The traditional classification of diabetic retinopathy assumes that all patients go through similar stages during their disease. Over many years, A/Prof Heriot has noted several different clinical patterns.
Clinical patterns in diabetic retinopathy
One pattern is of increasing importance as more people survive diabetes long-term due to better care. People who have had diabetes for 30 or more years often have minimal changes in the macula but develop very gradual closure of peripheral microvessels that can lead to unanticipated complications, including bleeding and loss of sight.
This can easily be prevented by ‘knowing where to look’ and early treatment (usually laser).
Final preparations of the manuscript reporting this pattern are being completed.
Clinical patterns in young diabetics
The other critical problem occurs in very young diabetics who have poor control for a variety of reasons and end up with aggressive complications that can be extremely difficult to control.
A variety of factors probably contribute to this aggressive pattern:
– hormonal changes due to puberty etc.
– high stress due to pressure to study and career establishment
– an avoidance of insulin because of the possibility of gaining weight.
Further, some young people experience difficulty making the transition from their paediatric endocrinologist to an adult endocrinologist and struggle with the belief that they know more about their disease than the new doctor.
There may be other contributing factors, but awareness of the severe complications and the need for specific counselling for this age group is critical. Retinology Institute is working to raise awareness of this clinical pattern in conjunction with diabetic associations.
Alternative strategies for proliferative diabetic retinopathy
Recent advances in managing the complications of diabetic retinopathy with anti-VEGF drugs are triggering a re-evaluation of traditional methods.
Macula oedema is now best managed with anti-VEGF drugs, not laser, if it is ‘centre involving’, meaning it is too close to the area of sharp central vision to treat with laser without leaving blind spots.
Preliminary evidence suggests that people with acute proliferative disease can be effectively controlled with anti-VEGF injections to stabilise the new blood vessels that constitute ‘proliferative disease’. Much better vision can be maintained in patients using this technique rather than laser.
Retinology Institute is focusing on recognising patients who will be best managed with a short series of injections instead of traditional laser treatment by emphasising identification of risk factors independent of traditional fluorescein