Therapeutic target
- To prevent or slow progression (progression) of diabetic retinopathy by consistent glucose (blood glucose) and blood pressure regulation.
- If necessary, also lowering elevated blood lipids (blood fats)* .
* No longer considered a risk factor according to an international case-control study of 2,535 type 2 diabetes patients.
Therapy recommendations
- Diabetic macular edema (swelling of the retina around the macula) with foveal involvement: Intravitreal drug administration (“into the vitreous”) primarily with vascular endothelial growth factor (VEGF) inhibitors; aflibercept and ranibizumab; bevacizumab, off-label use) if morphologic macular findings suggest a positive effect of IVOM (intravitreal surgical drug administration) on visual acuity (visual acuity lower limit 0.05)Therapy termination: When, based on the morphological and functional findings, no further improvement in visual ability can be expected.
- Intravitreal drug administration (IVOM) with corticosteroids (triamcinolone acetonide, dexamathasone implant, fluocinolone acetonide implant); in the absence of response of intravitreal therapy with VEGF inhibitors.
- Regarding adequate pharmacotherapy of diabetes: see under diabetes mellitus type 1 or diabetes mellitus type 2.
- Because of adjustment of blood pressure: see under hypertension / drug therapy.
- Note on further therapy:
- In addition to the treatment of blood sugar and blood pressure, treatment of blood lipids (if elevated) is also essential!
- See due toPharmacotherapy of hyperlipidemia under the respective indication (eg, LDL cholesterol elevation, etc.).
- See also under “Further therapy”.
Further notes
- DEGAM assesses the use of VEGF inhibitors somewhat more cautiously than the other professional societies involved in the guideline and therefore restricts as follows:
- VEGF inhibitors should be offered as first-line treatment when patients with fluid accumulation in the macula and fovea have noticeable visual loss.
- In patients without noticeable vision loss, administration of VEGF inhibitors may be considered. Note: According to a randomized trial, macular edema does not need to be treated with laser coagulation or injection of anti-VEGF drugs as long as there has been no worsening of visual acuity. The multicenter study enrolled 702 patients with diabetic macular edema (accumulation of extracellular fluid (edema) in the area of the yellow spot (macula lutea)) and a visual acuity of 20/25 or better. Patients were randomly assigned to three treatment strategies: first group received an intraocular injection with aflibercept every 4 weeks, the second group received laser coagulation, and the third group served as a control group. After 2 years of study the following result was found: the primary endpoint a worsening of visual acuity, occurred equally often in all three groups.Conclusion: Immediate anti-VEGF treatment may have protected the patients from complications (e.g. eye loss due to endophthalmitis). Furthermore, it should be mentioned that there was a more frequent increase in intraocular pressure during aflibercept treatment compared with the control group (8 versus 3%).
- The presence of retinopathy is not a contraindication (counterindication) to cardioprotective therapy (” heart-protective therapy”) with acetylsalicylic acid (ASA). The risk of retinal hemorrhage (bleeding of the retina) is not changed.
- In a comparative study from the U.S. National Eye Institute, the VEGF inhibitors aflibercept, bevacizumab, and ranibizumab improved visual acuity in patients with diabetic macular edema, even after two years. In poor baseline visual acuity, aflibercept achieved the best effect.
- Therapy with intravitreal drug administration should be terminated when no further improvement in visual function is expected based on morphologic and functional findings
