Compliance in the Management of Diabetic Retinopathy: The Reality and Risk of Loss to Follow-up

William C. Ou; Charles C. Wykoff, MD, PhD


July 27, 2018

In This Article

Diabetes mellitus affects approximately 30 million people in the United States, or nearly 10% of the US population.[1] Diabetic retinopathy (DR)—retinal microvascular damage due to chronic hyperglycemia—is a leading cause of vision loss and ultimate blindness.[2,3]

DR is classified clinically as nonproliferative or proliferative. Vision loss in nonproliferative DR is often secondary to vessel leakage, with consequent diabetic macular edema (DME). In proliferative DR (PDR), progressive ischemia leads to retinal neovascularization, which can be complicated by vitreous hemorrhage, retinal detachment, and neovascular glaucoma.

The Mainstays of Treatment

For decades, panretinal photocoagulation (PRP) has been a mainstay of PDR management.[4,5] Within this context, the introduction of intravitreally administered vascular endothelial growth factor A (VEGF-A) antagonists has provided an alternative or complementary approach to treatment, with results from randomized head-to-head trials demonstrating that anti-VEGF therapy can be noninferior to PRP with respect to outcomes in visual acuity.[6,7] Anti-VEGF therapy also appears to confer a reduced risk for the adverse effects associated with PRP, which include peripheral vision loss and secondary macular edema.

Nevertheless, although appropriately applied PRP confers a durable effect on PDR management, intravitreal pharmaceutical delivery may only be as durable as the effect of the medication. For example, in Protocol S, patients without DME at baseline required a median of 10 injections through 2 years, and those with DME at baseline required a median of 14 injections through 2 years.[6] In comparison, 55% of patients who were randomly assigned to PRP did not require any supplemental laser treatment through 2 years after the initial application, though some of these patients also received ranibizumab for DME during the course of the study.


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