In the past decade, the standard of care for patients with diabetic macular edema (DME) has evolved from laser photocoagulation to pharmacotherapy, which has resulted in an improvement in vision for many patients. Despite these advances, however, problems with instituting treatment for diabetes still exist. In fact, diabetes is still the number one cause of adult blindness and, because diabetic retinal changes are asymptomatic early in the disease, it is estimated that 25% of patients with diabetes are undiagnosed.^1-2

For 25 years, we’ve known that control of blood pressure, blood sugar, lipids, and smoking cessation can reduce progression; yet, very few patients achieve control of all four. A decrease of 1% in HbA1c reduces the risk of complications by 30% to 35%. Even with monthly anti-VEGF treatment for DME, as many as 30% of patients don’t respond adequately or experience only minimal visual acuity improvement.³ These poor or non-responders have encouraged researchers to evaluate other pathways, including the angiopoietin-Tie pathway, stronger and longer-acting anti-VEGF treatments, the integrin pathway, treatment of VEGF C and D, and the kalkerin pathways.⁴ The hope is that these alternative treatments, either alone or in conjunction with anti-VEGF, will improve the visual results for diabetic patients.

Improvements in screening and education are needed not only to reduce the number of undiagnosed cases, but also to provide better care for patients with diabetes. We must ensure that primary care physicians, internists, and others are educated on the importance of early referral. Equally important, ophthalmologists must recognize the need to refer patients back to their primary care doctors when we identify medical issues in our patients. ■

References

1. Statistics About Diabetes. American Diabetes Association website. Available at: http://www.diabetes.org/diabetes-basics/statistics ; last accessed April 15, 2019.
2. Cavallerano JD, et al. Ophthalmic complications in older adults with diabetes. In: Munshi MN, Lipsitz LA, eds. Geriatric Diabetes. New York: Informa Healthcare; 2007.
3. The relationship of glycemic exposure (HbA1c) to the risk of development and progression of retinopathy in the diabetes control and complications trial. Diabetes. 1995;44:968-983.
4. Zhang X, Zeng H, Bao S, Wang N, Gillies MC. Diabetic macular edema: new concepts in patho-physiology and treatment. Cell Biosci. 2014;4:27.