Non-Proliferative Diabetic Retinopathy: Goals of Therapy

W. Lloyd Clark, MD: How about questions about goals of therapy? The treatment goals in DME [diabetic macular edema] are straightforward, we’re looking for dry retinas and great vision. What are our goals of treatment and care for patients with nonproliferative diabetic retinopathy [NPDR]? Are we still in a surveillance mode? Is that standard of care changing? Is there a role for active intervention in NPDR?

Joseph M. Coney, MD: Lloyd, this is something, I’ve changed the way I look at NPDR for the past several years. When I had that patient who was lost to follow-up with severe disease, and she came back with a tractional retinal detachment, she was supposed to have come back in 3 to 4 months, and she came back in 9 months. And now, she has to go to surgery, and she’s hand motion. I always wondered if I would have started therapy early, would it have made a difference in her life? That’s the patient I always have in my mind when I see these individuals. My treatment goal is always to preserve vision when I can, and obviously at this level of disease, trying to prevent any worsening. What’s the kicker for me is the worsening of their retinopathy. If I’m seeing someone, and they’ve gone from mild, moderate to severe, or they’ve gone from severe to very severe, even when they don’t have any sight-threatening problems, I’m talking about a treatment. And I start talking about it before I probably do the injection because most of these patients, they’re very hands-off when it comes to therapy because they see really well. But I’m showing them the fluorescein angiograms, I’m showing them the differences and the changes in their eyes. For me, that’s been the biggest tool to help sell that point of why I wanted to give them an injection at such an early age.

We have such powerful data now; PANORAMA just came out. Depending on your level of severity of disease, if you have very severe NPDR, you can improve someone’s diabetic retinopathy severity score by up to 60% in some of these eyes. And by turning back the hands of time and treating them early, there’s no reason why patients need to lose vision. There’s no reason we need to wait until vision is lost. Now, this is something I normally don’t instill in every single patient. Obviously, I take a lot of things into consideration. I take what’s going on in other parts of their body. If they have heart problems, if they have kidney problems, if they have hypertension, these people are much sicker. When you have diabetic eye disease, and particularly diabetic edema, these individuals typically are seeing 4 to 6 doctors. It’s also true when you get to the more advancing forms of diabetic retinopathy. They may not have the edema yet, but you know it’s coming. But if you could just, again, save the vision, prevent them from progressing, you can decrease their level of vision loss over time.

The last thing I would say, and we hit on this, but COVID-19 has taught me a lot of things about my patients. We had a big reset in terms of how many patients were coming into the office, and I had more time to have discussions with patients. I’ve been talking to them more about their social determinants, where they come from, how is life where they live, what their social life is like, why do they miss their appointments? We always think that when patients miss appointments, they’re not compliant. But they can miss their appointment because they had an appointment with their kidney doctor. It helps me to figure out their follow-up. If I know Mrs. Jones needs to come in, in 2 months for a maintenance injection for her severe NPDR, and she has something going on in 2 months, I’m more likely to give her an appointment that she can adhere to. I have these discussions with patients early on because I know that to have an impact on their life, you need to have good communication.

I think being noncompliant has to do with the communication you have with your patients. And most patients will tell you that they already have a fear of the institution where they’re coming in, sometimes they have a fear of doctors. They have a fear of the way they’ve been treated sometimes. So you need to break down those walls and talk about what they want to get out of things and make sure that they feel like they have been listened to. When it comes to someone who has good vision, you have to do more selling, so to speak, and let them know what their goals are. Once you have those parameters set, you’ll be amazed at how well patients do long term, and you’ll have very few people missing their appointments.

W. Lloyd Clark, MD: To our audience, thank you very much for watching this HCPLive® Peer Exchange. If you enjoyed this content, please subscribe to our e-newsletters to receive upcoming Peer Exchanges and other great content right in your inbox.

Transcript edited for clarity.