Clinical Management of Diabetic Macular Edema - Episode 4
A panel of experts explains how diabetic macular edema progresses over time and how to educate patients about progression prevention.
Nancy Holekamp, MD: Dr Rahimy, if you have a patient with diabetic macular edema [DME], how does it progress over time? What’s the time course? How do you educate your patient about this diagnosis?
Ehsan Rahimy, MD: As a quick follow-up to the last question about the availability of OCT [optical coherence tomography], I would emphasize to colleagues that we are amid a paradigm shift. A lot of technological disruption is coming, and home-based OCT monitoring technology is here and will likely be launched within the next year for patients who are actively being monitored or receiving therapy. People envision a potential future where OCTs are available at a Rite Aid, CVS, Walmart for patients to get periodic screenings as well. The availability of it is ever-increasing, and it has been around for several decades now. The next big jump, we’re relying on our tech colleagues to compartmentalize and compress it to have it in a remote care-delivered setting.
To your question about the progression of DME, when I’m meeting with patients they’re often sent to me for an initial evaluation, either by their optometrist or their ophthalmologist who had detected DME. I’m hoping as I’ve become comfortable with my referral base over time, that they’ve at least introduced the concept of treatment. That treatment may be a possibility of needing an injection in the eye. If that’s the first time the patient’s hearing it from you, their eyes may glaze over, and then you’ve lost them. I try not to emphasize the need for urgent or immediate treatment at those initial visits. I like to spend time educating the patient about the background of the disease process, explaining to them that DME, if left untreated, has a pattern toward progression over time. The longer that fluid is in the retina, it is causing slow but permanent damage over time, such that even if I can make their OCT look pretty again, there may be permanent functional visual loss as a result.
We have many clinical trials in our field to rely upon and to pull based on how an interaction is going with a particular type of patient. We know from one study done by the Diabetic Retinopathy Clinical Research Network, the Protocol V study, that we can safely monitor some of these patients who have good starting visual acuity that’s relatively preserved, even if they have center involving diabetic macular edema. We don’t always have to be quick to the trigger to start injecting patients. I like to see the OCT first and then sometimes guess what the visual acuity is, and I’m always amazed, especially with DME, how often we’re wrong. We’ll see horrible OCTs, [but the visual acuity is] 20/25, 20/30, and the patient is completely asymptomatic. Not all DME presents with symptoms.
Nancy Holekamp, MD: That’s an excellent point, and as you said, it’s not an emergency. It’s not like someone showing up in our office with a retinal detachment; they don’t get this way overnight. We have time to educate patients and talk about the treatment options available. Dr Coney, often when patients understand that they have this condition they ask, “What can I do to prevent the progression of the disease? What can I do so that it doesn’t get worse?” What do you tell your patients?
Joseph M. Coney, MD: I try to be simple with my patients because health literacy is a phenomenon. They may not always understand what’s going on, so I try to leave them with a couple of pearls, and then we continue building on that as their journey with me continues. The most important thing is their A1C [glycated hemoglobin] levels, and I don’t expect them to have normal A1C levels because they have a problem. They have diabetes so they’re not going to be 4% to 6%, but I do want them to be less than 7%. I give them the alphabet: A, B, C, D, and E. A is for your A1C, B is for blood pressure. I want their blood pressure to be less than 140 over 80 mm Hg, to watch their cholesterol, monitor their diet, and increase their activity. The other part is smoking; smoking is an important thing. Sometimes it’s hard for patients to stop because they’ve been smoking for 20, 30, 40 years, but when you show them what their eye looks like, they begin to understand that they have problems they weren’t aware of. The last important thing is to maintain their routine or recommended eye examinations. These will be different depending on what stage of the disease they are in, if they have mild or moderate disease, you may see them annually. But as the disease progresses, they may be coming in every 4 to 6 months, sometimes every 3 months, because you’re monitoring for more sight-threatening problems. While they may not have problems today, they can progress rapidly, and we won’t know who those patients are. Our technology and our treatments have changed drastically. The landscape is changing in front of our eyes, in terms of the retina space, and we have medications available now with which we can turn back the hands of time and treat sight-threatening problems before the vision declines.
Theodore Leng, MD, FACS: I like to counsel my patients, the ETDRS study showed that if you keep the hemoglobin A1C at less than 7.0%, you have a 50% risk reduction in progression of disease. I like to quote that number because I think primary prevention is key in many areas of medicine, and diabetes especially. They know that if they do a good job with their sugar intake, they can reduce their risk by 50%. That’s going to be better than many other things that we can do for them.
Nancy Holekamp, MD: Patients with diabetic macular edema probably have a history of being noncompliant with managing their diabetes. Dr Coney mentioned that he takes a picture and shows them their retinas, and it doesn’t take a medical degree to see blood in your retina. If anyone needs a motivator for getting serious about their diabetes, their diabetic care, eating right, exercise, and taking their mediations, it’s having blurred vision and seeing blood in your retina. Not only can the OCT image see diabetic macular edema, but we can easily take a color fundus photograph and share it with patients, which is a huge motivator and something I try to do in my office as part of the education process.
Thanks to all of you for this rich and informative discussion, and thank you for watching this HCPLive® Peer Exchange. If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your inbox.
Transcript edited for clarity.