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How To Treat The Diabetic Eye Disease – The Eye or The Body?

In diabetic eye disease, it is important to treat both the eye and the diabetic patient as a whole. Patients with diabetes have a complex range of comorbidities associated with their condition.

Around 30% are overweight or obese, two-thirds have hypertension, and a quarter has cardiovascular disease. Other potential complications include cerebrovascular accidents, diabetic nephropathy, dyslipidemia, diabetic neuropathy, and DR.

Patients with diabetic eye disease may be at a particularly high risk of diabetes-associated complications. Patients with diabetic macular edema (DME) and/or DR are more likely to have a stroke and myocardial infarction than age- and gender-matched subjects with diabetes without ophthalmic manifestations, retinal disorders, or vitreous hemorrhage.

The prevalence of DME differs according to the type of diabetes and the treatment that the patient is undergoing, and it is higher in patients with type 1 diabetes than in those with type 2 diabetes taking insulin, who in turn have a higher prevalence than patients with type 2 diabetes who are not taking insulin.

The 25-year cumulative incidences of DME and clinically significant macular edema are 29% and 17%, respectively, in patients with type 1 diabetes. Diabetic eye disease, particularly DME, has a negative impact on patient quality of life.

In a prospective observational study, scores on the National Eye Institute 25-item Visual Function Questionnaire were significantly poorer in type 2 diabetes patients with DME compared with type 1 patients with DR.

Indeed, loss of vision is the most feared complication of diabetes, ahead of cardiac disease, renal problems, circulation problems, and problems with the feet or legs.

Effective management of diabetes, including diabetic eye disease, requires a multidisciplinary, patient-centric approach. This should aim to treat multiple targets (e.g. HbA1c, blood pressure, lipids, and body weight), provide ongoing medical and psycho-behavioral support, and help patients achieve self-management of their condition.

Individual-level care can be assessed at a system and country-level using population-based surveys and hospitalization and mortality data to guide administrative decision-making and policy implementation toward areas of greatest need.

There are several constraints to the effective management of DR and DME, from both the clinician and patient perspectives. Clinicians are challenged with managing wide variations in patient responses to treatment, the complex comorbidity profile of the high-risk population, and the suboptimal outcomes associated with delayed initiation of treatment with anti-VEGF therapy.

Meanwhile, patient challenges include compliance to treatment and monitoring schedules, the cost of treatment and/or medical insurance, the burden associated with long-term follow-up and management, problems with access to health care and treatment, and the time spent on treatment, visits, and follow-up, particularly for the working-age population.

The challenge of patient compliance, in particular, can significantly impact outcomes. A retrospective multicenter study reviewed data from 12 patients with proliferative DR (PDR) or nonproliferative DR (NPDR) with or without DME, treated exclusively with anti-VEGF therapy, who were lost to follow-up for a mean of 13.3 months.

Upon examination on their return to the clinic, these patients had an average worsening in visual acuity from a mean of 0.61 logMAR before the interruption in treatment to 1.53 logMAR at their final visit.

Reasons provided for the treatment hiatus included intercurrent illness, non-compliance, and financial issues. It seems that some patients are lost to follow-up not because they are not interested in attending clinic visits, but because they are not able to attend.

That is why we need to consider some different interconnecting factors to improve patient care, including social support from family and peers, control of systemic factors with medication and lifestyle changes, support to promote healthy eating, and regular medical examination to enable early detection and timely treatment of diabetic eye disease.

It is recommended that diabetic patients with no signs of DR, or with mild PDR only, are examined annually. Those with moderate NPDR should be examined every 6 months, those with any PDR and macular edema once every 3 months, and those at highest risk (young diabetic patients, pregnant patients, those undergoing cataract surgery, or those with nephropathy) should be seen at least once every 3 months or more frequently.

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