First ADA Guidance on Diabetic Retinopathy in 15 Years

Miriam E Tucker

February 21, 2017

A new retinopathy position statement from the American Diabetes Association (ADA) reflects the "dramatic" improvements in both assessment and treatment in the 15 years since ADA's last guidance on this diabetes complication.

Published online in Diabetes Care on February 21, the statement covers the natural history of diabetic retinopathy, including risk factors, and reviews the stages — from mild nonproliferative to moderate nonproliferative with macular edema, to severe nonproliferative.

The document also summarizes recent data on screening and treatment with recommendations given for both and includes a discussion about cost-effectiveness.

Recent improvements in evaluation include the widespread adoption of optical coherence tomography for assessing retinal thickness and intraretinal pathology and wide-field fundus photography to detect clinically silent microvascular lesions.

And advances in treatment include intravitreous injection of anti–vascular endothelial growth factor (VEGF) agents for both diabetic macular edema and proliferative diabetic retinopathy.

"Diabetic retinopathy diagnostic assessment and treatment options have improved dramatically since the 2002 American Diabetes Association Position Statement.…This position statement incorporates these recent developments for the use of physicians and patients," write lead author Sharon D Solomon, MD, an ophthalmologist at the Wilmer Eye Institute of Johns Hopkins Medicine, Baltimore, Maryland, and colleagues.

Senior author Thomas W Gardner, MD, professor of ophthalmology and visual sciences at the Kellogg Eye Center at the University of Michigan, Ann Arbor, says that diabetic retinopathy is "the most common cause of new cases of blindness in adults who live in developed countries and are between the ages of 20 and 74.

"Over the past decade, new research and significant improvements in technology have aided our ability to diagnose and treat diabetic retinopathy, and advances in medications are giving people with diabetes the opportunity to improve glucose management and potentially avoid or delay the progression of complications such as retinopathy," he notes in an ADA press release.

Optimize Blood Glucose, Blood Pressure and Lipids to Slow DR

For starters, the new statement advises optimization of glycemic control, as well as blood pressure and serum lipids, to reduce or slow the progression of diabetic retinopathy.

Screening via dilated and comprehensive eye exam by an eye specialist should begin within 5 years after onset of type 1 diabetes and at the time of diagnosis of type 2 diabetes. And women with preexisting diabetes who are planning pregnancy should be screened prior to becoming pregnant, or if that doesn't occur, during the first trimester.

For patients with either type of diabetes, if no evidence of retinopathy is found, follow-up eye exams can be scheduled about every 2 years. But if any retinopathy is identified, subsequent dilated-pupil retina exams are advised at least annually, and more frequently for those in whom the retinopathy is progressing or sight-threatening.

Pregnant women — or those planning pregnancy — with preexisting type 1 or type 2 diabetes should be counseled about the risk of development and/or progression of retinopathy during pregnancy, and they should be monitored each trimester and for 1 year postpartum as indicated by the degree of retinopathy.

Laser photocoagulation is still the mainstay of treatment for patients with high-risk proliferative diabetic retinopathy and for some cases of severe nonproliferative retinopathy.

But today, intravitreous injections of anti-VEGF are indicated for central-vision-involved and sight-threatening diabetic macular edema, Dr Solomon and colleagues say.

And the presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection, since data suggest that aspirin doesn't increase the risk for retinal hemorrhage, they note.

Jury Still Out on Role of Telemedicine in Diabetic Retinopathy

In a final section on cost-effectiveness, the authors point out that both screening and traditional laser treatment are long-established as cost-effective.

Regarding treatment, anti-VEGF injections have been shown in many studies to be more cost-effective than laser monotherapy for diabetic macular edema, but the same calculation has not yet been established for anti-VEGF treatment for proliferative diabetic retinopathy.

However there has been debate on the impact of telemedicine in the detection and management of diabetic retinopathy, with multiple studies providing evidence both for and against the conclusion that telemedicine is advantageous.

"Although a consensus has yet to be reached, telemedicine appears to be most effective when the ratio of providers to patients is low, the distance to reach a provider is prohibitive, or the alternative is no patient screening," Dr Solomon and colleagues conclude.

Dr Solomon receives academic support through the Katharine M Graham Professorship at Wilmer Eye Institute, Johns Hopkins School of Medicine. Dr Gardner has no relevant financial relationships. Disclosures for the coauthors are listed in the paper.

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Diabetes Care. Published onlineFebruary 21, 2017. Abstract

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