Update on Management of Non-proliferative Diabetic Retinopathy without Diabetic Macular Edema; Is There a Paradigm Shift?

Abstract

Diabetic retinopathy (DR) is the major cause of visual impairment and blindness in the working-age population. Conventional management for nonproliferative diabetic retinopathy (NPDR) without diabetic macular edema (DME) is derived from the findings of the Early Treatment Diabetic Retinopathy Study (ETDRS). Although the ETDRS protocol basically includes observation, selected cases of severe NPDR may undergo scatter laser photocoagulation. Post-hoc analysis of recent trials has shown that patients with NPDR receiving intravitreal anti-vascular endothelial growth factor (anti-VEGF) for DME would experience improvement in the DR severity scale (DRSS). In addition, recent randomized trials (PANORAMA and Protocol W) have revealed that early intervention with intravitreal aflibercept in eyes with moderately severe to severe NPDR is associated with significant improvement in DRSS and reduced vision-threatening complications of DR. Based on recent studies, it seems that the therapeutic approach to NPDR may undergo a substantial change and a paradigm shift toward considering early intervention with the administration of intravitreal anti-VEGF injections. However, the long-term results and the duration of adherence to anti-VEGF therapy for eyes with NPDR are not yet defined. It is also not apparent whether improvement in DRSS is a true disease modification. Studies showed that DRSS improvement is not associated with retinal reperfusion. In addition, DRCR.net Protocol W showed no visual acuity benefit with the early intravitreal aflibercept injection in moderate to severe NPDR as compared with performing observation plus intravitreal aflibercept applied only after progression to proliferative DR or vision-impairing DME. The cost–benefit ratio is also a challenge. Herein, we look at different aspects of early anti-VEGF application and discuss its pros and cons in the process of treating NPDR.

Management of Nonproliferative Diabetic Retinopathy: Where Do We Stand?

“…In the United States, the prevalence of DR is expected to double to over 15 million people by 2050, with similar trends predicted globally 4 . Premature vision loss associated with DR progression is the leading cause of visual impairment in working-age Americans, costing the United States ~$500 million annually in lost income 5,6 . Individuals with DR-associated visual impairment reported a lower vision-related quality of life than people without DR, including higher rates of mental distress and depressive symptoms 7 .…”

“…4 Premature vision loss associated with DR progression is the leading cause of visual impairment in working-age Americans, costing the United States ~$500 million annually in lost income. 5,6 Individuals with DR-associated visual impairment reported a lower vision-related quality of life than people without DR, including higher rates of mental distress and depressive symptoms. 7 The increasing prevalence of DM puts millions more at risk for DR-associated vision loss, but per the American Diabetes Association (ADA), up to 95% of this vision loss is preventable with timely diagnosis and treatment of DR. 8 Laser photocoagulation and, more recently, intravitreal antivascular endothelial growth factor (anti-VEGF) injections are the current standards of care in the treatment of DR, but both are typically deferred until the retinopathy progresses to a high-risk proliferative stage when the visual prognosis is often poor.…”

Aqueous Humor Cytokines in Non-Proliferative Diabetic Retinopathy

“…Recent studies have investigated NPDR without DME management, and there is a debate between conventional management derived from the Early Treatment Diabetic Retinopathy Study (ETDRS), which included controlling the systemic conditions and observation, and anti-VEGF therapy. The PANORAMA and Protocol W randomized trials showed that an early intervention with aflibercept in moderately severe to severe NPDR significantly improved DR severity scale scores and reduced vision-threatening complications of DR [ 36 , 37 , 38 , 39 ].…”

Explainable ensemble learning method for OCT detection with transfer learning

“…These conditions can result in progressive vision loss and, in severe cases, even blindness. With the global aging population, increased usage of electronic devices, and growing numbers of diabetic patients, the prevalence of DME is on the rise [1,2]. As the leading causes of irreversible vision loss worldwide, AMD and DME require reliable and accurate diagnostic and monitoring tools [3][4][5][6].…”