Roles for VEGF Inhibitors in the Management of Retinal Diseases - Episode 7
Joseph M. Coney, MD, and Ehsan Rahimy, MD, explain the complications of nonproliferative diabetic retinopathy and emphasize the importance of early detection.
W. Lloyd Clark, MD: Joe, talk to us about as disease progresses, what are some of the later complications of diabetic retinopathy? Obviously, the patients Diana is talking about who have early stages of retinopathy, either have mild symptoms or perhaps are asymptomatic. But over time, that tends to change. What type of end-stage complications are we dealing with as retina specialists in our practices?
Joseph M. Coney, MD: Diana alluded to it, as the disease progresses itself, there are more vascular changes that go along with that, and then there’s this feedback loop where ischemia checks in. Before you know it, patients have center-involved diabetic edema, the vision is getting worse, but the most important thing is that because you have a lack of circulation, the body tries to make new blood vessels to try to recuperate what’s not there. And in the heart, that’s good. When you have a heart attack, the collateral vessels that you make in the heart are good. But in the eye, they’re not good because they can bleed. These blood vessels bleed into the vitreous cavity; patients come in, they have blinding, vitreous hemorrhages. Sometimes they have floaters. And later, they have tractional retinal detachments [TRDs], and these, unfortunately, often require surgery. If we could turn back the hands of time in these patients and get them to a level where we can decrease their level of disease before they get to this area, we can save their sight. And again, the problem is getting patients in early enough. Like you said before, the screening is key.
The new guidelines are important, and communicating that to our optometric colleagues and medical physicians because oftentimes, they’re the first ones to see the patient, is critical. And then for us, it’s appropriate management, timely treatment, and the most important thing is always staging. If you do those 3 things, and you catch a patient before they lose vision, 90% of the time, we’re able to stabilize the vision. We may not always stop them from losing vision over time, but we can decrease the progression because once they have sight-threatening problems, within the next 3 to 4 years, their vision continues to decrease and sometimes becomes irreparable.
We learned a lot in some of our clinical trials, even with RIDE and RISE, one of the first landmark trials. Individuals who were randomized to the sham arm, when they crossed over to get treated at 2 years, those eyes never recuperated. They never improved to the same amount as the eyes that were initially treated in the study, and that’s been a consistent among all our trials. Early treatment for patients is better, no matter where the level is. We if catch them at 20/40 vision, although we may not be able to improve them, that may be the difference of driving, spending time with your loved ones, watching your kids play baseball. These are quality types of decisions, and we can help with that by catching them early.
W. Lloyd Clark, MD: You are spot-on about early treatment. What about to take it a step further, Ehsan, early detection, are we doing a good job with this today? Could we do better? Are there strategies that could be employed, either as an individual clinician or even at the health system level, to improve the detection of diabetic retinopathy?
Ehsan Rahimy, MD: Yes. We can certainly do much better, and earlier detection of NPDR [nonproliferative diabetic retinopathy] is something that happens outside of all our offices. It’s certainly not happening in the retina doctor’s office. The goal is, we’re looking in our referral networks and trying to identify at certain points where the opportunistic points are to capture these patients, get them screened, and get them appropriately referred. Oftentimes, this is happening at the level of our optometry colleagues, our general ophthalmology colleagues, and depending on the system you work in, primary care doctors, endocrinologists. I’m seeing it incorporated in our system in some areas nearby, where we’re returning to teleretinal screening programs. We’re potentially deploying cameras in the offices of internal medicine doctors, endocrinologists in a laboratory setting. It’s not too far off in the future where you’ll see this at a Walgreens, at a Costco, at a Walmart. There are going to be different points of entry for patients to be identified and referred in to see us.
I have 3 tips, at least that I use for my referral base, and this primarily applies to my optometrists and ophthalmologists to send patients to me, if they ever see anything concerning that they feel is out of their area of expertise, especially our ODs [optometrists]. Most of them have an optomap that they’re taking pictures with and following patients with diabetic retinopathy, and they all feel comfortable, maybe more comfortable or less comfortable, following a patient with moderate or maybe moderately severe disease. I tell them to send the patient to me for a baseline evaluation. I’m more than happy to see that patient and tell them, “You don’t need an injection,” but educate them about their disease process. I might tell them that, “You’re under good care with your optometrist or your ophthalmologist. Go back and see them if there’s ever any progression in the future. They may send you back to me for therapy.” That visit goes so smoothly, and I’ve seen this play out over the years where, unfortunately, it does progress to the point where they need treatment. That patient is automatically on board when they come back to me. They come back and they say, “You told me this may happen, we talked about therapy. I did my best to take care of my diabetes, but here we are. Let’s go ahead with treatment.”
This is as opposed to, if you’re seeing that patient for the first time and you’re already telling them that they need an injection, we’ve all had this experience. Patients’ eyes glaze over, and you’ve almost lost them at that point, and sometimes they don’t even return because of that fear factor. You’re suddenly throwing it on them that they need an injection. No. 2, for those visits where somebody does need treatment fairly soon, I’ve also educated my referral base to at least introduce that concept to the patient that they may need injections, and that it gives that patient more time to rest and digest that. They can go home, they can do their own Google research, or talk to a family member, friend, or a colleague, and get comfortable with the idea that maybe they need an injection by the time they come and see me, rather than hearing it for the first time when they’re in our office.
And the third reason I always encourage an early referral, even if it’s for a baseline, is we have access to potentially one of the most powerful tools that our colleagues don’t, which is fluorescein angiography [FA]. I use a plus-1 rule when I talk about DR [diabetic retinopathy] to my referral base, which is whatever amount of diabetic retinopathy you think you’re seeing, put a plus 1 on that because usually when we get the FA, that’s when we see that probably a moderate is not moderate. It could be severe or even you’re seeing early PDR [proliferative diabetic retinopathy] with occult neovascularization [NV]. And that isn’t to say that my optometry or ophthalmology colleagues aren’t good at detecting diabetic retinopathy. That’s saying that we as humans are not that great, and when we have access to the super tool like FA, we’re able to capture all these areas that we otherwise wouldn’t have seen ourselves. Sometimes I play a game with myself, where I look back post-FA and think, oh, that’s where the NV was. It would have been so easy to miss it otherwise.
These 3 tips help get everyone on board, make our referral base comfortable with sending patients to us. Sometimes they feel like, “Oh, you’re so busy. I don’t want to bother you with this,” and then next thing you know, they’re sending somebody over with PDR, vitreous hemorrhage, TRD. I think moving forward, that would basically be a failure of our care. That’s at least the standard we want to get to, where we’re identifying and intervening at a much sooner state than PDR.
W. Lloyd Clark, MD: To our audience, thank you very much for watching this HCPLive® Peer Exchange. If you enjoyed this content, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your inbox.
Transcript edited for clarity.