Tailoring Treatment Regimens and Measuring Outcomes in DME and AMD

Carl D. Regillo, MD, FACS:Blake, what factors do you consider when selecting the best approach to treatment for a patient?

Blake Anthony Cooper, MD, MPH: A personalized patient approach is extremely important. If we start with those with diabetes, understanding the medications they are currently taking and their glycemic stability or instability is important because certain classes of medications have been shown to potentially, at least in the short-term phase, worsen retinopathy. We know those who initiate insulin therapy or newer classes of hypoglycemic medications such as GLP-1 [glucagon-like peptide-1] receptor agonists can worsen stages of retinopathy. We are still understanding that as trials continue to evolve. But if someone comes in and they are moving in the correct direction with their glycemic control, if their hemoglobin A1c level is going down from 10% to 8%, oftentimes observation is critical as one of the treatment approaches. Because in the short term, although retinopathy may worsen, in the long term they are going to have a larger benefit, not only for their overall systemic health but within their diabetic retinopathy. But once treatment is required and initiated, it’s important to pick what’s going to work the best but also reduce the treatment burden. As we develop newer classes of medications that may last longer, it’s important to consider that first. If a patient is treatment naïve, we are going to start with the loading phase but then hopefully extend those intervals beyond monthly injections. As mentioned earlier, oftentimes patients develop tachyphylaxis, so considering change to a different medication or class of medication is important.

Carl D. Regillo, MD, FACS: There can be social aspects for patients that might lead you to think one treatment or another. For example, traveling far to the office. You might want to think about something more durable that requires fewer visits to the office at first. But for the most part, these are frequent treatment-intensive courses of therapy, so early on, patients need to get treatment. There is not a lot from a specific patient characteristic of their retina that’s going to necessarily make you decide one treatment or other, because they are all very similar.

Mike, the patient has started treatment. How is their condition monitored in terms of response, specifically from their vision?

Michael A. Klufas, MD: We hear about the major clinical studies and have to realize that in studies, this was ETDRS [Early Treatment Diabetic Retinopathy Study], so specific room, specific luminance, 1 place where they measure all vision. In clinical practice, we’re using Snellen visual acuity, and that could vary visit to visit. Often, I have a patient say, “I read 1 line worse,” but they’d read about the same as the previous visit. We are looking at Snellen visual acuity in the clinic. We are also looking at objective OCT [optical coherence tomography] measures, and patients learn about these OCTs and say, “Wow, that looks a lot better. My retina is less thick. There is less swelling or there is no more bleeding.” But those are the 2 metrics we’re using. In the past, we were using a lot of fluorescein angiography. We may be converting to OCT angiography to help us know when we might stop treatment in some patients. Snellen visual acuity and OCT are our biometrics to monitor our patients in the clinic in response to these agents.

Carl D. Regillo, MD, FACS: I’m glad you mentioned visual acuity, and that’s a specific term because what the patient sees is more than what they read on our charts. Hearing what the patient says is a big part of knowing whether they are improving or how they are doing. If they say, “Yes, I am seeing better,” even though their visual acuity is reading the same, that could tell you you’re making progress.

Michael A. Klufas, MD: You can have a patient come in with counting fingers vision and they go to 20/100 and say, “Wow, my vision is so much better.” And we say, “You can’t drive a car with that vision.” But that can be meaningful vision to our patients. I also provide them with hope as our colleague was saying. Most of the visual improvements in neovascular AMD [age-related macular degeneration] happen within the first 3 to 6 doses. Oftentimes I will say there can be some improvement the whole first year. DME [diabetic macular edema] treatment I find satisfying, especially for long-term patients, because they can continue to get better and gain better systemic control. That’s a gratifying part of being a retina specialist for working-age patients.

Blake Anthony Cooper, MD, MPH: I want to make a quick comment about the importance of patients evaluating their vision at home and making sure that they do so binocularly. Oftentimes you can lose vision in 1 year, and we may not notice symptoms until we cover 1 eye or the other, so it’s important for patients to be looking at an Amsler grid or something they can look at on a regular basis to see whether their vision is changing.

Carl D. Regillo, MD, FACS: That’s a good point, because we may be seeing these patients frequently, but sometimes they will have setbacks or worsening disease in between visits. And they have to recognize them, call, and be seen earlier.

Transcript Edited for Clarity