Diabetic Retinopathy : New and improved treatment strategies

There is a “new” approach for managing diabetic retinopathy. You are now at the front line when it comes to assessing diabetics and guiding their overall health – not just their ocular disease.  Here is what you need to know and must share with your patients.

New Treatment Strategies

We now use combination therapies to bring patients under control and our dependence on laser treatment is less than before.  Rather that destroying small areas of retina to preserve vision, we now use combination treatments such as an anti-VEGF drugs (Avastin, Macugen or Lucentis) with a topical anti-inflammatory drop (potent NSAID or fluorinated steroids) to stop leakage and improve vision.    Even capillary drop-out and retinal ischemia can respond to combination therapies utilized properly and strategically.  History of cataract, glaucoma, prior laser and blood glucose control can alter the treatment plan.  For complex cases we do add laser to stabilize the retina and reduce the need for injections, drops and even surgery. Some hopeless cases may be rescued with the right approach. Co-management of these patients with their retinal specialist is critical since side-effects from these therapies may include corneal toxicity and secondary glaucoma. 

Roles of Diet, Exercise and Supplements

Improved diet programs have a dramatic effect on diabetes.  Nutrisystem, as one example, reduces caloric intact and improves the glycemic index of the overall diabetic diet.  One study found the program on average reduced cholesterol by 45 points, reduced the HgA1C by about 1 point, improved daily blood glucose control 5 fold, and improved weight loss by 16 fold.  The real secret is reducing meal portions and increasing the frequency of meals.  For exercise, walking an hour a day using small steps with low impact increases the metabolic rate and reduces wear and tear on the body.  There is better compliance with an easier exercise regimen. The dietary supplements Chromium and Selenium can improve blood glucose control and Ginkobiloba may increase retinal blood flow and reduce retinopathy. Care must be taken when recommending supplements in renal failure patients.  Work on any new program with the patient’s medical doctor.    As patients adjust their diets, exercise program and supplements, their medications must also be adjusted.  Some Type II patients eliminate the need for diabetic and blood pressure medications all together. 

Complications of Improved Glucose Control

While long term tight control of blood glucose is critical for optimal health, short term complications from tight control may be severe.  Life threatening hypoglycemia may occur so patients must be sensitive to the signs including diaphoresis, nausea, and mental status changes.  Pre-existing diabetic retinopathy may become worse as a result of tight control in the short term – these patients must be followed more closely and managed more aggressively. Cut intervals for routine follow visits in half for your patients increasing their blood glucose control. 

Hemoglobin A1C

The HgA1c is the amount of glycosylated hemoglobin in the blood and gives a longer term measure of blood glucose control (weeks or even months) than the fasting blood glucose.   Just knowing this value will extend your diabetic patient’s life span an average of 10 years.  Please educate each of your patients about the importance of knowing their HgA1C level.  The average normal non-diabetic value is 6.0 or less.  For diabetics, good control is a value of 7-8, ideal control is less than 7.0.  By lowering the long term glucose levels damage to end organs including the eyes, brain, kidneys and nervous system are dramatically reduced.

Prevention is the key for your diabetic patients – both short and long term.  Educating your patients about diet, exercise, supplements and home monitoring of vision should be part of your patient care program.  New treatment strategies can rescue vision even in some of the more hopeless cases.   There are clinical trials underway exploring new therapies and new protocols which we have worked to develop.  It is an exciting new era for our diabetic patients.

Ron P. Gallemore, M.D, Ph.D.

Founder and Director

Retina Macula Institute and the

Retina Macula Research Center

South Bay 310-944-9393

Los Angeles 323-466-9393