly and towards preventing vision loss, the algorithm is: counsel, monitor, and wait to treat.

    Related: Using OCT with your diabetes patients

    This strategy has worked to reduce blindness and cardiovascular deaths from diabetes in the U.S. for a number of years (though rates of blindness increased 27 percent worldwide from 1990 to 2010)12 and would be “perfect” if it weren’t for a number of countervailing factors:

    • Patient education is difficult, time-consuming, and often ineffective at motivating behavioral change that prevents diabetes and reduces the risk of eye disease13

    • Achieving and maintaining good diabetes control is difficult even in the best of circumstances based on a number of factors (variable GI absorption of macronutrients and medications, variable onset of insulin action, hypoglycemia, and other environmental mediators of endocrine response)14

    • A host of societal/environmental/market forces predispose our citizenry toward diabetes despite individually “good” behaviors and, despite declining incidence rates of diabetes in the U.S., prevalence continues to climb15

    • Half of high-risk diabetes patients do not receive at least annual dilated eye exams as a function of “eye care ignorance” (by patients and providers) and other barriers to access16

    Treatment of diabetes and STR is expensive and isn’t always effective. All of this begs the question: Can we do more?

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