When diabetes goes from bad to worse

October 13, 2017
Cheryl N. Zimmer, OD

Dr. Zimmer is a consultant for several ophthalmic organizations providing freelance research and technical writing services. She is a former employee of Annidis Corporation.

A 30-year-old female with a 16-year history of insulin-dependent diabetes and no other ocular or systemic conditions developed proliferative retinopathy in March 2015. She had not been closely followed for the previous five years.

A 30-year-old female with a 16-year history of insulin-dependent diabetes and no other ocular or systemic conditions developed proliferative retinopathy in March 2015. She had not been closely followed for the previous five years.

Neovascularization of the disc and elsewhere was documented with multi-spectral

imaging (MSI) in each eye (Figure 1). Best-corrected visual acuity at this visit was 20/25- in each eye. She was referred for evaluation that resulted in a recommendation for pan-retinal photocoagulation (PRP). She was then followed bi-monthly over the next six months when a second round of PRP was applied.

PRP not the answer

Best-corrected visual acuity remained stable over this interval. The patient complained that the procedure was uncomfortable, did not immediately result in improved vision, and negatively impacted her night vision.

Previously from Dr. Semes: Diagnosing CHRPE lesions can be a challenge for ODs

Over the next two months, the patient experienced mild subjective vision reduction.

On evaluation in May 2015, she was diagnosed with center-involving, formerly designated as clinically significant macular edema (CSME) (Figure 2A). Visual acuity had declined to 20/400 in the right eye and 20/200 in the left eye.

Anti-VEGF injections provide hope

At the two-month follow-up visit, qualitative resolution of the edema in response to a single anti-vascular endothelial growth factor (VEGF) injection of ranibizumab 0.5 mg (Lucentis, Genentech) in each eye is seen in Figure 2B. The patient’s reaction to this treatment was more positive than to PRP. She reported some discomfort during the injection but experienced an almost immediate improvement in subjective visual performance.

 

By January 2016, best-corrected visual acuity had improved to 20/100 OD and 20/50 OS. With visual acuity at 20/60 OD and 20/50 OS in February 2016, an additional Lucentis injection was recommended and administered. On follow-up at one month, visual acuity had improved to 20/30 (OU) and one additional Lucentis injection was given.

On evaluation in June 2016 and subsequently October 2016, visual acuity had stabilized at 20/30 in each eye, and the foveal contour and thickness had been reestablished (See Figure 3). Selected MSI images are shown in Figure 4.

Following the initial diagnosis of proliferative diabetic retinopathy, the patient was placed on EyePromise DVS vitamins (ZeaVision) administered orally once per day.

PRP and anti-VEGF work cohesively

The results of a six-month prospective trial among patients with Type 1 or 2 diabetes demonstrated improvement in a number of clinical measures, including contrast sensitivity, color vision, and macular pigment as well as an improved profile of blood cholesterol and triglyceride levels.1

The results were achieved without adversely affecting glycemic control. The hope is that with appropriate glycemic control and adherence to the supplement regimen, the patient’s visual acuity will be maintained. Unfortunately, as a result of the PRP, her night vision performance has not improved, but this was to be expected.

Subsequent to the initial recommendation and application of PRP in the present case, a report advocating the use of PRP plus anti-VEGF therapy for high-risk proliferative diabetic retinopathy was published.2 Most recently, the Diabetic Retinopathy Clinical Research Network Protocol S has established a resolution of CSME as well as in the stage of non-proliferative retinopathy seen with the use of anti-VEGF injections, an effect not readily seen with PRP. 3-5

Related: The case of the blurred disc margins

In addition, the intravitreous administration of anti-VEGF agents may retard progression of diabetic retinopathy to proliferative disease.4,6 As guidance and protocols continue to evolve with nutraceutical therapy-PRP and anti-VEGF agents-ODs will be better equipped to minimize the ophthalmic consequences of diabetes.

References

1. Chous AP, Richer SP, Gerson JD, Kowluru RA. The Diabetes Visual Function

Supplement Study (DiVFuSS). Br J Ophthalmol. 2016 Feb;100(2):227-34.

2. Zhou A-Y, Zhou C-J, Yao J, Quan Y-L, Ren B-C, Wang J-M. Panretinal photocoagulation versus panretinal photocoagulation plus intravitreal bevacizumab for high-risk proliferative diabetic retinopathy. Int J Ophthalmol. 2016; 9(12): 1772–1778.

3. AAO PPP Retina/Vitreous Panel, Hoskins Center for Quality Eye Care. Diabetic Retinopathy PPP - Updated 2016. Available at: https://www.aao.org/preferred-practice-pattern/diabetic-retinopathy-ppp-updated-2016. Accessed 9/22/17.

4. Ip MS, Domalpally A, Sun JK, Ehrlich JS. Long-term effects of therapy with

ranibizumab on diabetic retinopathy severity and baseline risk factors for

worsening retinopathy. Ophthalmology. 2015 Feb;122(2):367-74.

5. Brown DM, Schmidt-Erfurth U, Do DV, Holz FG, Boyer DS, Midena E, Heier JS, Terasaki H, Kaiser PK, Marcus DM, Nguyen QD, Jaffe GJ, Slakter JS, Simader C, Soo Y, Schmelter T, Yancopoulos GD, Stahl N, Vitti R, Berliner AJ, Zeitz O, Metzig C, Korobelnik JF. Intravitreal Aflibercept for Diabetic Macular Edema: 100-Week Results From the VISTA and VIVID Studies. Ophthalmology. 2015 Oct;122(10):2044-52.

6. Ip MS, Domalpally A, Hopkins JJ, M, Wong P, Ehrlich JS. Long-term effects of ranibizumab on diabetic retinopathy severity and progression. Arch Ophthalmol. 2012 Sep;130(9):1145-1152. 

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