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Three experts discuss the increased mortality risk for patients with diabetic retinopathy, available screening tools, and counseling patients during eye exams.
Patients with diabetic retinopathy (DR) are at increased risk for cerebrovascular accident, myocardial infarction, congestive heart failure, and all-cause mortality, according to multiple studies. These studies also underscore the key role that ophthalmologists play in helping these patients maintain optimal diabetes and cardiovascular control.
More severe retinopathy appears to carry greater risk for each outcome, and retinal abnormalities can provide valuable insights into risk for future vascular disease and death, these studies noted.
Early screening, identification, and treatment of patients with diabetes can reduce their risk for vascular disease and death. Further, DR grading can be an effective predictive indicator for monitoring vascular status.
Three Experts Share Their Perspectives
Jay Chhablani, MD, Michael D. Abramoff, MD, PhD, and Michael Allingham, MD, PhD, talked with Physician’s Weekly (PW) about the relationship between DR and all-cause mortality and how ophthalmologists can help optimize health outcomes for their patients with diabetes.
PW: What is known about the link between diabetic retinopathy and all-cause mortality?
Dr. Chhablani: There is a well-established relationship between diabetic retinopathy and all-cause mortality, with DR serving as a significant marker for increased mortality risk. This is related to the association of DR with other systemic complications such as cardiovascular disease, vascular instability, and renal disease. Therefore, routine monitoring and comprehensive management of diabetes are vital in reducing both the incidence of DR and the associated increased mortality risk.
Dr. Abramoff: Multiple studies and meta-analyses have shown an all-cause mortality relative risk around 2.3 to 2.4 times for both Type 1 and Type 2 diabetes.
Dr. Allingham: Numerous studies have correlated the presence of diabetic retinopathy with increased risk for all-cause mortality. Speaking generally, the risks for all-cause mortality increase with the severity of retinopathy.
What is known about how cardiometabolic conditions are linked with DR and mortality?
Dr. Chhablani: The interplay between DR and conditions such as cardiovascular disease, hyperglycemia, hyperlipidemia, and hypertension is complex and significant. These conditions exacerbate the progression of DR but also contribute to poor response and worse outcomes of DR. Therefore, stringent management of blood sugar levels, lipid profiles, and blood pressure is crucial in mitigating these risks. Regular monitoring and comprehensive care strategies are essential for diabetic patients to reduce the incidence and severity of DR and to improve the treatment outcomes of DR.
Dr. Abramoff: While not the only factor in mortality, the primary factor for increased mortality risk is cardiovascular disease.
Dr. Allingham: In diabetic patients, there is an association between the presence of cardiovascular disease and diabetic retinopathy. In addition, the risk for developing retinopathy is increased in patients with worse glycemic control, worse blood pressure control, and abdominal obesity. Studies are mixed regarding the relationship between hyperlipidemia and diabetes.
Does treating DR affect mortality risk?
Dr. Chhablani: Treating DR will certainly influence mortality risk directly and indirectly. Addressing underlying risk factors such as hyperglycemia, hypertension, and dyslipidemia while performing specific retinal interventions can improve overall health. This comprehensive approach helps manage DR and reduces the incidence of life-threatening complications, thereby lowering all-cause mortality.
Dr. Abramoff: Many different management and treatment options are available for diabetic retinal disease, and while some of them primarily target the eye, others target the systemic disease itself and could help mitigate the risk for death by treating the underlying disease. Therefore, early diabetic retinal disease diagnosis and timely management are THE keys to better outcomes.
How can ophthalmologists help extend life expectancy in patients with DR?
Dr. Chhablani: Ophthalmologists can significantly impact the life expectancy of patients with DR by focusing on early detection, patient education, interdisciplinary collaboration, and comprehensive management of diabetes and its associated conditions. By addressing both ocular and systemic health, ophthalmologists help prevent DR progression and reduce the risk for life-threatening complications, thereby enhancing their patients’ overall health and longevity.
Dr. Abramoff: Ophthalmologists or autonomous AI for the diabetic eye exam are key to identifying diabetic retinal disease early, before symptoms exist. Early identification of DR allows earlier therapeutic interventions that might reduce overall mortality risk.
Dr. Allingham: Number one: Make the diagnosis of diabetes when findings are present on routine examination. For patients with known diabetes, it is critical to help the patient connect with the other necessary members of a multidisciplinary care team, including those in endocrinology, nephrology, cardiology, and others.
What do ophthalmologists need to tell patients about the link between DR and mortality?
Dr. Chhablani: Effective communication and education are crucial for helping patients with DR understand the link between their eye condition and overall mortality risk. By using educational material such as brochures and visual aids, ophthalmologists can empower patients to take proactive steps to manage their diabetes and improve their overall health.
Dr. Abramoff: People with diabetes often fear visual loss more than losing a limb or dying, so the diabetic eye exam is an effective opportunity for discussing the broader risks from diabetes.
Dr. Allingham: I do not generally bring up the correlation, as this can be upsetting to patients (unless they ask me). However, using patient clinical imaging for patient education is extremely effective. Ophthalmologists can get amazing clinical imaging, such as color fundus photos, optical coherence tomography, and fluorescein angiography, which show vascular manifestations of diabetes such as hemorrhage, vascular non-perfusion and/or leakage, and macular edema.
Explaining that these same problems are taking place in other vascular tissues, including the brain, heart, kidneys, and other soft tissues, can help patients understand the problem and appreciate the need to optimally manage their systemic disease.
What screening tests assess factors associated with increased mortality?
Dr. Chhablani: Comprehensive ophthalmic examination including dilated fundus examination can reveal early signs of DR. Optical coherence tomography and fluorescein angiography can help us identify early signs of DR. A1C, blood sugar, electrocardiogram, stress test, foot sensation, echocardiography, and lipid profile are some other tests that assess disease status.
Dr. Abramoff: Primary care physicians, endocrinologists, and other professionals managing people with diabetes can now use autonomous AI to perform the point-of-care diabetic eye exams, greatly enhancing the identification of patients at greatest risk for increased mortality and visual loss.
Dr. Allingham: Ophthalmologists need to document the presence and severity of retinopathy so that all members of the care team realize that the patient is at higher risk. We routinely test confrontation visual fields and ocular motility, which can detect certain neurological problems such as stroke and microvascular disease affecting the cranial nerves.
Our examinations can pick up other problems such as retinal intra-arterial plaques, which indicate risk for embolic disease and can prompt further testing, such as carotid ultrasound and cardiac echocardiogram. We also need to optimize secondary prevention for stroke, including anticoagulation, blood pressure, and lipid management.
What else should ophthalmologists consider in efforts to mitigate risks?
Dr. Chhablani: Educate your patients, consider the social determinants of their health, and consider their mental health while keeping in mind the importance of early detection and interdisciplinary collaboration.
Dr. Abramoff: Careful patient management in close collaboration with the physician managing diabetes, allowing sustainable focus on lifestyle, weight loss, metabolic control, diet, as well as the use of available highly effective treatments.
Is there anything else you’d like to mention?
Dr. Chhablani: Maintain a comprehensive, patient-centered approach that addresses the ocular manifestations of the disease as well as the systemic and psychosocial aspects of diabetes. By staying informed, fostering interdisciplinary collaboration, emphasizing prevention and early intervention, enhancing patient education, and addressing comorbidities and psychosocial factors, clinicians can significantly improve their patients’ outcomes.
Dr. Abramoff: Too few people with diabetes have access to an eye exam; the latest statistics show that only 20-30% of people with diabetes have access to eye exams. Every patient with diabetes should get the care they need and deserve.
Dr. Allingham: At my home institution, we grapple with making sure that all our patients with diabetes receive appropriate retinopathy screening. As an ophthalmologist and retina specialist, I worry a lot about patients who have undiagnosed retinopathy who are at risk for vision loss that timely treatment could prevent. Making sure that patients have an eye exam at least each year could significantly reduce vision loss in this population.
