On Day 2 of the 128th Annual Meeting of the American Academy of Ophthalmology (AAO 2024), the buzz around diabetic retinopathy (DR) was palpable as the Preferred Practice Pattern (PPP) Committee’s new guidelines offered a fresh playbook for ophthalmologists looking to tackle the condition head-on.
When it comes to diabetic eye disease, knowing when to act—and how to act—can be a game-changer for patients. That’s where the PPP Retina/Vitreous Panel steps in. This symposium was more than just an update; it was a comprehensive guide to help ophthalmologists manage DR with confidence, from screening to treatment. The goal? To arm attendees with practical, evidence-based strategies they can take straight to their clinics.
Screening for DR
According to Dr. Jennifer Lim (USA), the best way to prevent visual loss from patients with diabetes is to detect DR early. That’s why patients with Type 1 diabetes should start annual screenings five years after diagnosis, and those with Type 2 diabetes should begin at diagnosis. However, only 66% of individuals with diabetes mellitus get a yearly eye exam.1
“Perhaps one way to mitigate this is to have point-of-care screening,” Dr. Lim suggested. “This can mitigate socioeconomic disparities, transportation issues, referral follow through issues, as well as special needs.”
The solution could lie in telescreening programs. “Telemedicine can help address the shortage of eye care providers,” Dr. Lim noted, pointing to a Bastos de Carvalho et al. study which found that telescreening doubled the odds of catching issues early on.2
Artificial intelligence (AI) systems, like the FDA-approved EyeArtⓇ (Eyenuk; Woodland Hills, USA), are emerging to be useful in this field. “AI systems have very high sensitivity and specificity,” Dr. Lim explained, adding that handheld versions could make screening even more accessible.
DR progression
It’s no secret that keeping a lid on blood sugar levels and blood pressure can dramatically reduce the risk of developing or worsening DR. But there’s a twist: getting too aggressive with that control can sometimes make things worse, especially with newer drugs like OzempicⓇ (semaglutide).
According to Dr. Stephen Kim (USA), “Better A1C control is not always better,” and for elderly patients, a fasting glucose target range between 7% to 8% is recommended because research shows that some patients who drop their glucose levels too quickly can experience ‘paradoxical worsening,’ or the accelerated progression of DR.3
Beyond blood sugar, those with high blood pressure should also take note. While it’s a lesser factor compared to glucose levels, controlling blood pressure offers “a modest benefit in preventing diabetic retinopathy,” Dr. Kim reported. But it’s a benefit worth pursuing for anyone aiming to protect their sight.
As for how the disease itself unfolds, Dr. Kim explained that DR “progresses in an orderly fashion,” moving from mild to more severe stages if left unchecked. The earliest signs might be microaneurysms—tiny balloon-like bulges in the retinal blood vessels—or intraretinal hemorrhages. As things get worse, patients can develop venous dilation and cotton-wool spots. As Dr. Kim noted, without proper intervention, DR can progress, leading to retinal edema and the formation of hard exudates, ultimately resulting in clinically significant macular edema (CSME).
Treatment of DR
When it comes to the treatment of DR, the PPP guidelines have a clear message: there’s no one-size-fits-all solution. A tailored approach is critical, factoring in everything from the severity of the condition to patient compliance.
For diabetic macular edema (DME), anti-VEGF agents are the go-to in cases involving vision loss. These injections can not only improve vision in patients with center-involved DME but also reduce the severity of DR itself. As Dr. Jaclyn Kovach (USA) put it during the session, “Anti-VEGF therapy is standard of care and there’s an added bonus. It can improve DR severity in patients with and without DME.”
However, not every patient needs immediate treatment. “Center-involving DME with preserved vision… these patients can be observed,” said Dr. Kovach, referencing the DRCR Protocol V study, which allows some patients to defer anti-VEGF treatment until visual acuity dips below 20/30. This offers a bit of breathing room, though patient compliance and close monitoring are key.4
When it comes to proliferative diabetic retinopathy (PDR), the data speaks volumes. “Pan-retinal photocoagulation reduced the two-year incidence of severe vision loss by 60%,” noted Dr. Atma Vemulakonda (USA), highlighting how impactful laser therapy remains, particularly for high-risk patients. But the introduction of anti-VEGF has changed the game. “Patients do better with vision with anti-VEGF treatment,” he said, acknowledging the visual benefits of anti-VEGF compared to pan-retinal photocoagulation (PRP), especially for those who may balk at the idea of repeated injections.
That said, Dr. Vemulakonda shared sobering insights from a 2018 study by Jason Hsu, showing that PDR patients treated with PRP fared better than their anti-VEGF counterparts when they missed appointments. PRP, in a way, becomes “the gift that keeps on giving,” as the effects persist longer without requiring regular follow-up. In contrast, patients who skipped their anti-VEGF injections often saw a recurrence of complications like DME and neovascularization.5
And what about the ultimate fallback—surgery? While anti-VEGF and PRP dominate the conversation, vitrectomy remains crucial for patients with traction retinal detachments or non-clearing vitreous hemorrhages. “Any improvement in function is worthwhile,” said Dr. Vemulakonda, emphasizing that surgical intervention can still be a game-changer for those in more advanced stages of DR.
Editor’s Note: Reporting for this story took place during the 128th Annual Meeting of the American Academy of Ophthalmology (AAO 2024) from 18-21 October in Chicago, Illinois, USA.
References
- U.S. Department of Health and Human Services. Increase the proportion of adults with diabetes who have a yearly eye exam — D-04. 2023. Available at: https://health.gov/healthypeople/objectives-and-data/browse-objectives/diabetes/increase-proportion-adults-diabetes-who-have-yearly-eye-exam-d-04. Accessed on 10/19/2024.
- Bastos de Carvalho A, Ware SL, Lei F, et al. Implementation and sustainment of a statewide telemedicine diabetic retinopathy screening network for federally designated safety-net clinics. PLoS One. 2020;15(11):e0241767.
- Leung E, Wongrakpanich S, Munshi MN. Diabetes management in the elderly. Diabetes Spectr. 2018;31(3):245-253.
- Hutton DW, Glassman AR, Stein JD, et al. Costs of managing diabetic macular edema with good visual acuity with aflibercept, laser, or observation: DRCR Retina Network Protocol V. Am J Ophthalmol. 2021;230:297-302.
- Obeid A, Gao X, Hsu J, et al. Loss to follow-up in patients with proliferative diabetic retinopathy after panretinal photocoagulation or intravitreal anti-VEGF injections. Ophthalmology. 2018;125(9):1386-1392.
