Caution ahead: Confronting DME

Most atrophic retinal diseases are untreatable, including geographic atrophy. Thankfully, I believe efforts underway will ultimately prove successful in altering this unpleasant reality. Patients are desperate and scared, and our society has a long history of preying on these base human emotions. Too often such patients turn to patient-funded stem-cell research or buy some nonrefundable, useless visual aide like “pinhole glasses.”

Diabetic retinopathy is different. Because the attributable blindness is arguably almost completely preventable, the scale of the associated permanent vision loss is a particularly noxious scourge. 

Some studies have indicated that supplemental physician education of DR patients may not have a meaningful impact. Reassuringly, many studies have reported that patients indeed do regard their clinician’s recommendations more highly than many other sources of information in our rich, complex, distracting information ecosystem.¹ 

As one example, among a population of regular alcohol-consuming cancer patients at diagnosis, simple clinician counseling to quit drinking led to a fivefold greater likelihood of behavior modification. However, such clinician recommendations were remarkably infrequent.² 

Retina specialists often develop long-term relationships with our patients. Be mindful of both the opportunity and responsibility this affords. Your comments and recommendations can impact patient behaviors, such as cardiovascular risk factor control and choices for managing, or observing, concurrent retinal diseases. We’re called to be active participants in our patients’ lives instead of being fatalistic observers.

In this issue, Drs. Mustafi Safi and Roger Goldberg report on DRCR Retina Network Protocol V (page 25). I think we must remain skeptical about interpreting the results to imply that observation of a clinically relevant amount of center-involved diabetic macular edema is the best course for all patients with visual acuity better than 20/32. No data suggest DME, even without dramatic VA loss, is beneficial for an eye. 

Therefore, even though our current therapeutics, which require intravitreal delivery, carry risks and aren’t an optimal approach, we must remain vigilant in our goal to prevent needless visual loss. We must be willing and able to re-evaluate our threshold for initiating treatment as individual patient circumstances evolve, new therapeutics emerge and more data is generated. RS