Diabetic macular edema (DME), an accumulation of fluid in the retina from leaking blood vessels, is a major cause of visual acuity loss worldwide. Anti-vascular endothelial growth factor (VEGF) injections are a standard treatment today. VEGF is a protein that stimulates leakage from blood vessels, so blocking the protein can help reduce edema, or swelling of the retina.
Joining the podcast is Lee Jampol, MD, who recently co-authored a study published in JAMA that found that waiting to start injection treatments until patients began to experience vision loss had similar outcomes when compared to starting injection treatments as soon as the condition was diagnosed. The injections are time consuming, costly and can carry the risk of harmful side effects, so waiting until the treatment is necessary has advantages for both the patient and providers.
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Updates in Care for Diabetic Retinopathy
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Learn more about Lee Jampol, MD
Lee Jampol, MD
Lee Jampol, MD is a Professor of Ophthalmology at Northwestern Medicine.Learn more about Lee Jampol, MD
Transcription:
Updates in Care for Diabetic Retinopathy
Melanie Cole, MS (Host): Today we’re talking about updates in care for diabetic retinopathy. My guest is Dr. Lee Jampol. He’s a Louis Feinberg professor of ophthalmology a Northwestern Medicine. Dr. Jampol, it’s such a pleasure to have you joining us today. Speak a little bit about the standard treatments for diabetic macular edema. What is Northwestern Medicine doing differently?
Lee Jampol MD (Guest): Up until recently the standard treatment was using a laser beam to seal off the leaking spots in the retina and therefore diminish the diabetic macular edema. But in the last few years we have developed a group of mediations that are very powerful, more powerful than a laser for stopping the leakage and therefore improving the vision in patients with diabetic macular edema.
Host: You recently coauthored a study published in JAMA that looked at delaying treatment for diabetic macular edema. Tell us a little bit about your research and what you found.
Dr. Jampol: Up until last year for the previous five years I was a chair of the diabetic retinopathy clinical research network, sometimes called DRCR Net. We have initiated over 30 studies of diabetic eye disease. The most recent one which we’re talking about was published and demonstrated that the medications that we used—the injections—we know that they're very effective for treating diabetic macular edema. The question in that study was should they be administered early on when the vision is still good. So we look in at the patient and we see swelling of the retina, this diabetic macular edema. If the vision is diminished then we go ahead and treat with these new medications. They're called anti-VEGF medications. We didn’t know what to do if patients had good vision and had some swelling of the back of the eye.
So we did three separate groups. One group received the anti-VEGF medications despite the good vision; another group received laser treatment, which is the long-standing but older treatment; and the third group was just observed to see what happened over the next two years. The main finding of the study was that if you follow any of those three courses at the beginning—observation, laser, or anti-VEGF medications—and then you wait until the vision goes down and not treat until that point the outcome at two years is still the same. In other words, you could wait at the beginning and then only go in when the vision is diminished. That’s very important because it saves money for the system, it saves injections or laser treatments, and it allows the patients to be followed and then appropriately treated when the vision starts to go down.
Host: That is so interesting. So expand a little bit more on the effects that the treatments did have on visual acuity and diabetic retinopathy, and what did you find in that regard?
Dr. Jampol: Well, at the end of two years the average vision of all three groups was 20/20, which is basically normal vision. So there was not any vision loss no matter which of the three courses you followed. So we were concerned before the study that if you waited, perhaps there would be damage done and you would not be able to retrieve 20/20 vision. In the study we showed that that’s not the case. That you can clearly wait until something develops, until complications develop, loss of vision develops and then begin treatment and the patients did fine.
Host: So as far as the importance of this study, why would avoiding treatment early on be a desired option if they have similar outcomes? What do you want other providers to know when they're counselling their patients on seeing a specialist for this?
Dr. Jampol: Well, it’s important that any patient who is diabetic and has diabetic macular edema is referred to an ophthalmologist for evaluation. Part of that evaluation is measuring the swelling of the retina. We call that an OCT test. Another important part is the visual acuity. So now when the patients are referred to the retinal specialist and there's swelling of the retina, but the vision is normal, there's no treatment necessary at that point. We didn’t know that answer until this study. The importance is that for the healthcare system, first of all, the treatments are very expensive both laser and the anti-VEGF injections. It’s a lot of work for the patient to come in for the injections and for the doctor to administer the injections. It’s also a lot of work to do the laser. So now we know you don’t have to do those. The majority of patients that were in the study—two-thirds to three-quarters of them never acquired any treatment for two years. So it’s not just that you're delaying the treatments besides observing the patient, but you're also in many cases avoiding them completely for two years. That saves the system money and saves patient time and doctor time.
Host: As you’ve done this study and come up with such interesting findings, how do you envision this translating to patient care for ophthalmologists around the country? What would you like them to know about this study?
Dr. Jampol: So let’s start with the patients first. So I think it’s very important that patients know that that they need to have their retina examined if they have had diabetes. If they have diabetic retinopathy, they should be followed in general by a retinal specialist. So that’s the most important message for patients. Go in and get evaluated, see what your vision is, see if there’s thickening of the retina. Now for the doctors, we don’t want them to jump in right away. We used to worry about that, having to do that, but we want them to carefully follow the patient. We call that observation. Then only treat when the eye begins to deteriorate.
Host: As we wrap up, what would you like providers to know about optimizing treatment for patients with diabetic macular edema and when do you feel, Dr. Jampol, that it’s really important that they refer to the specialists at Northwestern Medicine?
Dr. Jampol: Well, at the beginning again the patients need to be aware that they need to be followed. The doctors need to be aware that diabetic patients should have eye exams. If there’s significant retinopathy, they need to see a retina person. Then we know that once the retina person has done the evaluation, we now have guidelines for them to determine whether intervention, whether laser or injections are necessary at that point. The doctors can follow the study, and we suspect that the vast majority will follow the guidelines we’ve set forward. We’ve already instituted those guidelines at Northwestern Medicine.
Host: Well, thank you so much. What an interesting study and thank you for sharing your expertise on this. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. To refer your patient or for more information on the latest advances in medicine, please visit our website at nm.org to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other Northwestern Medicine podcasts. For more health tips and updates on the latest medial advancements and breakthroughs, follow us on your social channels. Until next time, I'm Melanie Cole.
Updates in Care for Diabetic Retinopathy
Melanie Cole, MS (Host): Today we’re talking about updates in care for diabetic retinopathy. My guest is Dr. Lee Jampol. He’s a Louis Feinberg professor of ophthalmology a Northwestern Medicine. Dr. Jampol, it’s such a pleasure to have you joining us today. Speak a little bit about the standard treatments for diabetic macular edema. What is Northwestern Medicine doing differently?
Lee Jampol MD (Guest): Up until recently the standard treatment was using a laser beam to seal off the leaking spots in the retina and therefore diminish the diabetic macular edema. But in the last few years we have developed a group of mediations that are very powerful, more powerful than a laser for stopping the leakage and therefore improving the vision in patients with diabetic macular edema.
Host: You recently coauthored a study published in JAMA that looked at delaying treatment for diabetic macular edema. Tell us a little bit about your research and what you found.
Dr. Jampol: Up until last year for the previous five years I was a chair of the diabetic retinopathy clinical research network, sometimes called DRCR Net. We have initiated over 30 studies of diabetic eye disease. The most recent one which we’re talking about was published and demonstrated that the medications that we used—the injections—we know that they're very effective for treating diabetic macular edema. The question in that study was should they be administered early on when the vision is still good. So we look in at the patient and we see swelling of the retina, this diabetic macular edema. If the vision is diminished then we go ahead and treat with these new medications. They're called anti-VEGF medications. We didn’t know what to do if patients had good vision and had some swelling of the back of the eye.
So we did three separate groups. One group received the anti-VEGF medications despite the good vision; another group received laser treatment, which is the long-standing but older treatment; and the third group was just observed to see what happened over the next two years. The main finding of the study was that if you follow any of those three courses at the beginning—observation, laser, or anti-VEGF medications—and then you wait until the vision goes down and not treat until that point the outcome at two years is still the same. In other words, you could wait at the beginning and then only go in when the vision is diminished. That’s very important because it saves money for the system, it saves injections or laser treatments, and it allows the patients to be followed and then appropriately treated when the vision starts to go down.
Host: That is so interesting. So expand a little bit more on the effects that the treatments did have on visual acuity and diabetic retinopathy, and what did you find in that regard?
Dr. Jampol: Well, at the end of two years the average vision of all three groups was 20/20, which is basically normal vision. So there was not any vision loss no matter which of the three courses you followed. So we were concerned before the study that if you waited, perhaps there would be damage done and you would not be able to retrieve 20/20 vision. In the study we showed that that’s not the case. That you can clearly wait until something develops, until complications develop, loss of vision develops and then begin treatment and the patients did fine.
Host: So as far as the importance of this study, why would avoiding treatment early on be a desired option if they have similar outcomes? What do you want other providers to know when they're counselling their patients on seeing a specialist for this?
Dr. Jampol: Well, it’s important that any patient who is diabetic and has diabetic macular edema is referred to an ophthalmologist for evaluation. Part of that evaluation is measuring the swelling of the retina. We call that an OCT test. Another important part is the visual acuity. So now when the patients are referred to the retinal specialist and there's swelling of the retina, but the vision is normal, there's no treatment necessary at that point. We didn’t know that answer until this study. The importance is that for the healthcare system, first of all, the treatments are very expensive both laser and the anti-VEGF injections. It’s a lot of work for the patient to come in for the injections and for the doctor to administer the injections. It’s also a lot of work to do the laser. So now we know you don’t have to do those. The majority of patients that were in the study—two-thirds to three-quarters of them never acquired any treatment for two years. So it’s not just that you're delaying the treatments besides observing the patient, but you're also in many cases avoiding them completely for two years. That saves the system money and saves patient time and doctor time.
Host: As you’ve done this study and come up with such interesting findings, how do you envision this translating to patient care for ophthalmologists around the country? What would you like them to know about this study?
Dr. Jampol: So let’s start with the patients first. So I think it’s very important that patients know that that they need to have their retina examined if they have had diabetes. If they have diabetic retinopathy, they should be followed in general by a retinal specialist. So that’s the most important message for patients. Go in and get evaluated, see what your vision is, see if there’s thickening of the retina. Now for the doctors, we don’t want them to jump in right away. We used to worry about that, having to do that, but we want them to carefully follow the patient. We call that observation. Then only treat when the eye begins to deteriorate.
Host: As we wrap up, what would you like providers to know about optimizing treatment for patients with diabetic macular edema and when do you feel, Dr. Jampol, that it’s really important that they refer to the specialists at Northwestern Medicine?
Dr. Jampol: Well, at the beginning again the patients need to be aware that they need to be followed. The doctors need to be aware that diabetic patients should have eye exams. If there’s significant retinopathy, they need to see a retina person. Then we know that once the retina person has done the evaluation, we now have guidelines for them to determine whether intervention, whether laser or injections are necessary at that point. The doctors can follow the study, and we suspect that the vast majority will follow the guidelines we’ve set forward. We’ve already instituted those guidelines at Northwestern Medicine.
Host: Well, thank you so much. What an interesting study and thank you for sharing your expertise on this. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. To refer your patient or for more information on the latest advances in medicine, please visit our website at nm.org to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all the other Northwestern Medicine podcasts. For more health tips and updates on the latest medial advancements and breakthroughs, follow us on your social channels. Until next time, I'm Melanie Cole.