Systemic Approaches and Considerations in the Management of Diabetic Retinopathy

The role of certain factors on the progression of diabetic retinopathy needs to be clearly understood by healthcare professionals and patients alike. Detrimental effects can be avoided with effective communication and healthcare provision, ultimately limiting the progression of diabetic retinopathy, and more importantly, preventing one of the leading causes of blindness. The risk of developing diabetic retinopathy can be reduced by early detection and timely tight control of associated systemic risk factors. Intensive blood glucose control and blood pressure control are important in reducing the incidence and progression of diabetic retinopathy. Dyslipaedemia is associated with macular exudate and moderate visual loss. In the presence of nephropathy, the progression of retinopathy and macular oedema may be accelerated. There is no concrete evidence for smoking directly affecting the progression of retinopathy, but considering its other vascular effects it should be strongly advised against. A multifactorial approach, targeting control of the aforementioned factors will reduce the risk of onset and progression of DR. Optimising systemic health and taking precautionary measures will not only limit the progression of diabetic retinopathy but may prevent severe visual loss. Central Bringing Excellence in Open Access   Okhravi et al. (2015) Email: JSM Ophthalmol 3(3): 1035 (2015) 2/4 of 9.2% [3]. The investigators also noted that the effect of HbA1c changes with the duration of disease (with earlier tighter control clearly being more beneficial). In their follow up study, Epidemiology of Diabetes Interventions and Complications (EDIC), they reported that patients from the ‘intensive’ group maintained the reduction in risk for 4 years, even though HbA1c levels in the two groups gradually converged [5]. This coined the term “metabolic memory” which describes a long lasting benefit of previously intense glucose control. The UKPDS conducted a similar trial in type 2 diabetics (4). They randomly allocated 3867 patients to an ‘intensive’ therapy and ‘conventional’ therapy group for 6 years. Results of the study showed that intensive glycaemic control (with a mean HbA1c of 7.0%) had a 21% reduction in the progression of DR when compared to conventional glycaemic control (with HbA1c of 7.9%) [4]. One disadvantage of intensive glycaemic control reported in both trials was the increased incidence of hypoglycaemic attacks, with a threefold increase of severe hypoglycaemia in the ‘intensive’ group [3,4]. Another drawback recognised in the DCCT was an early initial worsening in retinopathy status. However after 18 months this reversed, with patients in the intensive group faring better in the longer term [4]. As a result of the above studies the overall recommendations are early intensive treatment of systemic disease, as safely as possible, for as long as possible with a goal of maintaining levels of glycaemia close to normal [3,4]. Although good glycaemic control is paramount to the management of diabetic patients to limit complications, the overall contribution of glycaemia on retinopathy amounts to 11% when evaluating total risk [6]. This means that other factors exist that contribute to the pathogenesis of diabetic retinopathy.