In Light of Managing Diabetic Eye Disease

In Light of Managing Diabetic Eye Disease

June 23, 2022

Diabetic eye disease is a group of eye problems that can affect people with diabetes. These conditions include diabetic retinopathy, diabetic macular edema, cataracts, and glaucoma.

Diabetes is a disease that affects the body’s ability to produce or use insulin effectively to control blood sugar (glucose) levels. Too much glucose in the blood for a long time can cause damage in many parts of the body.

Diabetes can damage the heart, kidneys and blood vessels. It damages small blood vessels in the eye as well. Even if diabetes is well controlled, it can affect your regular eye care.

The Centers for Disease Control and Prevention (CDC) says that about 90% of vision loss from diabetes can be prevented. Early detection is key. People with diabetes should get critical, annual eye exams even before they have signs of vision loss. Studies show that 60% of diabetics are not getting the exams their doctors recommend.

Macular edema is an important cause of visual impairment in patients with retinal vein occlusions (RVO), occurring in 5-15% of eyes with branch retinal vein occlusion (BRVO) and in the majority of those with central retinal vein occlusion (CRVO).

Anti-vascular endothelial growth factor (anti-VEGF) pharmacotherapy is the current mainstay of therapy, having demonstrated efficacy across several pivotal randomized clinical studies, although macular laser and intravitreal steroids are also used in some cases.

Various demographic, clinical, and imaging factors may predict visual outcomes after treatment, such as patient age, time to treatment initiation, baseline visual acuity, ischemic versus non-ischemic disease, and central subfield thickness, among others.

SD-OCT provides reproducible, high-quality, registered images to assess the treatment response in macular disease.

In our seven-doctor retina practice we use a variety of imaging equipment; however, one of the constants is our reliance on spectral-domain optical coherence tomography (SD-OCT).

Fifteen years ago, I was fortunate enough to train at the Tufts University/New England Eye Center with clinician-scientists who were instrumental in developing OCT technology.

Now what stands out to me is the resolution we can obtain with SD-OCT, specifically the high-resolution SPECTRALIS multimodal imaging platform (Heidelberg Engineering, Inc.) is as good as that of our investigational devices from the early-to-mid-2000’s.

We are eager to see where we will be in another 15 years. Here we will overview our practice’s approach to managing diabetic eye disease.

Clinical care should mirror clinical trials Imaging is integral to the management of diabetic eye disease, therefore, all newly referred patients in our practice receive baseline imaging along with the clinical exam.

What we do in the clinic should mirror, as best as possible, the best practices from randomized, controlled trials. Those lean heavily on angiography and especially OCT imaging to determine treatment selection and frequency.

Therefore, baseline imaging almost always includes those two modalities at the minimum. We also, secondarily, may obtain ultra-wide color fundus photography (Zeiss and Optos platforms) in our offices where that technology is available.

The sequence of follow-up imaging is determined by disease severity and treatability, whether it be diabetic macular edema (DME), which is the most common manifestation of diabetic retinopathy (DR) which we treat, severe non-proliferative DR, or proliferative DR.

Patients with disease for whom treatment is initiated we see more frequently to gauge their response. The image registration we can obtain with SPECTRALIS is remarkable, and the TruTrack Active Eye-Tracking feature allows me to compare live images to understand progression.

Rather than relying on maps, we prefer to scroll through the scans for a line-by-line comparison. This feature is especially helpful when initiating, changing, or adding treatment: for example, adding focal laser to an area of macular edema that is not responding to first-line anti-angiogenic therapy or adding a steroid for a patient who still has center-involving swelling despite frequent anti-angiogenic injections.

When it comes to DME, we value the ability to objectively determine if treatment is providing a measurable improvement. In the setting of proliferative diabetic retinopathy, I will occasionally perform repeat angiography; however, I generally do not repeat angiography frequently.

Although overall, surgeons do less angiography than in the past, ultra-widefield angiography is important in the initial assessment of patients with suspected proliferative disease to ensure control and a complete laser pattern.

In our practice, we use the Heidelberg Engineering Ultra-Widefield Module for that application in addition to other ultra-widefield platforms. Patient experience, education SPECTRALIS imaging is well tolerated by patients, and it can be done at any office visit.

The patient remains seated in one spot while receiving OCT, angiogram, and ultra-widefield angiogram imaging at the same machine. Regardless of dilation status, we obtain a high-quality image, and the laser light wavelength is not overly bright as may be the case with other systems.

For some widefield platforms, patients must be extremely dilated to obtain high-quality images and artifacts can be an issue. SD-OCT is by far the most utilitarian imaging modality available.

OCT and ultra-widefield color images play a key role in disease education, and we use them with all my patients to explain their disease process. In DME for example, we will show patients an example of a normal OCT versus their eye with a swollen macula.

By seeing their image, they better understand their disease severity and how close to normal they are. Using the ultra-widefield color image, we point out the red dots that indicate DR explaining that they have bleeding in or in front of their retina and, depending on severity, that that may be treated.

It is all about HbA1c; We also love talking to patients about blood sugar control. We give all our diabetic patients one homework assignment: learn your hemaglobin A1c – whatever that number may be – and make a numeric goal with their endocrinologist or primary care doctor.

Only about half of my patients know what their HbA1c is when they first come in. I tell them that blood sugar is the fuel for the diabetic fire; they can remove the fuel and put out the fire over time by controlling HbA1c.

We explain that their disease comes from a combination of the duration and severity of their diabetes. We say, “if you have diabetes and intend to live—and see—for a long time, you must get your blood sugar under control to reduce your risk of vision loss.”

We are currently involved in a large initiative to democratize diabetic eye care by moving it into a non-traditional setting. Patient access and education are some of the biggest gaps in diabetes care.

Repeated, patient-friendly messaging can go a long way to helping this significant public health problem. Diabetes is a US pandemic that preceded COVID-19 by many years and will be around long after COVID recedes.

We must ensure that the approximately 50% to 60% of patients with diabeties who do not go to eye exams have a pathway to care and treatment.

Having imaging that is high-quality, straightforward to obtain, and reproducible is a large part of their clinical care.

Diagnostic imaging is certainly required as part of the standard of care for managing diabetic eye disease.

At the bare minimum, the physician must be able to obtain high resolution OCT images and high-quality angiograms to assess the initial anatomy and pathophysiology and to track treatment. Both of these we can perform with SPECTRALIS.

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