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Diabetic Retinopathy: Prevalence, Risk Factors and Early Detection

By: Andrew Moshfeghi, MD, MBA;

Webinar Credits: 0.5

It is vital that optometrists continue to play a role in educating patients with diabetes about the potential ocular complications of their systemic disorder, as well as the benefits of comprehensive diabetic eye exams and early treatment. This activity reviews the increasing prevalence of diabetes and diabetic retinopathy and focuses on the need for early detection, use of advanced imaging, and timely referral. These points will be also illustrated through case presentations.

Expiration Date: Tuesday, January 31, 2023
Release Date: December 31, 2020

Learning Objectives

Upon completion of this activity, the participant should be able to:

  • Summarize the rise of diabetes and diabetic retinopathy (DR) in the US population and the related impact on ocular health.
  • Understand effective screening strategies and imaging tools for diagnosing DR and diabetic macular edema (DME).
  • Identify which patients need early referral to a retina specialist based on their behavioral patterns, disease state, and/or other risk factors.
  • Explain the latest treatment approaches to DR/DME.
  • Describe novel developments in DR screening.

Accreditation and Designation Statement

Sponsored by:

Evolve is an approved COPE Administrator.
This course is COPE approved for 0.5 hours of CE credit for optometrists.

COPE Course ID: 70627-PS
COPE Activity ID: 120836

 

Participation Method

In order to obtain credit, proceed through the program, complete the post-test, evaluation and submit for credit.

Course Viewing Requirements

Supported Browsers:
Internet Explorer 11 for Windows
Edge (recent versions; Chromium-based) for Windows
Google Chrome (recent versions) for Windows, Mac OS, iOS, Android, or Linux
Mozilla Firefox (recent versions) for Windows, Mac OS, iOS, Android, or Linux
Safari (recent versions) for Mac OSX, or iOS

Hardware Requirements:
4GB+ RAM

Recommended internet speed 5Mbps+

Faculty and Disclosures

 

Andrew A. Moshfeghi, MD, MBA (Program Chair)
Associate Professor of Clinical Ophthalmology
Medical Director of the USC Roski Eye Institute
Director of Clinical Trials
Director of the Vitreoretinal Surgery Fellowship Program
Director of the Medical Retina Fellowship Program
Los Angeles, CA

 

Group Leaders

Dilsher Dhoot, MD
California Retina Consultants/Retina Consultants of America
Santa Barbara, CA

David Eichenbaum, MD
Clinical Assistant Professor
Department of Ophthalmology
University of South Florida College of Medicine
Retina Vitreous Associates of Florida
Tampa, FL

Avni P. Finn, MD
Vitreoretinal Surgeon
Northern California Retina Vitreous Associates
Mountain View, CA

Roger A. Goldberg, MD, MBA
Partner, Bay Area Retina Associates
Faculty, CPMC Ophthalmology Residency
San Francisco Bay Area, CA

Esther Lee Kim, MD
Vitreoretinal Surgeon Orange County Retina
Santa Ana, CA

Lisa C. Olmos de Koo, MD, MBA
Associate Professor of Ophthalmology
Subspecialty Chief, Retina Division
Program Director, Vitreoretinal Surgery Fellowship
Department of Ophthalmology
University of Washington
Seattle, WA

Sonia Mehta, MD
Assistant Professor of Ophthalmology
Thomas Jefferson University School of Medicine
Philadelphia, PA

Ehsan Rahimy, MD
Vitreoretinal Disease & Surgery
Palo Alto Medical Foundation
Palo Alto, CA

Adrienne W. Scott, MD
Associate Professor of Ophthalmology
Retina Division
Wilmer Eye Institute
Johns Hopkins University School of Medicine
Baltimore, MD

Jayanth Sridhar, MD
Department of Ophthalmology
Bascom Palmer Eye Institute
Miami, FL

 

DISCLOSURE POLICY
It is the policy of Evolve that faculty and other individuals who are in the position to control the content of this activity disclose any real or apparent conflict of interests relating to the topics of this educational activity. Evolve has full policies in place that will identify and resolve all conflicts of interest prior to this educational activity.

The following faculty/staff members have the following financial relationships with commercial interests:

Andrew Moshfeghi, MD, has had a financial agreement or affiliation during the past year with the following commercial interests in the form of Consultant:  Allergan, Genentech, Graybug, Novartis, Ocular Therapeutix, Pr3vent and Regeneron. Grant/Research Support:  Genentech, Novartis, and Regeneron. Stock/Shareholder: Ocular Therapeutix, Pr3vent, and Placid.

The Evolve Medical Education staff and planners have no financial relationships with commercial interests.

Disclaimer

OFF-LABEL STATEMENT
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The opinions expressed in the educational activity are those of the faculty. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

DISCLAIMER
The views and opinions expressed in this educational activity are those of the faculty and do not necessarily represent the views of Evolve, Carl Zeiss Meditec or Regeneron Pharmaceuticals, Inc.

Pretest

  • 1. Not at all confident2. Not very confident3. Neutral4. Confident5. Extremely confident

Diabetes Prevalence: United States

In the United States, estimates from 2015 indicate that more than 30 million people have diabetes, which is nearly 10% of the population. Of those, just over 23 million are diagnosed; more than 7 million, or nearly 24% of people with diabetes, are unaware they have diabetes, according to the Centers for Disease Control and Prevention (CDC).  These numbers include 193,000 children and adolescents younger than 20 years (0.24% of the total US population younger than age 20 years). 1-4

Figure

Diabetes: Systemic Comorbidities

Diabetes is associated with a myriad of complications that require collaborative several medical specialties and subspecialties. The CDC estimates that patients with diabetes also have:

•Diabetic retinopathy (DR) (>28% of adults older than 40 years)
•Nephropathy (44%)
•Neuropathy (60-70%)
•Stroke (16% will have a stroke)
•Heart disease (6%)

 

Therefore, diabetes care providers often work in tandem with optometrists and ophthalmologists, nephrologists, vascular neurologists, and cardiologists, among others, to provide optimal care for patients with diabetes.5, 6

Figure

Ocular Complications of Diabetes

As mentioned, 28.5% of adults with diabetes age 40 and older have DR, which is caused by ongoing damage to the small blood vessels of the retina.  Patients with diabetes are also at higher risk for additional ocular complications. Compared with individuals without diabetes, patients with diabetes have a 60% higher risk of developing cataracts and a 40% increased risk of developing glaucoma. 7-10

Figure

DR Prevalence and Predictions: Global

Worldwide, there were 145 million people with DR in 2015, with roughly one-third of those with severe vision loss, according to the International Diabetes Federation. By 2040, those numbers expected to rise to 224 million people with some form of DR and 70 million with vision-threatening DR.11

Figure

Risk Factors

DR is the leading cause of vision loss in adults 20 to 74 years of age. The most common risk factors include duration of diabetes, poor control of diabetes, hypertension, nephropathy, obesity and hyperlipidemia, smoking, and pregnancy.

Early detection and treatment are necessary to forestall vision loss from DR. A working group of ophthalmic and diabetes experts developed a consensus on the key principles of an effective DR screening program, which are based on analysis of a structured literature review.

The recommendations for implementing an effective DR screening program are: (1) Examination methods must be suitable for the screening region, and DR classification/grading systems must be systematic and uniformly applied. Two-field retinal imaging is sufficient for DR screening and is preferable to seven-field imaging, and referable DR should be well defined and reliably identifiable by qualified screening staff; (2) in many countries/regions, screening can and should take place outside the ophthalmology clinic; (3) screening staff should be accredited and show evidence of ongoing training; (4) screening programs should adhere to relevant national quality assurance standards; (5) studies that use uniform definitions of risk to determine optimum risk-based screening intervals are required; (6) technology infrastructure should be in place to ensure high-quality images can be stored securely to protect patient information; (7) although screening for DME in conjunction with DR evaluations may have merit, there is currently insufficient evidence to support implementation of programs solely for DME screening.

The working group concluded that utilization of these recommendations may yield more effective DR screening programs that reduce the risk of vision loss worldwide. 9,12,13

Figure

Telemedicine

Telemedicine: Before and After the Pandemic

Even before the 2020 COVID-19 pandemic began, fewer than one-third of patients returned for DR screening at least every 15 months. This was for a variety of reasons, but transportation issues were the most reported. In addition, after adjusting for demographics, those living more than 8 miles from the eye care facility were less likely to be compliant, according to a study by Lee and colleagues.

Before social distancing mandates, 74% of patients were unaware of a telemedicine option in their physicians’ practices. The COVID-19 pandemic has transformed this scenario, such that some leading telehealth platforms now report virtual patient visits have increased between 257% and 700%, according to the results of a 2020 study. The paper by Saleem and colleagues indicate that recent patient and provider interest in telemedicine, the relaxation of regulatory restrictions, increased remote care reimbursement, and ongoing social distancing practices related to the COVID-19 pandemic compel many ophthalmologists to consider virtualizing services.

Telemedicine can be especially useful for patient discussions.14-15

Figure

Telemedicine can be helpful for those patients most at risk for DR progression.  The American telemedicine Association recognizes four categories of telescreening:

 

1. The system that identifies none or or very mild NPDR

2. The system that identifies patients with and without sight-threatening DR

3. The system that identifies NPDR, PDR, and macular edema with sufficient accuracy for appropriate decision making

4. The system that equals or exceeds the ability of ETDRS photographs to identify DR lesions

 

From a retina perspective, there is only one at-home monitoring system with imaging that is currently approved for use in the United States. It is intended to monitor patients with intermediate dry age-related macular degeneration (AMD) to determine if they progress to wet AMD.16

Figure

Duration of Diabetes = Highest Risk

Duration of disease is one of the greatest risk factors for the development of retinopathy. If a patient is diagnosed with diabetes at a young age, the longer the duration of disease, which means the patient is more likely to suffer complications.

Epidemiological data from two major studies categorized by the duration of disease.  The graphs show the prevalence of DR by duration of type 1 diabetes and age at examination in the Wisconsin Diabetes Registry Study (1990–2002) and the Wisconsin Epidemiologic Study of Diabetic Retinopathy (1979–1980). Duration groups: 3 to 7 years (7- or 4-year examination), 8 to 11 years (9-year examination), and 12 to 15 years (14-year examination). T-shaped bars show 95% confidence intervals. The number of individuals in each age and duration group is noted above the bar.

The percent of people with DR dramatically goes up after having the disease for 12 to 15 years compared with a duration of 3 to 7 years. If a patient is diagnosed at age 5, and he or she has the disease for 15 years, the chance of that patient having some retinopathy is roughly 90%.17

Figure

Disease Duration Plus Elevated A1c

As with type 1 diabetes, the Australian Diabetes, Obesity, and Lifestyle Study also demonstrated a relationship between disease duration, glycosylated hemoglobin (A1c) levels, and increasing DR prevalence in type 2 diabetes. At all levels of glycemic control, the likelihood of DR increased with duration of disease.

Census identified national diabetes prevalence of 7%, and this survey included 11,247 adults age 25 and older from all over Australia. A total of 2,476 participants with diabetic complications and control group were included, and after exclusion of participants who were unable to be photographed or whose photographs were not gradable, data were available for 2,177 participants. Patients with type 1 diabetes were excluded from this analysis.

The prevalence of DR in those with known type 2 diabetes versus those with newly diagnosed type 2 diabetes was 21.9% versus 6.2%, respectively. A similar relationship was shown for duration of diabetes, systemic blood pressure, and increasing DR prevalence in patients with type 2 diabetes.18-20

Figure

Case 1

Age
64
Gender
Female
Race
Filipino
Visual Acuity
20/20 OD, 20/40 OS
Most recent HbA1c
8.5%
Ocular History
No previous history of surgery, injections, laser, or trauma
Medical History
Type 2 DM x15 years, hypertension, hyperlipidemia

 

Widefield color fundus photography of this patient reveals evidence of numerous intraretinal hemorrhages/microaneurysms bilaterally without any signs of DME. Consistent with diagnosis of moderately severe NPDR (ETDRS-DRSS: 47)

 

Figure

Widefield fluorescein angiography demonstrates numerous microaneurysms and midperipheral areas of vascular pruning and assocated intraretinal microvascular abnormalities (IRMA). There is some evidence of late angiographic perivascular leakage, but no frank neovascularization of the disc or elsewhere in either eye. Additionally, there is no angiographic leakage in the macula, further reinforcing this is a case of NPDR without DME.

Figure

OCT imaging confirms a preserved foveal contour without center-involving DME in either eye.

Figure

Prevention & Improvement

Prevention of Retinopathy Progression is Possible

PDR may be classified as high-risk and nonhigh-risk. The hallmark of PDR is neovascularization, which occurs at the latter stages of the disease and can result in blindness; neovascularization is the consequence of abnormal fibrovascular proliferations with subsequent bleeding and retinal detachment.

  • According to the Diabetic Retinopathy Study Research Group, high-risk PDR was defined as any one of the following:

1.  NVD ≥at least 1/3 disc area

2.  Any NVD with vitreous hemorrhage

3.  NVE at least ½ disc area with vitreous hemorrhage

 

  • High-risk PDR was also defined as three or more of the following high-risk characteristics:

1.  Presence of vitreous hemorrhage or preretinal hemorrhage

2.  Presence of any active neovascularization

3.  Location of neovascularization on or within 1 disc diameter of the optic disc

4. NVD more than 1/3 disc area or NVE more than ½ disc area

 

In a pooled analysis of the phase 2 RISE/RIDE clinical trials, exploratory endpoints (2-step and 3-step DRSS improvements) evaluated the benefit of ranibizumab for DR at 36 months. Ip and colleagues showed that intravitreal ranibizumab reduced the risk of DR progression in eyes with diabetic macular edema (DME), and many ranibizumab-treated eyes experienced improvement in DR severity.

Figure

Patients in the study who had DME (n=759) were randomized to monthly sham, 0.3-mg ranibizumab, or 0.5-mg ranibizumab intravitreal injections. Macular laser was available per prespecified criteria. Fundus photographs, taken at baseline and periodically, were graded by a central reading center, and clinical examinations were performed monthly. The main outcome measures of this report were secondary/exploratory analyses including a 2-step or more and 3-step or more change on the Early Treatment Diabetic Retinopathy Study (ETDRS) Diabetic Retinopathy Severity Score (DRSS) in the study eye and a composite DR progression outcome, including photographic changes plus clinically important events such as occurrence of vitreous hemorrhage, or need for panretinal laser.

At 2 years, the percentage of participants with DR worsening by 2 or 3 steps was significantly reduced in ranibizumab-treated eyes compared with sham-treated eyes, and regression of DR by 2 or 3 steps was significantly more likely. The cumulative probability of clinical progression of DR as measured by the composite outcome at 2 years was 33.8% of sham-treated eyes compared with 11.2% to 11.5% of ranibizumab-treated eyes.21-23

VIVID/VISTA: Improvement in DR Scores

Like RISE/RIDE, the VIVID/VISTA trials also showed anti-VEGF injections can improve DR scores. Rather than ranibizumab, these two similarly designed, randomized, phase 3 trials compared the efficacy and safety of two dosing regimens of intravitreal aflibercept injection with macular laser photocoagulation in patients with type 1 or type 2 diabetes who had DME with central involvement.

Eyes received aflibercept 2 mg every 4 weeks (2q4), aflibercept 2 mg every 8 weeks after 5 monthly doses (2q8), or laser control.  In both VISTA and VIVID, the 52-week visual and anatomic superiority of aflibercept over laser control was sustained through week 100, with similar efficacy in the 2q4 and 2q8 groups.

Significantly more eyes in the aflibercept 2q4 and 2q8 groups versus those in the laser control group had at least a 2-step improvement in the DRSS score in both VISTA (37.0% and 37.1% vs15.6%; P <.0001) and VIVID (29.3% and 32.6% vs 8.2%; P ≤ .0004). The figure shows the integrated VIVID/VISTA results for DRRS improvement score.

Regarding visual acuity (VA), the proportion of eyes that gained at least 15 letters from baseline at week 100 was 38.3%, 33.1%, and 13.0% (P < .0001) in VISTA and 38.2%, 31.1%, and 12.1% (P ≤  .0001) in VIVID. The proportion of eyes that lost at least 15 letters at week 100 was 3.2%, 0.7%, and 9.7% (P ≤  .0220) in VISTA and 2.2%, 1.5%, and 12.9% (P ≤  .0008) in VIVID.24

 

Figure

Protocol T: 2-Year Results

The DRCR.net Protocol T study was the first trial to compare the efficacy and safety of the commercially available anti-VEGF drugs used to treat DME.

During the study, patients were randomized to receive 2.0 mg aflibercept, 1.25 mg bevacizumab or 0.3 mg ranibizumab up to every 4 weeks through 2 years following a retreatment protocol. A total of 650 participants were analyzed. Of those, 495 had nonproliferative DR (NPDR) and 155 had proliferative DR (PDR).

The figure shows the percentage with improvement of retinopathy at 1 and 2 years by baseline DR status.  Part A in the figure shows NPDR at baseline. The respective levels of significance for the pairwise comparisons at the 1-year and 2-year visits were aflibercept vs bevacizumab, P = .004 and P = .85; aflibercept vs ranibizumab, P = .51 and P = .85; and ranibizumab vs bevacizumab, P = .01 and P = .85. Part B in the figure shows PDR at baseline. The respective levels of significance for the pairwise comparisons at the 1-year and 2-year visits were aflibercept vs bevacizumab, P < .001 and P = .01; aflibercept vs ranibizumab, P = .02 and P = .06; and ranibizumab vs bevacizumab, P = .09 and P = .73.

Figure

According to the study results, at 1 year, among 423 NPDR eyes, 44 of 141 treated with aflibercept, 29 of 131 with bevacizumab, and 57 of 151 with ranibizumab had improvement of DR severity.

At 2 years, 33 eyes in the aflibercept group, 25 eyes in the bevacizumab group, and 40 eyes in the ranibizumab group had DR improvement; no treatment group differences were identified. For 93 eyes with PDR at baseline, 1-year improvement rates were 75.9% for aflibercept, 31.4% for bevacizumab, and 55.2% for ranibizumab. These rates and treatment group differences appeared to be maintained at 2 years.25

 

Case 2

37-year-old Type 1 diabetic who noted floaters in her left eye for 1 month
Diabetes for > 20 years
Well-controlled diabetes on an insulin pump with last HA1c 7.0
No other medical issues
VA: 20/20 OD, 20/40 OS
IOP: 17 OD and 15 OS
Anterior exam is unremarkable

Figure

Figure

Figure

Anti-VEGF Improved DR Severity at All Stages

More recently, Wykoff and colleagues published a posthoc analysis of the phase 3 RIDE and RISE trials, with two-step or more or 3-step or more improvement or worsening on the ETDRS DRSS and time to new proliferative event (composite end point) as the primary endpoint. DR outcomes were assessed through month 36 by baseline DR severity level.

At baseline, most patients were distributed evenly among mild or moderate nonproliferative DR (NPDR; ETDRS DRSS, 35/43), moderately severe or severe NPDR (ETDRS DRSS, 47/53), and proliferative DR (ETDRS DRSS, 60-75; 28.8%, 33.2%, and 31.1%, respectively).26

Figure

At month 24, rates of 2-step or more improvement with ranibizumab 0.3 mg, ranibizumab 0.5 mg, and sham treatment were highest among patients with baseline DR levels 47/53 (78.4%, 81.1%, and 11.6%, respectively) compared with patients with baseline DR levels 35/43 (10.3%, 15.8%, and 1.4%, respectively) or 60 through 75 without panretinal photocoagulation (31.0%, 36.4%, and 6.7%, respectively; all ranibizumab vs. sham comparisons, P <  .05). In patients with baseline DR levels 47/53, ranibizumab treatment reduced the probability of patients experiencing a new proliferative event at month 36 by 3 times compared with sham treatment (12.4% and 11.9% vs. 35.2% for ranibizumab 0.3 mg, ranibizumab 0.5 mg, and sham, respectively).

In patients with baseline DR levels 47/53 who achieved 2-step or more DR improvement, improvements were independent of all assessed baseline characteristics (P > .4).

The figure shows that after 12 months of treatment, the DRSS level improved from level 53 to level 35, which is essentially a 3-step improvement.26

Figure

Case 3

December 4, 2019

Figure

61 y/o AM, IDDM (A1c 7.2)
Patient believes he was diagnosed with diabetes around age 50, but he wasn’t exactly sure
20/40 OD
PCIOL OD

 

FA shows extensive leaking microaneurysms and capillary dropout.

Figure

OCT shows center-involving DME with an ERM.

Figure

Figure

Key Considerations:

When would you consider treating this patient?

What factors would influence your decision?

How would DRCR Protocol V impact your decision to treat? What about PANORAMA?

 

November 18, 2020

  • OD: s/p 11 anti-VEGF injections (monthly therapy)
  • 20/30
  • Patient has gained 1 line of vision after monthly anti-VEGF therapy for a year
Dramatic reduction in dot blot hemes;  clinically looks like mild NPDR

Figure

Many fewer microaneurysms, minimal leakage; still has capillary dropout.

Figure

OCT shows reduction in intraretinal fluid, and a CRT improvement from 428 to 406; some residual thickening may be from concurrent epiretinal membrane.

Figure

Figure

Figure

After 1 year:

Better NPDR, ~1 line of vision gain

 

Key Considerations

How should we feel about this treatment paradigm?
How would you consider adjusting treatment in year 2 (and beyond)?

The Sweet Spot

Anti-VEGFs appear to work best for patients in the moderate to severe NPDR stage. This falls to the 4-2-1 rule on clinical examination: four quadrants of hemorrhage or one quadrant of intraretinal microvascular abnormalities (IRMA), or two quadrants of venous beading.

Therefore, Wykoff and colleagues concluded that ranibizumab treatment resulted in DR improvements in all three baseline DR severity subsets examined. The greatest benefits in DR improvement occurred in patients with baseline moderately severe to severe NPDR (DR levels 47/53). DR improvements were rapid, clinically meaningful, and sustained through month 36.27

Figure

 

Clinical Questions:

1. Can early treatment of DR with anti-VEGF agents prevent progression to vision-threating DR?

 

2.. What is the window of maximum efficacy for treating DR with anti-VEGF agents?

 

The target is the NPDR eyes.23

Figure

 

PANORAMA: NPDR without DME

PANORAMA is a randomized, multicenter, placebo-controlled Phase 3 clinical trial designed to evaluate the safety and efficacy of aflibercept for treatment of moderately severe to severe NPDR without DME. The trial enrolled 402 patients with DRSS Level 47 or 53 NPDR only. It was designed as the first prospective study to test the hypothesis that anti-VEGF therapy also can induce NPDR regression as well as prevent worsening disease in patients having moderately severe or severe NPDR without DME.

In the trial, eyes were treating either once every 4 months or once every 2 months. The figure shows that essentially after 4 to 6 months of more aggressive treatment with aflibercept in the beginning. 65 to 80% of eye improved dramatically based on the DRSS.28-30

Figure

Case 4

Age
46
Gender
Male
Race
Hispanic
Visual Acuity
20/20 OU
Most recent HbA1c
11.2%
Ocular History
no previous history of surgery, injections, laser, or trauma
Medical History
Type 2 DM x10 years, hypertension, obese, and active smoker (1 pack per day)

Figure

Widefield color fundus photography of this patient reveals evidence of scattered intraretinal hemorrhages/microaneurysms bilaterally, along with scattered hard exudates in the macula, but did not have commensurate swelling to suggest DME. Consistent with diagnosis of moderate NPDR (ETDRS-DRSS: 43)

Figure

Widefield fluorescein angiography demonstrates numerous microaneurysms and midperipheral areas of vascular pruning and associated intraretinal microvascular abnormalities (IRMA). There is some evidence of late angiographic perivascular leakage, but no frank neovascularization of the disc or elsewhere in either eye. Additionally, there is no significant angiographic leakage in the macula, further reinforcing this is a case of NPDR without DME.

Figure

OCT imaging confirms a preserved foveal contour without center-involving DME in either eye (right eye does show exudates in the superior macula, while left eye shows exudates in superotemporal macula)

 

Conclusions

PANORAMA: NPDR without DME

From a practical perspective, by improving the DRSS score, there is a dramatic slowing of disease progression.

Figure

The figure shows that by not treating patients, there is a 58% chance of developing either PDR or center-involved DME. This can be reduced by nearly 80% with aflibercept injections every 4 months or by 75% with injections every 2 months.  These eyes still have an approximately 20% risk of progression.28

 

Case Study: Ranibizumab Improves VA

In this case study, the figure shows the eye treated with ranibizumab and the fellow untreated eye. The baseline images in both eyes show hemorrhages. On the top three images of the treated eye, beginning with moderately severe NPDR, the patient improved with treatment.  However, the three images on the bottom of the untreated eye show the progression to high-risk PDR as this eye was being observed.
Often patients are symptomatic in one eye and are treated but are asymptomatic in the other eye. As time passes, the asymptomatic eye can progress, so many retina specialists recommend monitoring of both eyes.

Figure

SUMMARY

DME is a serious problem.  Most eye care providers are familiar with the high-risk NPDR stage without DME and the potential improvements to be gained from earlier therapy with anti-VEGFs.  However, not all NPDR patients need treatment and they can be monitored carefully. It is important to ensure these patients do not have PDR – many patients do have PDR that is only visible with angiography – and if they are in the NPDR high-risk, the conversation with the patient must begin earlier to they are ready for the treatment if the progression occurs.

 

Figure

References

  1. www.cdc.gov/diabetes/data/center/slides.html
  2. CDC’s Division of Diabetes Translation. United States Surveillance System available at www.cdc.gov/diabetes/data
  3. www.cdc.gov/diabetes/data/statistics/statistics-report.html
  1. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2017
  2. CDC. National diabetes fact sheet, 2011. www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. Accessed August 9, 2019.
  3. CDC. Division of diabetes translation. At a Glance 2018. cdc.gov/chronicdisease/resources/publications/factsheets/diabetes-prediabetes.htm
  4. American Diabetes Association. Living with diabetes. http://www.diabetes.org/living-with-diabetes/complications/eye-complications/.
  5. Centers for Disease Control and Prevention. National diabetes fact sheet, 2011. www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. Accessed June 21, 2012.
  6. Lee R, Wong TY, Sabanayagam C. Epidemiology of diabetic retinopathy, diabetic macular edema and related vision loss. Eye Vis (Lond). 2015;2:17.
  7. Diabetic Retinopathy Defined. https://www.nei.nih.gov/eyedata/diabetic. Accessed August 9, 2019.
  8. IDF Diabetes Atlas 7th Edition (2015). www.idf.org/e-library/epidemiology-research/diabetes-atlas/13-diabetes-atlas-seventh-edition.html. Accessed August 9, 2019.
  9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4657234/
  10. Lanzetta P, Sarao V, Scanlon PH, et al. Fundamental principles of an effective diabetic retinopathy screening program. Acta Diabetol. 2020;57(7):785-798.
  11. Lee DJ, Kumar N, Feuer WJ, et al. Dilated eye examination screening guideline compliance among patients with diabetes without a diabetic retinopathy diagnosis: the role of geographic access. BMJ Open Diabetes Research and Care. 2014;2:
  12. Saleem SM, Pasquale LR, Sidoti PA, Tsai JC. Virtual Ophthalmology: Telemedicine in a COVID-19 Era. Am J Ophthalmol. 2020;216:237-242.
  13. Das T, Raman R, Ramasamy K, Rani PK. Telemedicine in diabetic retinopathy: current status and future directions. Middle East Afr J Ophthalmol. 2015;22(2):174-8.
  14. Lecaire T, Palta M, Zhang H, et al. Lower-than-expected prevalence and severity of retinopathy in an incident cohort followed during the first 4-14 years of type 1 diabetes: the Wisconsin Diabetes Registry Study. Am J Epidemiol. 2006;164(2):143-50.
  15. Yau JW, et al. Diabetes Care. 2012;35(3):556-564.
  16. Bedi R, et al. Impact of diabetic retinopathy. In: Managing Diabetic Eye Disease in Clinical Practice. Basel, Switzerland: Springer; 2015:1-12.
  17. Tapp RJ, et al. Diabetes Care. 2003;26(6):1731-1737.
  18. Diabetic Retinopathy Study Research Group. Photocoagulation treatment of proliferative diabetic retinopathy: Clinical application of the Diabetic Retinopathy Study (DRS) findings: DRS Report Number 8. Ophthalmology. 1981;88:583–600.
  19. Ranibizumab Prescribing Information.
  20. Ip MS, Domalpally A, Hopkins JJ, et al. Long-term Effects of Ranibizumab on Diabetic Retinopathy Severity and Progression. Arch Ophthalmol.2012;130(9):1145–1152.
  21. Brown DM, Schmidt-Erfurth U, Do DV, et al. Intravitreal Aflibercept for Diabetic Macular Edema: 100-Week Results From the VISTA and VIVID Studies. Ophthalmology. 2015;122(10):2044-52.
  22. Bressler SB, Liu D, Glassman AR, et al; Diabetic Retinopathy Clinical Research Network. Change in Diabetic Retinopathy Through 2 Years: Secondary Analysis of a Randomized Clinical Trial Comparing Aflibercept, Bevacizumab, and Ranibizumab. JAMA Ophthalmol. 2017;135(6):558-568.
  23. Wykoff CC, et al. Ophthalmology Retina. 2018;2(10):997-1009.
  24. Wykoff CC, Eichenbaum DA, Roth DB, et al. Ranibizumab Induces Regression of Diabetic Retinopathy in Most Patients at High Risk of Progression to Proliferative Diabetic Retinopathy. Ophthalmol Retina. 2018;2(10):997–1009.
  25. Wykoff CC. Intravitreal aflibercept for moderately severe to severe non-proliferative diabetic retinopathy (NPDR) The phase 3 PANORAMA Study. Presented at: Angiogenesis, Exudation, and Degeneration 2019 Symposium; February 9, 2019; Miami, Florida.
  26. Chous AP. Aflibercept PANORAMA study results in. Optometry Times. https://www.optometrytimes.com/view/aflibercept-panorama-study-results-in. Updated August 13, 2020. Accessed November 13, 2020.
  27. ClinicalTrials.gov Study of the Efficacy and Safety of Intravitreal (IVT) Aflibercept for the Improvement of Moderately Severe to Severe Nonproliferative Diabetic Retinopathy (NPDR) (PANORAMA). Available at: https://clinicaltrials.gov/ct2/show/NCT02718326. Accessed November 13, 2020.

 

Next

Test

Instructions

Step 1 of 2

  • 1. Not at all confident2. Not very confident3. Neutral4. Confident5. Extremely confident
  • AgreeNeutralDisagree
    Summarize the rise of diabetes and diabetic retinopathy (DR) in the US population and the related impact on ocular health.
    Understand effective screening strategies and imaging tools for diagnosing DR and diabetic macular edema (DME).
    Identify which patients need early referral to a retina specialist based on their behavioral patterns, disease state, and/or other risk factors.
    Explain the latest treatment approaches to DR/DME.
    Describe novel developments in DR screening.
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