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Management options for diabetic retinopathy

Glycaemic control

Anti-hypertensive therapy

Laser treatment

 

Glycaemic control:

• Clinical trials involving patients with Type 1 or Type 2 diabetes have shown that intensive diabetes therapy aimed at lowering glucose levels reduces the incidence and progression of retinopathy.
• The DCCT/EDIC Study Research Group examined whether intensive blood glucose control could decrease retinopathy frequency and severity over a 6.5-year period.(1)
  
  
• A total of 1441patients with Type 1 diabetes were randomised to either intensive (≥3 injections of insulin/day or treatment with an external insulin pump) or conventional treatment (1 or 2 injections of insulin/day).
• At baseline, 726 patients had no retinopathy and 715 had mild retinopathy.
• There was a 76% reduction in the risk of new retinopathy with intensive relative to conventional treatment.
• There was a 56% reduction in progression of retinopathy with intensive relative to conventional treatment.
  
  
• The UKPDS group compared the effects of blood glucose control with therapy (metabolic control using a variety of agents) versus lifestyle intervention on the risk of microvascular and macrovascular complications in 3867 patients with Type 2 diabetes.(2)
  
  
• At baseline, 36% of patients showed signs of retinopathy.
• A 25% risk reduction in microvascular endpoints was seen with intensive relative to conventional therapy.
• After 6 years of follow up, there was a reduction in the need for retinal photocoagulation and a significantly lower proportion of patients in the intensive group than in the conventional group had a deterioration in retinopathy (21% relative risk reduction).

Anti-hypertensive therapy:

• Diabetes and hypertension are commonly associated conditions that carry an increased risk of retinopathy.
• Tight blood pressure control in patients with hypertension and diabetes can achieve a reduction in the progression and/or incidence of retinopathy.
• The effect of treatment with an ACE inhibitor (lisinopril) on the development and progression of retinopathy in Type 1 diabetes was investigated as a secondary end point in the 2-year EUCLID study of non-hypertensive patients (3).
  
  
• A total of 354 of the 530 randomised patients had retinal photographs at baseline and follow-up.
• At baseline, 65% (n=117) in the placebo group and 59% (n=103) in the lisinopril group showed signs of retinopathy.
• Retinopathy progressed in 13.2% of patients on lisinopril and 23.4% of patients in the placebo group.
• This 50% reduction with lisinopril was the same when adjusted for centre and glycaemic control.
  
  
• A UKPDS subanalysis was designed to determine whether tight blood pressure control (<150/85 mmHg) relative to less tight control (<180/105 mmHg) could reduce morbidity and mortality in 1148 hypertensive patients with Type 2 diabetes (4).
  
  
• A high proportion of patients had retinopathy at baseline (86% in the tight and 82% in the less tight control group).
• There was a 34% relative reduction in the risk of deterioration of retinopathy with intensive blood pressure control (7.5-year follow up).
• There was a 47% reduction in the risk of deterioration in visual acuity with intensive relative to conventional treatment (9-year follow up).
  
  

Laser treatment:

• Laser photocoagulation is recommended for the treatment of proliferative diabetic retinopathy and clinically significant macular oedema. It has been found to reduce the risk of severe visual loss by at least 50% (5,6).
• It should be noted that laser treatment is a destructive treatment that may cause visual loss.
• However, whilst retinopathy progression in people with diabetes can be reduced by good glycaemic and tight blood pressure control, good control is difficult to achieve in clinical practice and sight-threatening retinopathy still develops.