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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Diabetic Microvascular Complications: Are We Doing Enough?
Part III: Diabetic Retinopathy


GOAL
To delineate the multifactorial pathogenesis of diabetic microvascular complications, review pathways of disease progression, and present emerging data on future treatment options.

TARGET AUDIENCE
This activity is designed for ophthalmologists, endocrinologists, diabetologists, and primary care physicians. No prerequisites required.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity. At the conclusion of this activity, participants should be able to:

  • Review the pathophysiology of diabetic retinopathy, at both the molecular and macroscopic levels.
  • Understand the mechanisms of action of current and future therapies.
  • Develop a patient management strategy that incorporates laser photocoagulation as well as best medical practice, including glycemic control and treatment of hypertension and hyperlipidemia.
  • Evaluate evidence for emerging therapeutic options.
  • Implement integrated strategies with physicians in other disciplines for the appropriate screening and early detection of all manifestations of diabetic retinopathy.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 category 1 credits toward the AMA Physician's Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity.

The estimated time to complete this educational activity: 2 hours.

Release date: October 15, 2004. Expiration date: October 15, 2006.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine name implies review of educational format design and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from Eli Lilly and Company.

Full Disclosure Policy Affecting CME Activities:
As a sponsor accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Directors and Participating Faculty reported the following:

PROGRAM DIRECTORS

Andrew P. Schachat, MD
Karl Hagen Professor of Ophthalmology
Wilmer Eye Institute
Johns Hopkins University School of Medicine
Baltimore, Maryland
Dr Schachat reports receiving grants/research support from Alcon, National Eye Institute/National Institutes of Health, Novartis, and QLT Inc; and serving as a consultant to Allergan, Concurrent Pharmaceuticals, Inc, Eyetech Pharmaceuticals, Genentech, NeoVista, Inc, and Pfizer Inc.

Charles P. Wilkinson, MD
Professor of Ophthalmology
Wilmer Eye Institute
Johns Hopkins University School of Medicine
Chair, Department of Ophthalmology
Greater Baltimore Medical Center
Baltimore, Maryland
Dr Wilkinson reports having no significant financial or advisory relationships with corporate organizations related to this activity.

PARTICIPATING FACULTY

Emily Y. Chew, MD
Medical Officer
Division of Biometry and Epidemiology
National Eye Institute
National Institutes of Health
Bethesda, Maryland
Dr Chew reports having no significant financial or advisory relationships with corporate organizations related to this activity.

Thomas A. Ciulla, MD
Assistant Professor of Ophthalmology
Indiana University-Purdue University
Staff Surgeon
Retina Vitreous Macular Service
Midwest Eye Institute
Indianapolis, Indiana
Dr Ciulla reports receiving grants/research support from Alcon, Eyetech Pharmaceuticals, Genentech, Pfizer Inc, and Theragenics Corporation; and serving as a consultant to Theragenics Corporation and Eli Lilly and Company.

Arthur D. Fu, MD
West Coast Retina Medical Group
San Francisco, California
Dr Fu reports having no significant financial or advisory relationships with corporate organizations related to this activity.

H. Richard McDonald, MD
Associate Clinical Professor of Ophthalmology
University of California, San Francisco
San Francisco, California
Dr McDonald reports having no significant financial or advisory relationships with corporate organizations related to this activity.

Sam S. Yang, MD
Fellow, California Pacific Medical Center
West Coast Retina Medical Group
San Francisco, California
Dr Yang reports having no significant financial or advisory relationships with corporate organizations related to this activity.

Notice: In accordance with the ACCME Standards for Commercial Support, the audience is advised that one or more articles in this continuing medical education activity may contain reference(s) to unlabeled or unapproved uses of drugs or devices. The following faculty members have disclosed that their articles have referenced the following unlabeled/unapproved uses of drugs or devices:

Drs Fu, Yang, and McDonald—triamcinolone acetonide.

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Prevention And Treatment Of Diabetic Retinopathy For Patients With Diabetes
Andrew P. Schachat, MD,* and Charles P. Wilkinson, MD†

Diabetic retinopathy and diabetic macular edema affect the visual acuity of millions of individuals with diabetes throughout the world. These conditions are the single largest cause of blindness in the working-age population and account for approximately 8% of the cases of new-onset blindness diagnosed in the United States each year. Diabetes-related blindness and visual impairment extract a significant toll from society, not only in economic terms (eg, cost of medical care, lost wages, and productivity) but also in the resulting decline in the quality of life for patients and their families.

Of the 10.2 million adults aged 40 years and older known to have diabetes, an estimated 40.3% have diabetic retinopathy and 8.2% have vision-threatening retinopathy. With the aging of the population, this percentage can be expected to increase: the longer an individual has diabetes, the greater the likelihood of developing diabetic retinopathy. By the 20-year mark, nearly all individuals with type 1 diabetes have retinopathy. Most individuals with type 2 diabetes also eventually develop retinopathy over the course of their lifetimes. As diabetes continues to increase in prevalence worldwide, diabetic retinopathy also is likely to increase, which suggests prevention and treatment of diabetic retinopathy will continue to be an important focus for individuals with diabetes, their families, and medical professionals.

This issue of Advanced Studies in Medicine contains an article by Thomas A. Ciulla, MD, that reviews the epidemiology and impact of diabetic retinopathy. Dr Ciulla describes the pathogenesis of retinopathy and its associated physiologic changes, details its natural history, and explains how hyperglycemia triggers processes that lead to diabetic retinopathy. Dr Ciulla also provides an overview of the roles the various pathways play in hyperglycemia, including the polyol pathway, advanced glycation end products, protein kinase C pathway, and oxidative stress, which are the pathways presently being targeted for pharmacologic interventions.

Emily Y. Chew, MD, offers a clinician's viewpoint on the rationale for diabetic retinopathy screening to allow for early intervention. She highlights the importance of teamwork among the primary care physician, the endocrinologist, and the ophthalmologist to attain the best possible outcome for the patient. Dr Chew describes the newly proposed international classification scale regarding the severity of diabetic retinopathy and diabetic macular edema and the importance of the classification in facilitating communication between members of the healthcare team and international researchers. Dr Chew also presents a case study involving a patient with type 2 diabetes who developed diabetic retinopathy, describing the diagnostic techniques used by the ophthalmologist, clinical findings, and appropriate treatment. In her case study, she emphasizes the importance of integrating the medical management of diabetes and its associated complications into retinopathy treatment, pointing out that diabetes control directly affects the success of all forms of diabetic retinopathy treatment and preservation of vision.

Arthur D. Fu, MD, Sam S. Yang, MD, and H. Richard McDonald, MD, describe the clinical management of diabetic retinopathy and the importance of addressing comorbid conditions. They document studies showing the interrelationships between the severity and progression of retinopathy, hyperglycemia, hypertension, hyperlipidemia, nephropathy, anemia, and pregnancy. Drs Fu et al then explain the basis for the team approach to diabetes care and the importance of different specialists in improving the outcomes associated with diabetic retinopathy. They offer an overview of the studies that have shaped current therapy and the guidelines derived from those studies that have improved patient care. In addition, they discuss the conclusions from the  Diabetic Retinopathy Study, the Early Treatment Diabetic Retinopathy Study, and the Diabetic Retinopathy Vitrectomy Study regarding how best to use interventions, such as photocoagulation and vitrectomy, in patients with significant diabetic retinopathy, macular edema, vitreous hemorrhage, and diabetic traction retinal detachments. Drs Fu et al describe potential pharmacologic interventions for retinopathy that appear promising in clinical trials, including vascular endothelial growth factor inhibitors (eg, pegaptanib), protein kinase C-b inhibitors (eg, ruboxistaurin), intravitreal triamcinolone acetonide, pigment-epitheliumÐderived factor, and inhibition of release of growth hormone. In addition, they  present a case study involving a patient with a history of type 1 diabetes mellitus who presented with partial vision loss in both eyes, describing the ophthalmic examination, diagnostic imaging, and course of management.

As diabetic retinopathy receives more and more scrutiny from clinicians, researchers, and pharmaceutical companies, the therapeutic options will continue to expand. However, the degree of glycemic control, coupled with regular screening examinations for early detection of retinopathy and timely intervention, remains the strongest predictor of good outcome. Regrettably, neither intervention is used as effectively as it could be. Many patients with diabetes still have hemoglobin A1c levels that exceed the recommended 7%. Despite the strong recommendations from the American Diabetes Association and the American Academy of Ophthalmology that individuals at risk for diabetic retinopathy progression have regular eye examinations, studies show that far too many patients have not had eye examinations in 2 or more years. Attention to these 2 interventions, glycemic control and regular eye examinations, has the potential to significantly improve outcomes for individuals with diabetes and diabetic retinopathy, even as technology races to provide additional modes of treatment and prevention.


*Karl Hagen Professor of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland.
 
Professor of Ophthalmology, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Chair, Department of Ophthalmology, Greater Baltimore Medical Center, Baltimore, Maryland.

Address correspondence to: Andrew P. Schachat, MD, Wilmer Eye Institute, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Maumenee 713 Ophthalmology, Baltimore, MD 21287.
E-mail:
aschachat@jhmi.edu.





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