Geeta Lalchandani-Lalwani, MD: Screening, Treatment of Diabetic Retinopathy

Geeta Lalchandani-Lalwani, MD

Patients with moderate-to-severe non-proliferative diabetic retinopathy have an increased risk of experiencing disease progression towards diabetic macular edema (DME) and/or proliferative diabetic retinopathy (PDR), according to a study presented at the American Academy of Ophthalmology (AAO) 2020 Virtual Conference.

In part 1 of a Q&A with HCPLive®, Geeta Lalchandani-Lalwani, MD, ophthalmologist at Boulder Community Health in Colorado, introduced the study and its findings. In this next and final part, she discusses additional findings as well as gestures towards the future of diabetic retinopathy clinical trials and treatment. She talked more in depth about the importance of early screening, the treatment and management landscape, as well as the potential of genetic studies to elucidate more personalized therapies.

HCPLive: What does the treatment and management landscape look like for these patients who are more progressed in diabetic retinopathy?

Lalwani: So, that's the interesting part. Among these patients who progressed with diabetic retinopathy, we found them to have distinct clinical subtypes. They either developed DME or PDR. However, very few developed both. They seemed to go in one pathway and progressed along those stages. As you can imagine, the more severe diabetic retinopathy they had at baseline, the higher numbers. But they still stayed in their same pathway.

In other words, even patients who had severe nPDR at baseline within 5 years still seemed to develop either diabetic macular edema (DME) or proliferative diabetic retinopathy (PDR), and typically not both.

We found that a little bit unusual. You would have expected that more severe patients would have gotten more severe in every way, but that wasn't true.

Similar findings were observed in the panorama study to back up this criteria that patients seemed to get in their lane and stay in their lane throughout their development of diabetic retinopathy.

For us, it seems to point that there are other factors at play. If you look at numerous genetic studies — in basic genetics — there seems be a high concordance in twin studies in the severity of diabetic retinopathy from one twin to the other twin.

But if you look further, there are certain genes that seem to be possibly implicated in developing either PDR or DME. And some of the systemic factors that we focus on seem to have no effect on the development of DME versus PDR.

HCPLive: Earlier, you mentioned the importance of screening and early detection for DR in diabetic patients. Can you say a bit more about the importance of it in a clinical setting?

Lalwani: Sure. I can't say enough about it. I think the importance of screening is still underestimated. If you see that 10% of all-comers of patients go on to develop a 2-step worsening within 5 years, that is a large number from a large population, right?

And then if you see that they have moderate-to-severe nPDR at baseline, now your numbers are at 35-40% in terms of progression. That is significant, because if you are starting that high, then that progression is putting you into the zones of proliferative diabetic retinopathy risk. That's where we talk about blindness. That's where the concept of blindness comes in as well as DME.

What I think is very interesting about these genetic studies is the question: Now, how do we manage it? If we can isolate or identify genes that may give you a predisposition developing PDR or DME before you get to that point, how can we can address it differently? What are we going to focus on? Obviously, a lot more work needs to be done. We're going to need to do a genetic trial, similar to so much of what is going on.

I think this points to more of a personalized medicine development in the future, where we're going to focus on individuals and be able to identify and say, "you have this genetic phenotype, this is what we need to focus on, and this is how we're going to manage it."

But we have a long way to go before we get there.

HCPLive: Do you have any final comments or thoughts you want to add?

Lalwani: I would just say that the basic thing is that patients with moderate-to-severe nPDR at baseline have the greatest risk of progression to vision-threatening forms of DR. I think it behooves us to get that out to public knowledge and to get people to realize the importance of diabetic retinopathy screening.

I always explain to my patients that unfortunately when they start to have symptoms, it is often too late. So, we need to do a better job.

It's also interesting because we do have therapies now that are directed specifically towards diabetic retinopathy, not necessary DME. So, it's a challenge for us to figure out how to use these treatments more effectively and safety. I believe that's a question where we we still need more long-term data to answer.

But, it's exciting that we even have an opportunity to possibly regress the disease process. It's a question of finding out who this should be applied to best.