A weekly e-newsletter to help increase awareness and support patient education. This week features Szilárd Kiss, MD, discussing the diabetic risk factors and key conversations to have with patients. This week’s edition features Charles C. Wykoff, MD, PhD, discussing types of diabetes and shifting treatment options resulting from new data and studies. David Eichenbaum, MD, discussing tips to help physicians motivate their patients to adhere to therapy for their diabetic eye disease. Geeta Lalwani, MD; and A. Paul Chous, OD, CDE, discussing comanagement tips for diabetic eye disease.


Risk Factors


Treatment News


Adherence to Therapy





"How long have you had Diabetes?" An important question to ask your patients.

We know disease duration is the leading risk factor for vision loss from diabetes.1

  • It is critical to perform comprehensive dilated fundus examinations throughout a patient’s life, starting at diagnosis for patients with type 2 diabetes and within 3 to 5 years of diagnosis for those with type 1 diabetes.
  • Thereafter, these comprehensive examinations should be performed at least every 1 to 2 years, keeping in mind that these patients have an increased risk for glaucoma and cataracts in addition to diabetic retinopathy (DR). Diabetes can affect both central and peripheral vision, contrast sensitivity, and color vision, ultimately affecting every aspect of vision in daily life. While disease duration is an immutable fact, there are three systemic factors that patients can modify and control to minimize their risk of vision loss.

The Big 3 Modifiable Risks for Diabetic Vision Loss

Elevated levels of blood sugar, blood pressure, and blood lipids are all associated with disease progression and the onset of DR.1,2

  1. Hyperglycemia. Diabetes causes leaky blood vessels, resulting in part from high circulating sugar levels. The worse those daily sugar levels are, the worse the hemoglobin A1c is, and the more likely a patient will experience vision-threatening ocular changes.
  2. Hypertension. Uncontrolled high blood pressure increases the level of DR, similar to water squeezing out of a leaky hose as pressure increases.
  3. Hyperlipidemia. High blood lipids and blood cholesterol increase the risk of diabetic eye disease. They seep out of the leaky vessels and settle in and underneath the retina, ultimately resulting in vision loss.

Regular eye examinations along with good control of blood sugar, blood pressure, and blood lipids are the primary steps patients can take to minimize their risk of diabetic eye disease.

other risks to consider

1. Pregnancy. Pregnancy can cause changes to diabetic eye disease, almost independent of blood sugar levels. In the setting of abnormal blood sugars, the retinopathy can progress.3 Women with diabetes should be examined as the family planning process progresses, during the first and second trimesters of pregnancy, and after giving birth.

2. Sleep Apnea. Sleep apnea has been linked to worsening diabetic eye disease, owing to intermittent hypoxia,4 but eye care providers and primary care physicians often do not associate this condition with vision loss. If your patient is obese, has some difficulty breathing, and seems tired most of the time, ask about sleep apnea, particularly if his or her DR seems out of proportion to what you think it should be. Treating sleep apnea may help a patient’s diabetic eye disease.

3. Denial. Some patients, for many reasons, do not visit their doctors, even when they suspect something may be wrong. Educating patients on the risk factors associated with diabetes and the consequences of nonadherence is vital to preventing tragic results.

what’s the point? — diabetic vision loss is life-changing

Diabetes is an incurable disease; however, it can be controlled. It is important for eye care providers to counsel patients about lifestyle changes and medications that will help them control risk factors associated with diabetes.

We are all a part of the education solution to teach our patients about the risks associated with this disease. We also need to make the consequences of untreated diabetes tangible. Taking the time to bring the picture together for patients can make a big difference in how they interpret these consequences.

remember to tell your patients:

  1. Vision impacts every facet of your life.
  2. Taking the steps to manage your diabetes avoids vision loss and maintains your ability to do the things you love and to be independent.
  3. Vision loss is life-changing, and you can help prevent it from happening to you.

1. Jau JW, Rogers SL, Kawasaki R, et al.; Meta-Analysis for Eye Disease (META-EYE) Study Group. Global prevalence and major risk factors of diabetic retinopathy. Diabetes Care. 2012;35:556-564.

2. Yun JS, Lim TS, Cha SA, et al. Lipoprotein(a) predicts the development of diabetic retinopathy in people with type 2 diabetes mellitus. J Clin Lipidol. 2016;10:426-433.

3. Morrison JL, Hodgson LA, Lim LL, Al-Qureshi S. Diabetic retinopathy in pregnancy: a review. Clin Exp Ophthalmol. 2016;44:321-334.

4. Nashimura A, Kasai T, Tamura H, et al. Relationship between sleep disordered breathing and diabetic retinopathy: Analysis of 136 patients with diabetes. Diabetes Res Clin Pract. 2015;109:306-311.

Diabetic Retinopathy Update – Shifting Treatment Paradigms

Advances in pharmacotherapy signal a move toward earlier treatment.

Diabetic retinopathy (DR) is a blinding disease, but in a majority of cases today, it is treatable, and blindness can be prevented if patients are diligent about compliance (See last week’s article).

Positive outcomes over the last decade stem from advances in pharmacotherapy — both anti-VEGF agents and steroids — that built on the value of retinal lasers. New data and ongoing studies are expanding our indications. By initiating treatment earlier in the disease course, you can attempt to preserve vision, improve quality of life, and ultimately reduce the treatment burden for your patients.

Here is a snapshot of where we stand now, with a look at the most recent FDA approval and ongoing trials that may trigger future paradigm shifts.

Treating PDR and DME

The two most common causes of blindness in diabetes are proliferative diabetic retinopathy (PDR) and diabetic macular edema (DME).

  1. PDR. All patients with PDR need treatment or, at the very least in rare instances, close monitoring, with treatment likely in the near future.
  2. DME. Most patients with DME will ultimately be treated, particularly those with center-involved macular edema with associated loss of visual acuity or associated symptoms if their visual acuity is good.
    • Patients who have DME but are asymptomatic, or symptomatic with excellent visual acuity, may be actively treated or not, but they need to be closely monitored. A large ongoing DRCR.net trial (Protocol V) is investigating these patients.

DR News

  1. United States. The FDA expanded the approved indications of ranibizumab (Lucentis, Genentech) to include treatment of all forms of DR, based on data from the Phase 3 DRCR.net Protocol S trial.1
  2. United Kingdom. Investigators for the smaller Phase 2 CLARITY trial studied the use of aflibercept (Eylea, Regeneron) in a similar PDR population and reported similar findings,2 adding further support to the efficacy of anti-VEGF therapy for PDR.

The data from these trials are shifting treatment patterns. Many cases of PDR are now managed with anti-VEGF therapy, often in combination with more limited peripheral laser application.


Optimal management of patients with nonproliferative diabetic retinopathy (NPDR) without DME, is in flux.

  1. Earlier Treatment Ongoing Trials. Two large randomized trials — PANORAMA sponsored by Regeneron and Protocol W sponsored by the DRCR.net — are currently underway, looking at treating these patients earlier than we traditionally would have. In both trials, patients with moderately severe NPDR, DR without DME, are receiving aflibercept or the clinical standard of care, observation.
  2. Targeting the NPDR “sweet spot.” There appears to be a “sweet spot” for patients with DR just before they progress to PDR.
    • Based on analyses such as the LA Latino Eye Study,3 we know this patient population, who are currently not being actively treated, have already experienced significant reductions in vision-associated quality of life, and, on average, they have decreased functional vision.
    • When we treat these patients with anti-VEGF therapy, many of them have significant and clinically relevant improvements in their DR severity levels.
    • If we can capture these patients before they develop PDR or DME, we may be able to turn back the clock by improving their DR severity level. This has the potential to improve their quality of life from a visual function perspective, and substantially decreasing the rate at which they develop PDR and DME.

Is Earlier Intervention the Key?

I believe we will find that the earlier we treat DR and DME, the fewer treatments patients will need and the better ultimate visual outcomes they will enjoy. I believe our treatment paradigms will continue to shift toward intervening earlier, giving our patients better long-term visual potential.

1. Beaulieu WT, Bressler NM, Melia M, et al.; Diabetic Retinopathy Clinical Research Network. Panretinal photocoagulation versus ranibizumab for proliferative diabetic retinopathy: patient-centered outcomes from a randomized clinical trial. Am J Ophthalmol. 2016;170:206-213.

2. Sivaprasad S, Prevost AT, Vasconcelos JC, et al.; CLARITY Study Group. Clinical efficacy of intravitreal aflibercept versus panretinal photocoagulation for best corrected visual acuity in patients with proliferative diabetic retinopathy at 52 weeks (CLARITY): a multicentre, single-blinded, randomised, controlled, phase 2b, non-inferiority trial. Lancet. 2017;389:2193-2203.

3. McKean-Cowdin R, Varma R, Hays RD, et al.; Los Angeles Latino Eye Study Group. Longitudinal changes in visual acuity and health-related quality of life: the Los Angeles Latino Eye study. Ophthalmology. 2010;117:1900-1907.

Five Tips to Encourage Adherence to Therapy for Diabetic Eye Disease

Positive conversations keep patients engaged.

Physicians who care for patients with diabetes are challenged to keep their patients engaged and to encourage them to continually strive to achieve their health goals. This includes motivating them to adhere to therapy for diabetic eye disease.

The fact that we can effectively treat all stages of diabetic retinopathy (DR) — not just control it but actually improve the level of retinopathy — is tempered by the need for frequent treatments for at least the first 12 months to achieve optimal therapeutic effect.

How do we help prepare patients to adhere to this course of therapy? Communication is key. Here are five tactics I have found effective with my patients. I encourage referring ophthalmologists and optometrists to adapt these conversations for use in their offices, as well.

1. Start with the Good News.

When I diagnose patients with DR, I start the conversation by telling them something they rarely hear from their other doctors: “I can make you better.” Then I follow up with “…but it requires a commitment to therapy.”

  • I remind patients that although diabetes is a chronic incurable disease, we have novel technology to treat DR.
  • Knowing that we can improve their retinopathy and visual prognosis and help them maintain their quality of life motivates them to commit to this sometimes inconvenient course of therapy.

2. Use Visual Aids.

My favorite graphic teaching tool is ultra widefield angiography. I think these high-quality black-and-white pictures are even more impactful than lower-contrast color photos for our layperson patients.

  • In fact, I may reshoot the angiograms periodically during treatment to show patients how they have improved. Patients like seeing pictorial proof that their anatomy is getting better, and the angiograms can help me deliver good news.
  • Often, I say, “You have had this great success. While we usually cannot completely stop treatment because you are still diabetic, we can start to increase the intervals between treatments while monitoring your disease.”

3. Acknowledge the Time Commitment.

Whatever evidence-guided treatment I recommend, I know the first year involves a fairly high burden of frequent office visits, so I tell patients, “We are going to get to know each other very well during this first year, but after that, I probably will not see you quite as often.”
This is how I segue into an explanation of the course of treatment — whether it involves anti-VEGF or steroid injections, laser, or a combination — and the importance of staying the course to achieve the optimal benefit.

4. Explain the Power of Momentum.

When I sense that a patient is becoming fatigued, usually after a few injections, I tell him that diabetes is like a freight train that has been heading in the wrong direction for a long time. We are trying now to put it into full reverse by treating his local disease and by controlling his blood glucose going forward.

I explain that even though his diabetic “train” is now in reverse with treatment, momentum is going to keep it going down the track of disease for a while. I explain, “You are riding on that momentum. We are not battling the sugars from 5 months ago, we are battling the sugars from the last 5 years. If you can commit to a loading course of injections and keep your sugars under control now, we can keep this freight train from rolling further down the track of disease advancement. With your commitment, your diabetic disease will slow down or stop getting worse before you run out of track.”

I find that analogy helpful with both the commitment to frequent intravitreal therapy when initiating injection treatment for DR, as well as for encouraging patients to better control their sugars and affect their systemic disease progression.

5. Celebrate Every Success.

Patients need to control their diabetes, and for many, this can be daunting. I want my patients to know that I am as interested in their progress as their diabetologist is.

  • I make a point of asking patients what their HbA1c is (and if they do not know it, I have them find out and report back to me), and I encourage them to keep me apprised of any changes.
  • The simple act of patients learning what their HbA1c is if they did not know it before and then getting it lower is gold. It is evidence of the patient’s buy-in and engagement in the disease process. Patients do not have to go from a 9 to a 6 overnight, but reducing a 9 to an 8.2 is a win.
  • I always congratulate and encourage patients when they make small strides on the way to their glycemic goals.

Referring ophthalmologists and optometrists play an important role in managing and treating the stages of DR. Encouraging patients to adhere to therapy is a challenge, but with these five tactics, it should make the process smoother for both the physician and patient.

Comanagement of Diabetic Eye Disease: It Takes a Village

Two perspectives on shared goals for patients with diabetes.

Diabetes is a chronic, life-long condition and calls for careful comanagement among a patient’s diabetic eye care team members. In honor of Diabetes Awareness Month, a retina specialist, Geeta Lalwani, MD, and an optometrist, A. Paul Chous, OD, CDE, offer insights on their individual roles and working together when caring for patients with diabetes. They share the following tips on developing and maintaining relationships for referring partners and key members of the diabetes care team.

  • As primary eye care providers, optometrists often care for patients who have diabetes and detect signs or symptoms of diabetic eye disease as a first line of entry into the medical care system. They must communicate with numerous medical professionals involved in a patient’s care, including retina specialists, but also primary care physicians, and endocrinologists.
  • Diabetic eye disease is unlike other diseases that retina specialists manage with the same frequency, such as macular degeneration and vein occlusions, because diabetes is a chronic systemic disease. Often, the pathology of the retina mimics pathology in the kidneys, heart, brain, and peripheral appendages. The difference is that the pathology in the retina is easily visualized and serves as a red flag to the other end organs.
  • The relationships between retina specialists and their referring partners are key to the successful management of systemic diabetes.

From the OD Perspective

  1. Refer according to your comfort level. Criteria for referral to a retina specialist may vary among primary eye care providers.
    1. Some refer patients when they see a few microaneurysms or hemorrhages, but that may not always be necessary from an efficiency standpoint. Patients definitely should be referred when treatment is necessary or imminent.
    2. Patients who are at high risk of progression — those with diabetic macular edema (DME), moderate nonproliferative diabetic retinopathy (NPDR) with a history of poor adherence to recommended dilated retinal exams, or severe NPDR — should be referred early for consideration for therapy that may lower their odds of losing vision, especially in the context of poor metabolic control.

    Generally, a good rule of thumb is to refer when you are no longer comfortable managing a patient or are unsure of a diagnosis/severity.
  2. Send concise, meaningful reports. Retina specialists prefer to know/have the following:
    1. Reason for referral
    2. Imaging studies (ultra widefield, optical coherence tomography, fundus photographs), serial if available to demonstrate progression
    3. Duration of diabetes, if the patient is using insulin, level of glucose control, history of HbA1c control
  3. Communicate with non-eye care physicians in language they understand. Simply spelling out abbreviations is helpful, as they are not familiar with some of our eye-related jargon. These physicians are most interested in learning the significance of your eye findings, namely:
    1. Do you expect the disease to progress?
    2. Will the patient need treatment? If so, has a referral to a retinal specialist been made and completed?
    3. Is the patient likely to lose vision?
    4. When should the patient be re-evaluated?
  4. Remind patients of the risks. It is critical to remind patients that good vision on an eye chart or in real-world settings does not mean that a patient with diabetes does not have a serious diabetes-related eye disease.

From the Retina Specialist Perspective

  1. Communicate with everyone on the diabetes care team. Communication is particularly crucial in diabetes, because what is happening in the retina is often happening in other parts of the body. Be sure to communicate to everyone on the patient’s diabetes care team about their status and treatment plan, including the referring doctor, primary care doctor, and other subspecialists. It often seems as if eye care is disjointed from systemic care, even though the underlying culprit is diabetes. Staging of the severity of the disease should coincide with the severity of the systemic diabetes process, including all of the end organs.
  2. Establish relationships with primary eye care providers to facilitate comanagement. The majority of optometrists understand diabetic retinopathy (DR) well, and they understand when a patient needs to see a retina specialist versus when they can monitor the disease. Work on developing relationships with your network to facilitate timely conversations about individual patients and decide on the best course of action. Your part in the education process, not only of patients, but also of optometrists, primary care doctors, and endocrinologists, about treatment options and recommendations is crucial.
  3. Share new research and how it may influence coordination of care. The science of retina is moving forward for diabetic intervention. For the first time, with the use of anti-vascular endothelial growth factor (anti-VEGF) treatment, we are able to reverse the severity of DR. This is in stark contrast to the past gold standard of controlling it. Be sure to disseminate new research to your network and explain how it may influence coordination of care.

The Value of Communication and Partnership

In summary, communication remains key and is a team sport across eye care, as well as a patient’s other diabetes care physicians. The role of the general eye care provider is irreplaceable and needs to remain front and center in the routine care of all patients. Applying the latest retina clinical advances to provide patients the best opportunity for saving vision takes a village. Communication with patients is also a key element to managing diabetic eye disease. Eye care team partnerships and partnerships with patients themselves serve everyone well.

Contact Info

Bryn Mawr Communications LLC
1008 Upper Gulph Road, Suite 200
Wayne, PA 19087

Phone: 484-581-1800
Fax: 484-581-1818

Scott Krzywonos

Janet Burk

About Retina Today

Retina Today is a publication that delivers the latest research and clinical developments from areas such as medical retina, retinal surgery, vitreous, diabetes, retinal imaging, posterior segment oncology and ocular trauma. Each issue provides insight from well-respected specialists on cutting-edge therapies and surgical techniques that are currently in use and on the horizon.