Diabetic Retinopathy: Updated Guidelines Reflect Improved Assessment and Treatment

The American Diabetes Association (ADA) released their first position statement in 15 years regarding diabetic retinopathy. The updated statement reflects the significant advancements made in both assessment and treatment of the condition since ADA’s last guidance in 2002.

The report notes the recent improvements made in evaluating the diabetes complication, such as the implementation of optical coherence tomography for assessing retinal thickness and intraretinal pathology, and wide-field fundus photography to detect clinically silent microvascular lesions.

Therapies have also made advancements, with treatment now given by intravitreous injection of anti-vascular endothelial growth factor (VEGF) agents.

Treatment recommendations from the ADA include:

• Promptly refer patients with any level of macular edema, severe nonproliferative diabetic retinopathy, or any proliferative diabetic retinopathy to an ophthalmologist.
• Laser photocoagulation therapy reduces risk of vision loss in patients with high-risk proliferative diabetic retinopathy and, in some cases, severe nonproliferative diabetic retinopathy.
• Intravitreous injections of anti-vascular endothelial growth factor are indicated for central-involved diabetic macular edema.
• The presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection, as aspirin does not increase the risk of retinal hemorrhage.

The ADA recommends optimization of glycemic control, as well as blood pressure and serum lipids, to reduce or slow the progression of diabetic retinopathy. The report also advises screening via dilated and comprehensive eye exam by an eye specialist within 5 years after the onset of type 1 diabetes and immediately at the time of diagnosis of type 2 diabetes. Women with preexisting diabetes who are planning to become pregnant should be screened beforehand or during the first trimester.

Screening and traditional laser treatments are both long-established, cost-effective therapies. Anti-VEGF injections have also shown to be more cost-effective than laser monotherapy for diabetic macular edema, although this has not been confirmed for proliferative diabetic retinopathy.

The authors conclude that more studies are needed to evaluate the cost-effectiveness of anti-VEGF medications as a first-line treatment.

Reference

Solomon SD, Chew E, Duh EJ, et al. Diabetic Retinopathy: A Position Statement by the American Diabetes Association. Diabetes Care. 2017; 40(3): 412-418. https://doi.org/10.2337/dc16-2641