Diabetic retinopathy debate resurfaces with new perspectives
The debate over pharmacologic therapy versus laser treatment for diabetic eye disease is back. The players are different–anti-VEGF agents and panretinal laser photocoagulation instead of anti-VEGF agents and macular laser photocoagulation–but the result could be the same: more anti-VEGF treatment and less laser treatment.
“Panretinal laser photocoagulation is a proven, effective and safe therapy that we have been using for many decades in the management of our patients who develop proliferative diabetic retinopathy,” outlined Michael Ip, MD, associate professor of ophthalmology and co-director, Fundus Photography Reading Center, University of Wisconsin School of Medicine and Public Health. “But the preponderance of the evidence, what we have been seeing in the clinic anecdotally, secondary outcomes from clinical trials, and from Protocol S indicate that we have a new treatment option for those patients who have proliferative diabetic retinopathy. In some patients, we may wish to start with anti-VEGF.”
Or maybe not
“Protocol S is the first good prospective study looking at laser versus injection for the treatment of proliferative diabetic retinopathy,” explained Rishi Singh, MD, staff physician, Cole Eye Institute/Cleveland Clinic and associate professor of ophthalmology, Case Western Reserve University, Cleveland. “This study validated the safety and benefits of anti-VEGF therapy. The question is whether and how you can apply those findings in clinical practice. When you try to apply findings from clinical studies in real patients, the benefits don’t always gel.”
Drs. Ip and Singh faced off during a debate on whether “Anti-VEGF Injection is the New Standard of Care for Proliferative Diabetic Retinopathy” at the 2015 American Academy of Ophthalmology meeting. For some patients and practices, anti-VEGF can transform the course of disease. For others, laser remains the treatment of choice.
For Dr. Singh, who argued against anti-VEGF as a new standard of care, it comes down practical issues, such as patient adherence. Anti-VEGF treatment can be as effective as laser, but only if patients come into the clinic for scheduled follow-up evaluations and successive injections.
“If you look at patients with diabetes who get anti-VEGF injections and macular degeneration (AMD) patients who are much older and also get anti-VEGF injections, the rate of no shows in the diabetic population is almost twice the rate in the AMD population,” he said. “That’s telling, because if you are the clinician trying to get something into your patients’ eye once a month, you expect them to be able and willing to come back for monitoring and therapy. If they don’t come back and you have a high rate of no shows, you can’t apply the successful clinical trial practice to that patient and the outcome is poor.”