Issue link: https://optometricmanagementsupplements.epubxp.com/i/531600
6 • INTEGRATED CROSS-DISCIPLINARY APPROACHES TO THE MANAGEMENT OF DIABETIC EYE DISEASES DR. DUNBAR: Along those same lines, when I refer patients who have DME to a retina specialist, I try to manage their expectations by letting them know what the future may hold. For example, I explain that the latest treatments, which are safe and effective, involve injections into the eye and that the injections are well tolerated with minimal pain be- cause an anesthetic is used. I feel I'm doing patients and retina specialists a service by preparing my patients for what they can expect during their visit. COMMUNICATE AND COORDINATE DR. PIZZIMENTI: One of the challenges of educat- ing patients who have diabetes is making sure they hear the same message from all of their healthcare providers — their optometrist, retina specialist, endocrinologist, podiatrist, dentist and so on. How can we improve communication and coordination among the various medical specialties? DR. DUNBAR: Every time a patient comes in for a comprehensive eye examination, including an evalu- ation to determine if he has diabetic retinopathy, I summarize the visit in a note to the endocrinolo- gist or primary care physician. Whether I write my fndings on a prescription pad or print the examina- tion from our electronic health records, I think it's important to share this information so the doctors who are managing patients with diabetes know that their patients are also being seen and cared for by an eyecare professional. ANTI-VEGF THERAPY DR. PIZZIMENTI: Dr. Albini, what are the current treatment options for diabetic eye disease, both medical and surgical? DR. ALBINI: Our treatment paradigm for DME has shifted dramatically. For years, the standard treat- ment protocol was based on results from the Early Treatment Diabetic Retinopathy Study (ETDRS), which found that focal laser photocoagulation was better than observation, even though a large per- centage of patients still lost vision over time. 11 Today, frst-line therapy in most cases is an intravit- real injection of one of several anti-vascular endothe- lial growth factor (VEGF) agents, which can improve vision over time and have a favorable safety profle. 12 In the RISE and RIDE trials of ranibizumab (Lucentis, Genentech), for example, patients gained 12 letters of visual acuity over a 2-year period, an effect that was maintained with continued treat- ment. 12,13 Recently, the U.S. Food and Drug Administra- tion expanded the approved use for ranibizumab 0.3 mg to treat diabetic retinopathy in patients with DME. 14,15 In March 2015, FDA expanded the approved use for afibercept (Eylea, Regeneron) to treat diabetic retinopathy in patients with DME. The Diabetic Retinopathy Clinical Research Network (DRCR.net) is studying the effects of ranibizumab on patients with DME and those who have retinopathy without DME. Depending on their fndings, we may see a broadening of the indication, allowing us to use an anti-VEGF agent instead of laser treatment for severe nonprolifera- tive diabetic retinopathy and proliferative diabetic retinopathy. DR. PIZZIMENTI: How do the other anti-VEGF agents differ from ranibizumab? DR. ALBINI: Ranibizumab, afibercept, and bevaci- zumab (Avastin, Genentech), which is used off-label in ophthalmology, differ in their molecular weight, structure and pharmacokinetics. 16 Ranibizumab