Advances in the Clinical Management of Diabetic Macular Edema and Age-Related Macular Degeneration - Episode 16
Retina specialists share advice and practice pearls regarding the management of DME and neovascular AMD, including counseling patients about the importance of healthy lifestyles.
Carl D. Regillo, MD, FACS: This is going to be a broad, overreaching question. I’ll start it off by asking Dave. What advice or practice pearls do you have for other ophthalmologists or optometrists in the management of diabetic macular edema [DME] and neovascular age-related degeneration [AMD]?
David R. Lally, MD: For the general ophthalmologist or optometrist, it’s important to stress: take a moment to counsel your patients to maintain a healthy lifestyle. Do not underestimate the value of taking that moment to tell them: if it’s a diabetic patient, stop smoking, get control of your glycated hemoglobin A1C, keep your blood pressure down, exercise. The same goes exactly for our AMD population because there are a lot of natural history studies, observational studies, and population studies that have shown if our patients can maintain better control of their overall systemic health, it’s going to lead to better outcomes in the future for their retinal diseases than if they were not maintaining a healthy lifestyle. Take that extra minute to counsel your patients. I’d also say have a low threshold for referring your patients to a retina specialist. Every week referring providers in the community text me OCT [optical coherence tomography] images of their diabetic and AMD patients and ask what do you think about this? It doesn’t bother me at all because I am helping the patient and the physician make the correct choice about what to do with that patient as opposed to trying to manage something themselves and not having the expertise and thinking that everything is OK, and then the patient ends up in my office a few months later with a severe visual impairment that we could have done something about earlier on. So have a very low threshold to refer these patients to your friendly retina specialist.
Carl D. Regillo, MD, FACS: Blake, any comments, advice, or practice pearls to add?
Blake Anthony Cooper, MD, MPH: I think that communication is key. If we are communicating appropriately with our patients and our colleagues, then we are serving everyone, and it’s important for those who are seeing patients to communicate the idea and concept that there is hope, that there are treatment options, and those treatment options are evolving. The idea of intravitreal injection is frightening, and if they can set the stage that this is routine care, it’s going to serve our patients better when they are in front of us and we are having that conversation about intravitreal injection. It’s important for us as retina specialists to communicate back to the ophthalmologists and optometrists how our patients are doing, because oftentimes we get used to seeing patients on a regular basis, and if they are doing well, not communicating. But it is important for us to make sure that we are updating them so that they realize that they are still part of the patient’s care.
Carl D. Regillo, MD, FACS: Great. How about you, Mike? Any other words of wisdom?
Michael A. Klufas, MD: It’s a team approach. That patient with diabetic macular edema came into their optometrist’s to get new glasses. As a retina specialist you initiate anti-VEGF therapy, but they want the glasses at some point. After a couple of injections, let’s get them the glasses—get them seeing better, and stay up-to-date with the most recent treatment paradigms. Five or 10 years ago, we weren’t treating diabetic retinopathy without DME, but someone with severe NPDR [nonproliferative diabetic retinopathy] and uncontrolled A1C. In 2022, we have to discuss anti-VEGF as a treatment option. It may not be treating all our patients that way, but some of those patients do need to see retina a bit earlier—before things get worse. Staying up-to-date with all the treatment options as well can be a good practice for all of our eye care providers.
Carl D. Regillo, MD, FACS: I will add in 2 more things—2 more pearls of advice for our primary eye care providers. Number 1 is mention the importance of early detection, so if you have OCT at your disposal, anything that looks like it’s vision-affecting or vision-threatening complications of DME, or whether it might be neovascular AMD—early detection, early referral, early treatment have the best results. Have a low threshold to refer earlier. I find a lot of people underestimate the level or degree of diabetic retinopathy in particular and may miss early signs of wet AMD. The other is help us help our patients adhere to the treatments. Compliance—adherence to the regimens—is challenging, so having that reinforced by the primary eye care provider where the patient might go back and look for that new pair of glasses or help them manage their glaucoma—that can help us manage their wet AMD and their DME.
Thanks to all of you for this rich and informative discussion. Before we conclude I would like to get your final thoughts from each of you. Dr Klufas?
Michael A. Klufas, MD: 2022 has been an exciting year. Not only did we get the Port Delivery System but also faricimab, and we’re continuing to work hard with all the ongoing clinical trials. The future is bright, and I am looking forward to offering all these therapies to our patients.
Carl D. Regillo, MD, FACS: Blake?
Blake Anthony Cooper, MD, MPH: Goldilocks and the 3 bears sums it up: not 1 size fits all. We need to continue to personalize care for our patients and consider our patients’ preference when deciding how best to manage someone who lives with diabetes or macular degeneration.
Carl D. Regillo, MD, FACS: And Dave?
David R. Lally, MD: I agree with all, and I just add that the therapeutic pipeline is robust for both of these diseases. There is a lot in development for both diabetic disease and neovascular AMD, so the future, like Michael said, continues to look bright. We have a lot of more exciting therapies in the near future.
Carl D. Regillo, MD, FACS: I agree. Management and outcomes are definitely looking better, and we can do so much more for our patients now more than ever, and that’s going to continue to improve over time. Thank you for watching this HCPLive® Peer Exchange. If you enjoyed the content, please subscribe to our eNewsletter to receive upcoming Peer Exchanges and other great content right in your inbox.
Transcript Edited for Clarity