Spotlight on diabetic retinopathy

Medical management of diabetic retinopathy

An accessible overview of the treatment goals for diabetic retinopathy (DR) and the evidence from clinical trials that glycemic control is associated with a reduction in the progression of DR.

Summary points

Controlling HbA1c is associated with a reduction in the progression of diabetic retinopathy (DR).
Clinicians should strive to achieve HbA1c values of <7% and blood pressure <140/80 mmHg to reduce the risk of microvascular and macrovascular complications.
However, HbA1c goals for patients must be individualized due to the complications associated with intensive glycemic control and patient characteristics.
Treating hypertension through lifestyle modification and medications is important in decreasing progression of DR.
Patients with diabetes who become pregnant need to set appropriate HbA1c and blood pressure goals due to the risk of progression of retinopathy during pregnancy.

Thomsen SL, Welch RJ, Do DV. In: Managing Diabetic Eye Disease in Clinical Practice. Edited by Singh RP. Springer International Publishing, 2015. doi: 10.1007/978-3-319-08329-2_4

Fenofibrate and diabetic retinopathy

This article reviews the clinical evidence and the mechanisms by which fenofibrate may reduce the progression of diabetic retinopathy.

Summary points

Diabetic retinopathy (DR) is a common microvascular complication in persons with types 1 and 2 diabetes and is the leading cause of vision loss in working-aged adults globally.
Medical therapies including intensive control of hyperglycemia and hypertension have been shown to reduce the incidence and progression of DR.
Two recent randomized clinical trials have demonstrated beneficial effects of systemic fenofibrate therapy in reducing the rate of progression of DR independently of serum lipid levels in patients with type 2 diabetes mellitus.
These findings suggest that fenofibrate may be an effective strategy for reducing the progression of DR, thus reducing the large and growing public health burden of treating the sight-threatening complications of DR.
However, despite an increased number of fenofibrate prescriptions in the USA over recent years, fenofibrate is still not routinely used for its beneficial effects on DR.
Further treatment trials with a focus on the primary outcome of DR progression are warranted prior to the general acceptance of fenofibrate for the treatment of DR, especially for those who are already affected with DR.

Knickelbein JE, Abbott AB, Chew EY. Curr Diab Rep 2016; 16: 90. doi: 10.1007/s11892-016-0786-7

Laser therapy in the management of diabetic retinopathy

A summary of laser treatment options, including subthreshold micropulse laser, beyond the established focal/grid laser photocoagulation protocol initially demonstrated in the Early Treatment of Diabetic Retinopathy Study.

Summary points

Diabetic macular edema is the major cause of decreased vision in diabetic patients.
Laser treatment options beyond the established focal/grid laser photocoagulation protocol initially demonstrated in the Early Treatment of Diabetic Retinopathy Study are explored in this review.
Subthreshold micropulse laser seems to be an effective adjunctive therapy in conjunction with intravitreal anti-angiogenic injections in a subset of patients.
This treatment options is specifically effective in those with a retinal thickness of less than 400 μm, without the risk of scotomas and potential vision loss, which can occur with conventional laser treatment.
Given the absence of scarring from this “invisible” laser, the subthreshold micropulse laser may allow for earlier treatment prior to the onset of clinically significant macular edema, potentially preventing symptomatic vision loss and permanent photoreceptor damage.

Shah S, Fortun J. J Curr Ophthalmol Rep 2016; 4: 90–96. doi: 10.1007/s40135-016-0097-9

Surgery for diabetic eye complications

An overview of the indications, surgical objectives and techniques, adjunctive pharmacotherapy, and outcomes of vitrectomy for proliferative diabetic eye complications.

Summary points

New modalities for the treatment of diabetic eye complications have emerged in the past decade. Nevertheless, many severe diabetic retinopathy (DR) complications can only be treated with vitreoretinal surgery.
Complications from DR can result in severe pathologies that are very challenging to repair surgically and can carry a poor visual prognosis.
Early vitrectomy to remove the posterior hyaloid and early fibrovascular proliferation is ideal to prevent the progression to tractional retinal detachment and combined tractional and rhegmatogenous retinal detachment, particularly in young diabetics.
With the availability of new microincisional vitrectomy technology, wide angle microscope viewing systems, and pharmacologic agents, vitrectomy can improve visual acuity and achieve long-term anatomic stability in eyes with severe complications from proliferative DR.
As a result of these advances in technology, surgical intervention for complicated DR can be performed earlier than suggested by the Diabetic Retinopathy Vitrectomy Study, allowing for better visual and anatomical results.

Berrocal MH, Acaba LA, Acaba A. Curr Diab Rep 2016; 16: 99. doi: 10.1007/s11892-016-0787-6

Medicine Matters Diabetes

Spotlight on diabetic retinopathy

Treatment

Medical management of diabetic retinopathy

Fenofibrate and diabetic retinopathy

Laser therapy in the management of diabetic retinopathy

Surgery for diabetic eye complications

Contents