Strategies in Diabetes GETOCT 5

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What to do in diabetic retinopathy? by Martin K. Schmid, MD

The strategies change, new knowledge has to be evaluated and proofed. The findings of today may already be obsolete tomorrow. We can only show a snapshot of the current knowledge about diabetes. General recommendations must always be placed in the context of the affected patient. There is no standard diabetes patient, each person is different, everybody needs a customized procedure.

Basic frame:
It sounds simple but first of all: the basic frame of all diabetic problems, is the diabetes itself. Diabetic retinopathy represents “only” the complication of the underlying disease, called diabetes. Good interdisciplinary management of the underlying disease means control and treatment of the most important paramaters. Responsible for the treatment and control of the underlying disease are the internist and the patient together.

How should we monitor patients with diabetes?
It is important to know that after 20 years, more than 80 percent of affected patient develop a diabetic retinopathy. There are mainly the situations:

1. Pregnancy:

Pregnancy can be a source of danger in diabetes. Pregnancy can lead to a diabetes decompensation. A baseline checkup should already occur if a desire for pregnancy exists. During pregnancy the patient should be checked every three months, even monthly in special cases.

2. Type 1 diabetes:
Currently it is recommended in type 1 diabetes: annual check from the fifth year of manifestation, or from the age of eleven. In the presence of type 1 diabetes without retinopathy annual inspection should be performed. In the presence of type 1 diabetes with retinopathy, the procedure corresponds to the severity.

3. Type 2 diabetes:

In type 2 diabetes, it is different because at diagnosis 36 percent already show a retinopathy. If the retina is healthy in diabetes type 2, nevertheless the retina should be examined annually.
In diabetes with a healthy retina or only a few microaneurysms an annual inspection is recommended.
A moderate diabetic retinopathy means only a few hemorrhages, microaneurysms, beaded veines. In question of an ischemia a fluorescence angiography is worthwhile.  An OCT may be helpful in a decrease of visual acuity with looking for a macular edema.
The checks are carried out every 6 to 12 months depending on the situation.

An advanced diabetic retinopathy is characterized by the 4-2-1 – rule
-Presence of more than 20 microaneurysms in the four quadrants
-or venous beading in two quadrants and/or one quadrant with IRMA

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Therapeutic strategies in macular edema:

Currently, the treatment of a macular edema is a most discussed topic. A proposal for control and treatment in diabetic macular edema is presented in this video.

A proposal for control and treatment:
In severe diabetic retinopathy a fluorescence angiography (FA) and OCT are performed. These two methods are the basis for the indication of a therapy. The laser is still an important tool, especially for the treatment of ischemia. After treatment, frequent monitoring is necessary.

Consider the morphology and function of the macula:
In a dry macula, good visual acuity and inconspicuous biomicroscopy, checks are carried out every year.
In borderline cases an OCT or fluorescence angiography (FA) should be performed, followed by an appropriate therapy.
In a clinically significant macular edeme, OCT and/or fluorescence angiography (FA) are the basis, followed by Laser and/or anti VEGF therapy. After treatment, a frequent monitoring is necessary in every case.

In cases with a thickened foveola a proposal may be:

If the edema is not located quite centrally, a focal laser may be sufficient. When this laser is not successful, we go back again in the proposed scheme.
If the foveola is thickened centrally, the anti-VEGF therapy is then possible.
If no stabilization occurs, the vision rises an additional laser treatment may be useful.
If therapy stabilized the situation, ​​a break and a close monitoring follows. If everything remains stable, the patient remains in the small control loop.
If the situation worsens, the patient returns to the top level of control.

This is not a fixed regimen, but must be customized and changed over time.