Photo Credit: Claudio Ventrella

In part one of our series on treating advanced diabetic macular edema, four experts discuss the disease’s progression and the role of interdisciplinary care.

This is the first in a two-part series on treating advanced diabetic macular edema.

Diabetic macular edema (DME) treatments have dramatically evolved in recent years. Four experts in diabetic retinopathy and DME talked with Physician’s Weekly (PW) about how recent advances in treatment are affecting outcomes for patients with advanced DME.

PW: At what point is DME considered to be advanced?

Jay Chhablani, MD: Advanced DME is associated with significant vision loss. On examination, we see significant edema; on scans, we see structural damage to the retina.

Zachary A. Coates, OD, MS: Historically, the clinically significant macular edema criteria developed by the Early Treatment of Diabetic Retinopathy Study determined how advanced DME was. With the development of optical coherence tomography (OCT) and the work of the Diabetic Retinopathy Clinical Research Retina Network, we now classify DME as either center-involved or non-center-involved. Advanced DME now applies to patients with center-involved DME with less than 20/25 vision or with significant thickening of the fovea on OCT imaging.

T.Y. Alvin Liu, MD: Roughly 10% to 15% of patients respond poorly to treatment and may drop out of care. However, chronic, long-term DME can lead to permanent damage. Even if a patient resumes treatment and we see anatomic improvement of DME, their vision may not improve much.

How does the treatment of diabetes influence DME and its progression?

Dr. Chhablani: Diabetes control is key. Diabetes control affects DME, especially in the early stage. With well-controlled diabetes, there is less chance of DME and a higher likelihood of good response to treatment if DME is present. Therefore, we advise our patients that our first step is strict diabetes control. With long-standing uncontrolled diabetes, DME management is very challenging and may not lead to a great visual outcome.

Dr. Coates: The risk of developing DME is generally low if a patient is well-controlled. However, the duration of diabetes is a large risk factor in the development of both diabetic retinopathy and DME. Longer diabetes duration puts patients, even those under good control, at increased risk for DME. Patients with poorly controlled blood glucose and those who have elevated hemoglobin A1C values are at much higher risk for both retinopathy and DME.

Dr. Liu: We now have very good treatments for DME. The standard of care is repeated intravitreal injections, typically anti-VEGF (vascular endothelial growth factor) medications. Patients treated consistently have a greater than 85% chance for stabilization or improvement of visual acuity. In year one, an average patient may need around nine injections, four to six weeks apart. By years two and three, the treatment requirement goes down to about two to three per year, and they may need injections in years four and five.

Does DME continue to progress despite treatment for diabetes?

Dr. Chhablani: Yes, the possibility of DME worsening despite diabetic control always exists. If diabetes is not controlled very well in the beginning and DME sets in, DME management is challenging despite controlled diabetes.

Pradeep S. Prasad, MD, MBA: Optimal diabetes control decreases the risk for DME progression. However, DME can progress even in patients with good glycemic control. All patients need regular checkups with an eye care provider to ensure adequate surveillance for DME so treatment can be initiated when needed. I always encourage patients to optimize their diabetes, blood pressure, and lipid control because this is the best way to prevent ongoing damage and future complications.

What interdisciplinary care is required to treat DME?

Dr. Chhablani: DME management is certainly a multidisciplinary, comprehensive approach. Control of systemic factors such as diabetes, hypertension, lipids, and kidney function is key for overall diabetic retinopathy management.

Dr. Prasad: Interdisciplinary communication is critical. Ophthalmologists should regularly communicate with primary care clinicians, endocrinologists involved in diabetes care, and other members of the interdisciplinary team, which may include nephrologists, cardiologists, neurologists, and podiatrists.

Dr. Liu: The correlation between damage in retinal vessels and blood vessels elsewhere in the body is very high, especially around the heart and kidneys. So, with advanced or severe diabetic retinopathy, we provide holistic care with particular attention to the heart and the kidneys.

Look for more from Dr. Chhablani and colleagues in part two, where they’ll discuss treatment approaches, unmet needs in advanced diabetic macular edema, and other important considerations.