Dr. Kiss: We are seeing a revolution in the diagnosis and treatment of diabetic eye disease. Ultrawide-field imaging has now replaced the traditional seven-standard fields as the preferred method for fundus evaluation of our diabetic patients. Pharmacotherapy, in the form of anti-VEGF intravitreal injections, is slowly replacing laser as the first line therapy for DR and DME in many of our patients. Despite these advances, compliance with follow-up from all our diabetic patients will nonetheless remain an important determinant of their visual outcome.
Dr. Coney: The most important factor that guides my decision to begin anti-VEGF agents in DR patients is the level of severity. The availability of these agents has shifted our focus from thermal treatment to modulating the pathophysiology of the disease. Newer imaging modalities may change the landscape on when and how we initiate our therapy. Emerging studies will continue to refine our management and tailor individualized treatments.
Lost to Follow-Up
The Potential Consequences for Treatment Interruptions Among Patients Treated Solely With Anti-VEGF Therapy
While the use of anti-VEGF therapy for treatment of diabetic retinopathy (DR) has shown promise for regressing DR severity, patients’ adherence to recommended follow-up may be an important determinant for the ultimate success of treatment.
During the AAO Annual Meeting, Mark W. Johnson, MD, presented data suggesting that eyes with proliferative DR treated solely with anti-VEGF injections have worse anatomic and functional outcomes after losses to follow-up compared to eyes that receive PRP.1
- Investigators reviewed records of 13 eyes of 12 patients treated exclusively with anti-VEGF therapy and who had a temporary loss to follow-up:
- Mean age, 56.6 ± 10.4 years; 50% (6/12) women.
- 100% type 2 diabetes mellitus (median duration = 19 years); mean hemoglobin A1c, 9.5 ± 2.5%.
- Mean treatment duration was 16.8 ±21.7 months and patients received a mean 7.1 ± 6.4 injections.
- Median duration of treatment interruption was 12 months (range, 3-25 months).
- New complications after treatment interruption:
- Vitreous hemorrhage, n = 9 (69%);
- Neovascular glaucoma, n = 5 (38%); and
- Traction retinal detachment, n = 4 (31%).
- Ten patients (77%) lost three or more lines of VA, including 6 (46%) with final VA of hand motion or worse.
- Mean VA before hiatus 0.61 ± 0.41 versus mean VA after hiatus 1.53 ± 1.02 ( P = .013).
- Author’s conclusion: The potentially severe consequences of interruptions in anti-VEGF therapy should be carefully considered when making initial treatment decisions.
1. Johnson MW, Wubben TJ, Hsu J. Anti-VEGF therapy for diabetic retinopathy consequences of inadvertent treatment interruptions. Presented at the Annual Meeting of AAO. October 27-30, 2018; Chicago, Illinois.
Dr. Chiang: We are in the midst of a paradigm shift in the management of DR. Our diagnostic capabilities continue to improve; wide-field imaging and OCT-A represent advances that increase our ability to detect pathology. Artificial intelligence and telemedicine hold the promise of enabling early detection across a population. As far as therapeutics, the mainstay for decades was laser. We now have clinical trial data to support the use of anti-VEGF therapy as a capable and noninferior treatment modality that can achieve impressive results in terms of disease regression. However, patient education and compliance remain an issue since DR is progressive, particularly when utilizing anti-VEGF therapy over laser. Future treatments possessing greater durability will likely help alleviate this concern. In the meantime, retinal physicians should stay up-to-date on emerging data and tailor the treatment plan to the patient to the best of their ability.
Dr. Wykoff: Clearly, there is tremendous variation in how each of us employs anti-VEGF agents in the management of DR. In particular, many management questions remain to be clarified regarding the use of imaging, the timing of initiation of treatment, and the follow-up protocols while on treatment for high-risk NPDR eyes without DME. I think we can all agree that, currently, decisions about when and how to initiate therapy for DR are highly individualized to the specific needs and desires of each patient. Ongoing trials, such as PANORAMA and the DRCR.net Protocol W, will continue to shape these discussions.
Thank you all for your participation.
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