Seeing into the Future Collaborative Care to Maintain Eye Health in Patients with Diabetes

In a session of the Pri-Med West conference at the Anaheim Convention Center, John E. Anderson, MD, internal medicine and diabetes, The Frist Clinic, Nashville, Tennessee, and John W. Kitchens, MD, ophthalmologist and vitreoretinal surgeon, Retina Associates of Kentucky, Lexington, Kentucky, described how primary care physicians (PCPs) and ophthalmologists (including retina specialists) can effectively collaborate to minimize the occurrence of blindness in their diabetic patients.

Explaining the purpose of the session, Kitchens told the audience of PCPs, “We want to better educate you, the frontline care provider for the diabetic patient, with how diabetic eye disease affects your patients. Most importantly, what you need to be doing and telling your patients to ensure that they don’t lose vision from diabetic eye disease.”

Because diabetes is now at epidemic levels in the United States, and 29% of diabetic patients over the age of 40 display symptoms of diabetic retinopathy (DR) caused by changes in retinal vasculature, blindness from diabetes has become the leading cause of vision loss in adults aged 20 to 74.

Unfortunately, many patients do not realize when their DR is advancing, as damage begins undetectably on the periphery of the retina, mandating the use of dilated eye exams to detect progression. However, nearly 40% of diabetic patients do not receive even annual dilated eye exams.

After outlining the 3 strongest predictors of DR are poor glycemic control, long duration of diabetes, and hypertension, Kitchens said. “The number one driver is dysglycemia. Glucose in the retina is the toxin.” While this points to lowering hemoglobin A1C (A1C) levels as key, Anderson said that one size does not fit all in primary care, continuing, “Different approaches for lowering A1C and blood pressure should be used depending on the condition and age of the diabetic patient. More aggressive approaches are more appropriate for relatively younger patients versus patients in their 70s, where safety may be more of an issue.”

Describing best practices for PCPs in treating DR, Anderson emphasized the importance of effectively communicating to their patients with diabetic the impact of the disease on eye health and discussing the importance of annual dilated eye exams. The dilated eye exam may be performed by an optometrist, a general ophthalmologist, or a retinal specialist, depending on the symptoms the patient presents and how long they’ve had diabetes.

Kitchens described established treatments available to patients with DR, such as laser treatment to fix leaky blood vessels and intraocular injection of steroids. Introducing the topic of anti-vascular endothelial growth factor (VEGF) therapy (using three common VEGF inhibitors, aflibercept, bevacizumab, or ranibizumab), he told the audience, “We have some new options that are absolutely revolutionary.”

Kitchens reviewed data from trials conducted by the Diabetic Retinopathy Clinical Research Network, a group established in 2002 to help determine appropriate standards of care for DR. “This is a network of over 100 retinal practices in the US and Canada comprising over 300 providers who have organized to perform clinical trials that are supported by industry but with results routed through the National Eye Institute at the NIH.”

The DRCR data show that in addition to efficacy, another advantage of anti-VEGF therapy is that it can be performed less frequently than injection of steroids. The DRCR network also conducted studies to see which of the available anti-VEGF agents were most effective in treating DR. All were efficacious, but aflibercept was best in the worst cases. According to Kitchens, “Intravitreous aflibercept, bevacizumab, or ranibizumab improved vision in eyes with centerâ€involved diabetic macular edema. At worse levels of initial visual acuity, aflibercept was more effective at improving vision.”

In concluding their talk, Kitchens and Anderson emphasized again the importance of annual dilated eye exams for all patients with diabetes so that interventions can be applied most successfully if disease progression is evident.

Kitchens encouraged the assembled physicians, “Your patients no longer have to go blind from diabetic eye disease, but it does take a team effort. If we engage these patients early enough in treatment and self-care, we can really change the dynamic of this disease.”