Emerging Concepts in the Treatment of Diabetic Retinopathy
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Purpose of Review
Diabetic retinopathy (DR) is the leading cause of vision loss in working-age adults in the developed world. This review discusses the current approach to managing the disease, such as glycemic and blood pressure control, as well as laser photocoagulation, as well as emerging concepts and controversies on novel therapies.
In recent years, the rise of intraocular anti-angiogenesis treatments is changing the paradigm of classic laser photocoagulation in the management of DR, but its long-term benefits remain an area of controversy. We also discuss new targets including anti-inflammation, neuroprotection, and novel laser technologies. Finally, we discuss new advances in retinal imaging that has vastly improved the diagnosis and management of DR.
Diagnosis and management of diabetic retinopathy is a rapidly progressing field. Emerging concepts in ophthalmic imaging, medical treatments, and surgical approaches provide insights into how DR management will evolve in the near future.
KeywordsDiabetic retinopathy Blood pressure Glycemic control
Glenn Yiu GY received research support from Alcon, Clearside Biomedical, Genentech, and Iridex, and is a consultant for Allergan, Alimera, Carl Zeiss Meditec, and Genentech.
Compliance with Ethical Standards
Conflict of Interest
Michael Patrick Ellis, Daniella Lent-Schochet, and Therlinder Lo declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 6.Progression of retinopathy with intensive versus conventional treatment in the Diabetes Control and Complications Trial. Diabetes Control and Complications Trial Research Group. Ophthalmology. 1995;102(4):647–61.Google Scholar
- 7.Barr CC. Retinopathy and nephropathy in patients with type 1 diabetes four years after a trial of intensive insulin therapy, by The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Research Group. N. Engl. J. Med 342:381-9, 2000. Surv Ophthalmol. 2001;45(5):459–60.PubMedGoogle Scholar
- 8.Diabetes C, Complications Trial Research G, Nathan DM, Genuth S, Lachin J, Cleary P, et al. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329(14):977–986.Google Scholar
- 9.Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352(9131):837–53.Google Scholar
- 11.Writing Team for the Diabetes C, Complications Trial/Epidemiology of Diabetes I, Complications Research G. Effect of intensive therapy on the microvascular complications of type 1 diabetes mellitus. JAMA. 2002;287(19):2563–9.Google Scholar
- 14.Group AS, Group AES, Chew EY, Ambrosius WT, Davis MD, Danis RP, et al. Effects of medical therapies on retinopathy progression in type 2 diabetes. N Engl J Med. 2010;363(3):233–44.Google Scholar
- 21.Preliminary report on effects of photocoagulation therapy. The Diabetic Retinopathy Study Research Group. Am J Ophthalmol. 1976;81(4):383–96.Google Scholar
- 22.Photocoagulation treatment of proliferative diabetic retinopathy: the second report of diabetic retinopathy study findings. Ophthalmology. 1978;85(1):82–106.Google Scholar
- 23.Photocoagulation treatment of proliferative diabetic retinopathy. Clinical application of Diabetic Retinopathy Study (DRS) findings, DRS Report Number 8. The Diabetic Retinopathy Study Research Group. Ophthalmology. 1981;88(7):583–600.Google Scholar
- 24.Early Treatment Diabetic Retinopathy Study design and baseline patient characteristics. ETDRS report number 7. Ophthalmology. 1991;98(5 Suppl):741–56.Google Scholar
- 25.Techniques for scatter and local photocoagulation treatment of diabetic retinopathy: Early Treatment Diabetic Retinopathy Study Report no. 3. The Early Treatment Diabetic Retinopathy Study Research Group. Int Ophthalmol Clin. 1987;27(4):254–64.Google Scholar
- 27.G. T. Preferences and Trends (PAT ) Survey. American Society of Retinal Surgeons. 2016.Google Scholar
- 37.Sivaprasad S, Prevost AT, Vasconcelos JC, Riddell A, Murphy C, Kelly J, et al. 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, n. Lancet. 2017;389(10085):2193–203.PubMedGoogle Scholar
- 38.CC W. Intravitreal aflibercept for moderately severe to severe non-proliferative diabetic retinopathy (NPDR). The phase 3 PANORAMA study. Angiogenesis, exudation, and degeneration 2019; Feb. 9, 2019; Miami.Google Scholar
- 44.•• Bressler SB, Liu D, Glassman AR, Blodi BA, Castellarin AA, Jampol LM, et al. Change in diabetic retinopathy through 2 years. JAMA Ophthalmology. 2017;135(6):558. Findings from this study suggest anti-VEGF treatment with ranibizumab, bevacizumab or aflibercept of DME also shows improvement for DR to 2 years. A greater effect in patients with PDR was seen with aflibercept.PubMedPubMedCentralGoogle Scholar
- 46.Writing Committee for the Diabetic Retinopathy Clinical Research N, Gross JG, Glassman AR, Jampol LM, Inusah S, Aiello LP, et al. Panretinal photocoagulation vs intravitreous ranibizumab for proliferative diabetic retinopathy: a randomized clinical trial. JAMA. 2015;314(20):2137–46.Google Scholar
- 48.Baker CW, Glassman AR, Beaulieu WT, Antoszyk AN, Browning DJ, Chalam KV, et al. Effect of initial management with aflibercept vs laser photocoagulation vs observation on vision loss among patients with diabetic macular edema involving the center of the macula and good visual acuity: a randomized clinical trial. Jama. 2019;321(19):1880–94.PubMedPubMedCentralGoogle Scholar
- 49.Wu L, Martinez-Castellanos MA, Quiroz-Mercado H, Arevalo JF, Berrocal MH, Farah ME, et al. Twelve-month safety of intravitreal injections of bevacizumab (Avastin): results of the Pan-American Collaborative Retina Study Group (PACORES). Graefes Arch Clin Exp Ophthalmol. 2008;246(1):81–7.PubMedGoogle Scholar
- 70.• Simo R, Hernandez C, Porta M, Bandello F, Grauslund J, Harding SP, et al. Effects of topically administered neuroprotective Drugs in early stages of diabetic retinopathy: results of the EUROCONDOR Clinical Trial. Diabetes. 2019;68(2):457–63. Findings from this paper indicate that the neuroprotective agents brimonidine and somatostatin can slow worsening of neurodegeneration, but only in a subset of patients with pre-existing neuro-dysfunction.PubMedGoogle Scholar
- 71.Grauslund J, Frydkjaer-Olsen U, Peto T, Fernandez-Carneado J, Ponsati B, Hernandez C, et al. Topical treatment with brimonidine and somatostatin causes retinal vascular dilation in patients with early diabetic retinopathy from the EUROCONDOR. Invest Ophthalmol Vis Sci. 2019;60(6):2257–62.PubMedGoogle Scholar
- 76.Scott IU, Jackson GR, Quillen DA, Larsen M, Klein R, Liao J, et al. Effect of doxycycline vs placebo on retinal function and diabetic retinopathy progression in patients with severe nonproliferative or non-high-risk proliferative diabetic retinopathy: a randomized clinical trial. JAMA Ophthalmol. 2014;132(5):535–43.PubMedGoogle Scholar
- 81.Liesfeld B, Amthor K-U, Dowell D, Weber U, Teiwes W. Navigating comfortably across the retina. Berlin: Springer; 2009.Google Scholar
- 86.Silva PS, Walia S, Cavallerano JD, Sun JK, Dunn C, Bursell S-E, et al. Comparison of low-light nonmydriatic digital imaging with 35-mm ETDRS seven-standard field stereo color fundus photographs and clinical examination. Telemed E Health. 2012;18(7):492–9.Google Scholar
- 93.An L, Wang RK. Volumetric imaging of microcirculations in human retina and choroids in vivo by optical micro-angiography: SPIE; 2008.Google Scholar
- 95.Spaide RF, Klancnik JM Jr, Cooney MJ. Retinal vascular layers imaged by fluorescein angiography and optical coherence tomography angiography. JAMA Ophthalmol. 2015;133(1):45–50.Google Scholar