In another live recording of The Spotlight Series Podcast from the Hawaiian Eye Meeting, host Mario Nacinovich and Judy Kim, MD, of the University of Texas Southwestern Medical Center, discuss the link between diabetes and the ocular conditions diabetic macular edema and diabetic retinopathy. They also tackle treatment options for these conditions, and Dr. Kim shares how she selects the most optimal treatment for each patient.
Mario Nacinovich:
Welcome to The Spotlight Series podcast. I’m your host, Mario Nacinovich. Today, we’re shining a spotlight on diabetic retinopathy and diabetic macular edema, focusing on evolving strategies and screening, treatment, and long-term management. Joining me is Dr. Judy Kim, the Jean and Tom Walter, distinguished chair in ophthalmology in honor of James Fleet McCauley, professor of vitreoretinal surgery and diseases, vice chair of education, and medical director of clinical research at the University of Texas Southwestern Medical Center in Dallas, Texas. Dr. Kim, it is a pleasure to have you on the program.
Judy Kim, MD:
Thank you, Mario. Thanks for having me.
Mario Nacinovich:
We’re going to frame up the disease burden and the stakes at hand here. Dr. Kim, to start, can you briefly frame the current burden of diabetic retinopathy and diabetic macular edema in terms of prevalence and impact on vision and quality of life?
Judy Kim, MD:
Yes. There is an epidemic of diabetes around the world, not just the United States. It’s an epidemic around the world. In 2025, there were about 589 million with diabetes. In the United States, in 2021, there were about 38.4 [million] people with diabetes. That means about 11.6% of U.S. population has diabetes. When there’s a lot of diabetes, then the disease diabetic retinopathy also increases. In fact, diabetic retinopathy is a leading cause of vision loss in working-age adults, and it affects about a third of patients with diabetes. Of those patients, about 10% will develop diabetic macular edema. Diabetic macular edema is the leading cause of vision loss, along with other complications of diabetic retinopathy, such as vitreous hemorrhage, tractional retinal detachment. We really want to impress upon people that early detection of diabetic retinopathy and diabetic macular edema is very important.
Mario Nacinovich:
How early in the course of diabetes do you begin to worry about the microvascular retinal changes? What does the epidemiology tell us about the window of opportunity for prevention and stabilization?
Judy Kim, MD:
The importance of the screening is that many times, there’s no symptoms with diabetic retinopathy. People with diabetes may think that, oh, I see well, I have no pain, nothing’s bothering me. Therefore, they don’t get the screening that is needed to get the early detection. Studies have shown that high hemoglobin A1C levels as well as duration of disease, and whether you have type 1 versus type 2, they all make a difference in when you’re going to develop diabetic retinopathy. But even within patients with prediabetes where A1C is not as high, even among pre-diabetics, people with pre-diabetes, they have diabetic retinopathy in some cases. Anyone, even people with pre-diabetes, should be screened as well.
Mario Nacinovich:
From your perspective, are the key messages clinicians should be conveying to their patients right now about the importance of early detection and timely referral for both DR and DME?
Judy Kim, MD:
Yes, because once vision loss occurs and anatomic damage occurs from diabetes, then it sometimes is very difficult to make them better. Fortunately, as we’ll talk about, there are a lot of treatments available, but still, once there’s structural damage, still, we have no treatment that can reverse that. Once treatment is delayed, then one might need more costly treatments too. It’s sort of like cancer. It’s better to get the diagnosis of cancer early on, then your prognosis for 5-year survival is a lot higher compared to getting your cancer diagnosis after metastases. Same thing with diabetic retinopathy. If we catch it early on, then one might not need as many treatments or more severe treatments compared to if we were to diagnose it later on. In order to prevent late diagnoses, we recommend people with diabetes to have annual dilated fundus examination or equivalent such as ultra-widefield fundus photographs.
Mario Nacinovich:
Let’s talk about that and dig into screening because certainly, that’s where outcomes are often won or lost. I like your analogy to oncology where earlier is better. How do you currently structure DR screening in your practice or perhaps even in the larger institution of the University of Texas Southwestern, particularly for patients with type 1 versus type 2?
Judy Kim, MD:
At this time, we rely on our primary care physicians and pediatricians to refer to us patients with type 1 or type 2 diabetes. But over the years, we found that it really doesn’t work very well. In type 1, after 5 years of diagnosis, they should start getting screening every year. Type 2, at the time of diagnosis of type 2 diabetes, they should get an eye examination every year. But the reality is that less than 50% of people with diabetes get this annual screening in the office with dilation. Some people think that, oh, I got my glasses checked, so I must have diabetes exam. No, no. You have to have a dilated eye examination so that the doctor can look inside the eye.
Well, because this in-office examination with dilation only yields about 50% screening, people have been working on teleophthalmology where cameras are placed at different places. With the fundus photographs that are taken of our patients, those images are then sent to a reading center, and then, they would review the photographs to screen whether the person has diabetic retinopathy or not. Then, now, more recently, ophthalmology is the first subspecialty, specialty in medicine, to have gotten the FDA clearance of autonomous artificial intelligence algorithms for screening these photographs for diabetic retinopathy that are referable to doctors.
With these, you could take an image of a patient even at a primary care doctor’s office. Our patients don’t even have to come to an eye doctor’s office. Then, at the point of care where they go to get their systemic checkups and so forth, they can get images taken, and within a minute, they can get response, the results of whether they should go see an ophthalmologist or not. We’re hoping that as teleophthalmology and now, artificial intelligence algorithm involving screening will increase the screening rate. The countries that have utilized these AI screening such as Singapore and other countries do show that screening rate does go up and vision loss from diabetic retinopathy goes down. In fact, there are studies out of the UK where diabetic retinopathy used to be the number 1 cause of blindness in working-age people, but now it’s maybe number 8 because they implemented telehealth, telescreening, and also education on the hemoglobin A1c level.
Mario Nacinovich:
We’ve definitely rapidly moved from concept to real-world development in terms of these DR screening programs, and the use of AI is they’re definitely enabling that quick image analysis that’s needed to screen out. But this takes a particular full healthcare system approach. Like you said, there’s no longer the reliance completely on the referral network from primary care teams, takes a village. Certainly, AI has helped pave the way in terms of safe, efficient, and equitable treatment in terms of these patients and incorporated it very quickly to close that screening gap.
Judy Kim, MD:
I love the part you mentioned about equitable because our patients who are out in the remote areas or rural areas where the specialists like ophthalmologists or even optometrists are rare, not readily accessible, these telescreening will play a bigger role. It might also keep the healthcare costs down because taking a photo is a lot less expensive than seeing a doctor. Also, it’ll be reducing treatment burden and travel burden for our patients to find a doctor and park. Sometimes our patients have to get their relatives out of their work to give them a ride. All in all, I think this will work really well.
Another thing you mentioned is the system-based. The practices that really have been successful with utilizing telehealth or AI involving screening are healthcare systems like Kaiser, VA, Veterans Administration, or large healthcare systems where they invested money upfront, and then they’re reaping the benefit of that. The caveat is that there is the upfront cost because cameras do cost money, but if there’s a will, there’s a way. We are learning that it can work well. Now, it’s getting reimbursed. AI involving screenings are getting reimbursed for the physicians. It’s a win-win for everyone: the patients, the doctors, the healthcare system.
Mario Nacinovich:
I’m sure your overburdened staff definitely appreciates…
Judy Kim, MD:
Yes. Yes, exactly.
Mario Nacinovich:
That’s a few less patients they need to see a day. Let’s turn to treatment now, and let’s focus on the center-involved diabetic macular edema. When you first evaluate a patient that may be referred to clinic that’s center-involved DME, do you structure your assessment to decide between observation, anti-VEGF therapy, focal/grid laser, and steroid-based options? Can you walk us through how that works?
Judy Kim, MD:
Yes. When we talk about center-involved diabetic macular edema, it’s when the swelling of the retina involves the foveal center, the center of the retina that gives our best vision. Studies have shown that if the visual acuity is really good, like 20/20 or even 20/25, patients can be observed, and we could focus more towards getting their A1c level and other health conditions more better controlled. I have a pneumonic: A-B-C-D-E-S. What do they stand for? Concentrate an A1c blood sugar, B for blood pressure, C for cholesterol, D for diet, E for exercise, and S for smoking cessation.
Mario Nacinovich:
Especially in the diabetic patient.
Judy Kim, MD:
Yes. With each visit, I try to address at least 1 of these of my pneumonic. Even though I’m an eyeball doctor, I try to work with my colleagues in primary care because as you said, it takes a village. It’s a team effort. Well, when the visual acuity is worse or even when visual acuity is better, despite some of our diabetic retinopathy, DRCR retina network studies like Protocol V or even other studies like PANORAMA, we sometimes do start therapy earlier in some patients. We may need to customize, but the first-line agent that if we do decide to treat will be anti-VEGF agents. We have many anti-VEGF agents now, fortunately.
Mario Nacinovich:
Wasn’t always that case.
Judy Kim, MD:
It wasn’t, but now, it’s like the TGIF Fridays menu book. It’s like almost a library book now. Many may have to start with off-label agents such as Avastin or bevacizumab, generic name, because of insurance mandates. Don’t get me started on the insurance mandates…
Mario Nacinovich:
We won’t go down that road. No.
Judy Kim, MD:
But a lot of the on-label agents work very well for diabetic macular edema, especially if the patient’s visual acuity is still relatively good and their center subfield thickness on OCT imaging is not that thick, they can do very well. What I impress upon my patients is that diabetic macular edema, if we really work on it together initially with frequent injections, it’s one of these conditions where we can, over time, decrease the number of injections and even be able to dry the retina so they don’t even have to get injections. This DME is different than neovascular AMD where… age-related macular degeneration where you might need injections forever. Or retinal vein occlusion, I find that they need lots of injections for many, many years. But with diabetic macular edema, if we really work on it together with monthly injections to start with, the number of injections required to treat diabetic macular edema at year 2, year 3, year 4, year 5 went down to the point where we can stop and observe.
That’s something that I really impress upon my patients so that they’re encouraged. They stay on therapy because the adherence to treatment in these chronic diseases are very important. Besides the anti-VEGF agents, we can do focal grid laser, which used to be the first-line therapy when we didn’t have any of these anti-VEGF agents, but I still do it in very select cases where there’s group of microaneurysms that are extra foveal, but the edema is involving the fovea or patient says, “I can’t come that often for these anti-VEGF agents. Is there anything else?” If their anatomy with the microaneurysm location is ideal, then I will do a focal grid laser even now.
But then, we can also think about steroids because in diabetic macular edema and diabetes in general, it’s not just VEGF, vascular endothelial growth factor, that’s playing a role, but many other cytokines. Studies have shown that anti-VEGF agents will control VEGF level only, but steroids will attack all these other cytokines that are activated with inflammation in diabetes. I do utilize steroids as well. Obviously, we don’t use steroids in the United States as first-line therapy because of the side effects such as cataract formation or the risk of intraocular pressure going up. But in some patients who are already pseudophakic or already had cataract surgery, and we don’t have to worry about cataract formation, and those who don’t have steroid-induced glaucoma response, I think steroid is also an excellent alternative to anti-VEGF or as a switch therapy from anti-VEGF non-responders to see whether that will get the retina to dry. Then, obviously, we’re also looking at the surgery option in some of our patients, especially if they have prolifera of disease in addition to diabetic macular edema.
Mario Nacinovich:
I’m very curious about your first-line treatment algorithm, specifically for the center-involved DME in 3 specific patient types. Let’s talk first about patients that are presenting with a good baseline visual acuity versus those with more advanced visual loss. What’s first-line treatment in that case?
Judy Kim, MD:
Protocol T of DRCR.net compared bevacizumab, Avastin, to ranibizumab, Lucentis, to aflibercept, Eylea 2 mg. They found that those with 20/40 or better visual acuity, it didn’t matter which of these 3 agents that we used to treat the DME. But those with 20/50 or worse visual acuity, Eylea 2 mg was superior to Avastin in terms of drying effect as well as improving visual acuity. I would recommend, in those patients, to start with 2 mg Eylea. But then now we have second-generation anti-VEGF agents such as Vavismol, faricimab, and aflibercept 8 mg, Eylea HD, which is 4 times the molar dose of the 2 mg Eylea, and studies are showing that they are excellent in drying compared to the first-generation agents, and they last longer, more durable. The clinical trials went out to 16 weeks between treatment interval. The more and more real world data that’s coming out, and we’re here today at Hawaiian Eye, retina sessions showed that it’s probably about 12 weeks on average.
Mario Nacinovich:
Is that what you’ve been seeing in your clinical practice as well, about 12 weeks?
Judy Kim, MD:
Yes. That is still longer in durability than the first-generation where on, average, it was 6 to 8 weeks.
Mario Nacinovich:
Now, you can see patients 4 times a year as opposed to every month.
Judy Kim, MD:
Exactly. These are the patients if we start treating early as a first-line therapy with the second-generation agents. If we’re switching from the first-generation agents to second-generation agents, it seems like we’re adding about 2 weeks longer than what the patients were on with the first-generation agents.
Mario Nacinovich:
Understood.
Judy Kim, MD:
If it were my eye, I would love to be starting with the second generation to get that benefit of the durability.
Mario Nacinovich:
Well, we won’t even mention insurance because I know traditional Medicare is covering that, which is fantastic. Patients with Medicare Advantage need a little bit of a different change, but there’s a great program available now for commercial insurance patients to be covered by this. The companies are definitely supporting the use of the high dose as well. In terms of phakic versus pseudophakic patients, do you have a different approach?
Judy Kim, MD:
Wwith the pseudophakic patients, I’m not afraid of using steroids as a first-line therapy in subset of patients such as women who are lactating after giving birth, because there’s a small worry about these anti-VEGF agents being expressed. Although, some people at the meeting said they might just wait 1 or 2 days after intravitreal injection of anti-VEGF agents before giving milk, but I don’t want to have my baby go hungry, although you could store some…
Mario Nacinovich:
Well, before. Yeah.
Judy Kim, MD:
Before, right. There’s some options.
Mario Nacinovich:
Sure. It just takes some planning.
Judy Kim, MD:
Yeah, you could still plan and do anti-VEGF. Some other scenarios where I might start with steroids would be a pregnant woman. Again, we don’t know what the effect of these anti-VEGF agents are in the fetus because they were not studied, so that could be another one. Then, some people who are not wanting to travel as often, treatment burden, steroids tend to last a little bit longer than anti-VEGF…
Mario Nacinovich:
What’s the duration with a steroid? Is it the 16, 18 weeks or beyond?
Judy Kim, MD:
It can go beyond. Iluvien, for instance, it was approved for 3 years. In real-world, unlike clinical trial, I don’t see a lot of people going to 3 years, but I have had a number of patients with 1 injection last 1 to 2 years.
Mario Nacinovich:
That’s fantastic.
Judy Kim, MD:
In those patients, you might. But otherwise, I would say pretty much majority of my patients are started on anti-VEGF agents as my first-line, whether they’re phakic or pseudophakic.
Mario Nacinovich:
Well, I think I can predict this next answer for this next patient type. I’d love to hear your thoughts on it because I know intravitreal corticosteroids are a delicate discussion in this patient type, but patients that are at higher risk for increased intraocular pressure and those that particularly potentially have cataract progression.
Judy Kim, MD:
Yes. For those who have no cataract, I probably would hesitate from using steroids, but if those who already have a lot of cataract and they’re going to go down to cataract surgery route anyway, I might be less reluctant to use steroids. That’s the cataract. If the patients are at risk for steroid glaucoma, and you can sometimes test that with the topical steroids first, and if they have a pressure spike, then I probably wouldn’t…
Mario Nacinovich:
Avoid. Yeah.
Judy Kim, MD:
Yeah, I wouldn’t use it.
Mario Nacinovich:
Okay. Let’s move on. We’ve talked a little bit about aflibercept in DME. Let’s drill down specifically on its role in DME. How do you position it relative to the other anti-VEGF agents, particularly in patients with a worse baseline visual acuity or more diffuse edema?
Judy Kim, MD:
I did mention that Protocol T showed in the head to head to a head trial that aflibercept 2 mg was superior to bevacizumab, Avastin, especially for those with 20/50 or worse visual acuity. Interesting thing is that now, we have some data from aflibercept 8 mg, high dose, and they compared against aflibercept 2 mg at a different visual acuity, stratified 20/40 or better or 20/50 or worse. Then, when they compared it, 8 mg works as good for any visual acuity. We might not…
Mario Nacinovich:
Did you anticipate that? Did you and your colleagues anticipate that?
Judy Kim, MD:
It was curious. That’s why the study, the sub-analysis, was done, post-hoc analysis was done. The post-hoc analysis, it was interesting. I mean, so it takes some of the guesswork out, and visual acuity in cell and chart doesn’t always equate with the clinical trial ETDRS chart, first of all. Secondly, depending on whether the patient has glasses on and in certain places, there can be 1- or 2-line variable. What it means is that with Eylea 8 mg, you could use it for any visual acuity as with a 2 mg because it was better than Avastin.
Mario Nacinovich:
Definitely simplifies the algorithm for you.
Judy Kim, MD:
Yes.
Mario Nacinovich:
It takes a lot of the guesswork out, especially when you’ve got that post-hoc analysis.
Judy Kim, MD:
Also, the Protocol T of DRCR.net for patients who started with Avastin and were seen monthly, 70% of them had to be changed over to Eylea 2 mg by year 1. Yes, some people can do okay with Avastin off-label, but majority eventually required Eylea anyway, so why don’t we start with Eylea, right? Again, insurance company…
Mario Nacinovich:
Well, insurance does…
Judy Kim, MD:
… mandates that…
Mario Nacinovich:
Just for the record.
Judy Kim, MD:
Don’t get me started.
Mario Nacinovich:
You mentioned that. Again, I did not.
Judy Kim, MD:
Yes. No. Yeah, it’s my pet peeve.
Mario Nacinovich:
In real-world practice, tell your colleagues how you approach loading doses versus treat and extend versus fixed dosing and decisions that you make around extending intervals, when to switch therapy, if response is suboptimal. When do you pivot?
Judy Kim, MD:
Oh my goodness. This is a million-dollar question, and you talk to different retina doctors and they all have different answers for you. Even though we have clinical trials, not everybody follows that in the real world, and there’s the practicality as well. I mean, this morning, I was doing a CME meeting and I asked, “Do the number of loading doses that we see in clinical trials make a difference in how you actually treat in the real world?” It didn’t.
Mario Nacinovich:
Resounding no.
Judy Kim, MD:
Yeah. People were using everything such as do 1 injection, do the OCT, and if the person dried, then they will start extending out after 1 injection.
Mario Nacinovich:
Wow. Are you comfortable with that?
Judy Kim, MD:
Well, one might. If one injection dried it, why not? But it required doing an OCT to confirm it. Then, there are people who do 3 injections either with or without OCT. They automatically do monthly injections times 3. With that modality, you don’t need to do OCT at every visit because you’ve already decided that you’re going to give 3 monthly loading doses anyway. Then, some clinical trials had even 5 injections for certain agents. Some had only 3 injections. But I think in the real world, I think people don’t really follow those clinical trial setup of 4 loading doses, 3 loading doses, 5 loading doses. They just go more by…
Mario Nacinovich:
Individualized.
Judy Kim, MD:
… the OCT and be individualized. Exactly.
Mario Nacinovich:
Wow. That’s fascinating. I’d love to talk a little bit beyond treating macular edema and talk about the influence of anti-VEGF therapy on diabetic retinopathy, specifically around severity score. How do you think about the goal of improving DR severity scores with anti-VEGF agents in your daily practice, especially for patients with moderately severe or severe non-proliferative DR?
Judy Kim, MD:
Again, I’ve been involved with DRCR.net since its inception in 2003, and we’ve done a number of trials regarding DR and DME. One of the studies looked at whether during anti-VEGF therapy earlier without DME in patients with severe NPDR helped or not. What the study found was that yes, it can modify the disease. When you asked about the disease severity score, it improved 2 or more levels. But at the end of the day, visual acuity, it didn’t matter. It is possible that we can watch these patients until their visual acuity declined or they had other progression to proliferative disease and complications of proliferative disease. That’s one way of looking at it. Other people say, “Well, if we can disease-modify and we can prevent these more severe complications, then why not?” I think of these anti-VEGF agents and disease modification as sort of like Botox. You give Botox, people look younger, but it wears off.
Mario Nacinovich:
True.
Judy Kim, MD:
Same thing with anti-VEGF. It’ll look better. The DRSS score will improve, but the effect of anti-VEGF agents will wear off. They will need another injection and another injection. Just as Botox, you’ll need continuous injection. It’s not a one-and-done deal. The underlying problem of aging is going to continue in Botox, underlying…
Mario Nacinovich:
…diabetes control if it’s getting worse.
Judy Kim, MD:
Yes. In the anti-VEGF agents for NPDR, the underlying pathophysiology of diabetes and diabetic retinopathy is still going to continue despite fundus photo, DRSS score looking better. I think if we can get gene therapy where in 1 injection and it will continue to produce anti-VEGF, that might be the place where…
Mario Nacinovich:
Well, hold that thought because I want to talk more about that later on. That’s where the future is.
Judy Kim, MD:
It’s because I don’t see 20/20 vision person with severe NPDR getting injection every 4 months for the rest of their life.
Mario Nacinovich:
No, no. I am really curious based on our conversation so far is how you translate that into patient conversation because I understand your treatment algorithm, but then, how do you translate it from patient to patient conversation from disease modification rather than just symptom control? Because that’s got to be a wonderful conversation to be able to have with a patient now.
Judy Kim, MD:
Well, fortunately or unfortunately, many of our patients with diabetes and diabetic retinopathy have relatives who have had vision loss from diabetic retinopathy. Sometimes the conversation is not that hard because they’ve lived with people with vision loss. They know what that is like. Many people say, “I don’t want to go blind like my mother. I don’t want to go blind like my Uncle Jose.”
Mario Nacinovich:
Some of those families have experienced that for decades.
Judy Kim, MD:
Yes. Yes. Even if it’s not vision loss, some may be on dialysis, had a knee amputation, or a peripheral neuropathy, had a stroke or heart attack, all the other complications of diabetes. When I say, “This disease can cause you to go blind,” it’s actually not a difficult conversation, but the adherence to therapy, that’s the difficult conversation because this is a chronic disease and we still don’t have a one-and-done deal treatment. That’s where I sometimes feel like I’m a cheerleader, and I use OCT images, fundus photos of their visits to educate them. I say, “Hey, listen, last time, before the injection, you looked like that. Now, after your last injection, you’re drier, you’re looking better. That OCT went down.” I actually use imaging as a teaching tool. My patients have gotten so well-educated that after coming back from photography, they already know, “Okay, Dr. Kim, I’m doing better, and you got to pat me on the back.” Or they say, “I need an injection, don’t I? I saw that fluid coming back.”
I think there are many different ways that we doctors can be advocate, educator, and cheerleader for our patients to adhere therapy. I have said our patients, and audience maybe even, are more afraid of going blind than losing a limb. Some people are even more afraid of going blind than getting the diagnosis of cancer even. Vision loss is profoundly affecting our patients in many different ways. If we can do anything to keep our patients’ sight and be able to empower their lives, improve their quality of life so that they can live a long time to see their children, their grandchildren, do the things they like, continue to drive, read, work, that’s what motivates me to do what I do.
Mario Nacinovich:
I think that would motivate me to adhere to therapy, especially if you were my doctor. Thank you for that. I know even the best therapies fail if patients don’t receive them consistently over time. Certainly, a lot of practical strategies that you’ve employed and endeared yourself to your patients in terms of addressing some of those constraints that may be on their lives. Certainly, with the treatment algorithms expanding out so they don’t have to come as frequently, sure that will help. But certainly, healthcare systems, the payers themselves, these policymakers that we’ve joked around about a little bit, everyone has an opportunity to better support an integrated diabetes and eye care approach, but the patients have to play their part. Certainly, in terms of the models that are currently in existence to support them, the community outreach, the mobile imaging units, the teleophthalmology that you mentioned earlier. The AI certainly is helping in terms of promising a better future and improving equity, as we talked about in terms of both DR and DME.
You mentioned it. It’s at that point in the program that we’re looking ahead in terms of innovation. You mentioned gene therapy. Talk a little bit about the innovation that’s underway in both DR and DME and what you’re looking forward to.
Judy Kim, MD:
Yes. As for gene therapy, many companies are in this space and congratulating them. I want more companies to come in and help us come up with better treatment options. When we talk about gene therapy, we can talk about different viral vectors and as a result, how they work. Also, we worry about inflammation with some of these viral vectors. We’re looking at not only efficacy, but also side effects. Different gene therapy delivery method are different. Some are subretinal injections in the operating room. Some are intravitreal injections in the office. Some are looking at even suprachoroidal delivery in the office as well. It’s going to be really interesting to see not only which viral vector and dose gene therapy, but also what delivery modality would be helpful. Besides gene therapy with different anti-VEGF agents, including ranibizumab and aflibercept, we can also look at different modalities of action. For many, many years, we were looking at anti-VEGF, only anti-VEGF-A in specific, but now TKI, tyrosine kinase inhibitor…
Mario Nacinovich:
Very promising.
Judy Kim, MD:
Very promising. It’s a pan-VEGF inhibition and tighter affinity. That might be also helpful as well, as well as many different pathways, anti-inflammatory pathways as well. I think the future is really bright. A friend of mine who’s consulting many different companies, he says, “Retina is where we need to be.”
Mario Nacinovich:
Where it’s at. Yes. That’s where we are today.
Judy Kim, MD:
It’s lot of innovation coming on, and we need it because as I said, there’s an epidemic. The number of people with diabetes are going to continue. Now, on the other hand, the new twist is GLP-1 agonists. It can decrease diabetes severity. It can also decrease weight in some of our patients with diabetes.
Mario Nacinovich:
Dramatically. Yeah.
Judy Kim, MD:
As you know, BMI is a risk factor for worsening eye disease. If our patients take GLP-1 agonists and they lose weight and their A1c is better controlled, then is it going to reduce the incidence of diabetic retinopathy?
Mario Nacinovich:
Well, we will see. We’ll see.
Judy Kim, MD:
Yeah, it’s really interesting. I mean, although there are some ocular side effects of GLP-1 agonists, so it’s not for everyone, but it is an area that I’m really interested in seeing besides the ocular therapies that we just talked about as systemic therapies for diabetes come into the market, how is it going to affect the incidence and severity of diabetic eye disease?
Mario Nacinovich:
I’ll share with you a personal reflection as somebody who at one point, had an A1c of 10 and had it reduced to 5 on an A1c and has also lost over 100 pounds on Mounjaro. Always in the back of my mind was, this is hopefully going to help potential vision changes. Thankfully, being in ophthalmology as long as I had, I’ve always had my dilated eye exam, and I’m very thankful for my ophthalmologist who has ensured that there’s no retina changes. Thankfully, things are all going and looking very well for me.
Judy Kim, MD:
Congratulations.
Mario Nacinovich:
Thank you. Thank you. Thank you. Before we move to our closing topic, I wanted to gather a couple practical key takeaways in terms of clinical pearls for other practitioners in everyday practice. For both the comprehensive ophthalmologists and your colleagues in retina that may be listening today, any pearls that you’d like to highlight for optimizing outcomes for them, your prescription for them for treating patients with DR and DME and just routine practice?
Judy Kim, MD:
I like to communicate with other discipline primary care doctors, endocrinologists, diabetologists, and…
Mario Nacinovich:
The whole care team.
Judy Kim, MD:
Whole care team. Through educating them with conferences. American Diabetes Association, I’ve given a lot of lectures. Getting them involved as well. When I see patients with diabetic retinopathy or diabetic retinopathy screening even, I always send a letter so they know that their patients are getting screened. This dialogue between the teams are important, I think. Also, really stressing the adherence to therapy and adherence to screening for early detection to our patients. I also do education program of families of people with diabetes…
Mario Nacinovich:
They’re getting the right support.
Judy Kim, MD:
… so that they get the support system because it is possible that even the family members, they don’t know that they have diabetes, but they might. Or they might be the ones that taking the patients to the doctor’s office. In certain ethnic groups, racial ethnic groups, it’s women, or the wives, or sisters who are managing the healthcare of the family, especially their husbands or brothers. Men don’t want to go to a doctor, so they’re the ones who are taking these people…
Mario Nacinovich:
Dragging them along.
Judy Kim, MD:
Yeah, dragging them along. Getting even the family members involved. When I had a grant for teleophthalmology screening, we actually screened everyone, not just people with diabetes and…
Mario Nacinovich:
The whole family.
Judy Kim, MD:
Yes. Use that as an education session and say, “Hey, you go tell your relatives that they can come and get these screening done.”
Mario Nacinovich:
Wow.
Judy Kim, MD:
Raise awareness. And then…
Mario Nacinovich:
Real change is being brought forth in a whole community at that point.
Judy Kim, MD:
Yes. Then, working with industry to share the need, the gap. For the longest time, recently now, the longer durability has been the mantra and how can we make the treatments last longer? Then, obviously, do no harm. How can we make it safer? Then, we also worked on post-marketing surveillance of safety. These newer agents, once they come into the market, do they show any safety signal that we did not see in clinical trials?
Mario Nacinovich:
When it comes to those real-world populations, a little bit more diverse population.
Judy Kim, MD:
Exactly. Definitely research and education.
Mario Nacinovich:
I like that. As we close, as Dr. Kim mentioned, we are here at the Hawaiian Eye Meeting, and we are also on the verge of February being age-related macular degeneration, AMD Awareness Month. We know the American Academy of Ophthalmology is reminding people with AMD that they can often save their vision thanks to recent advances. The American Academy of Ophthalmology is reminding people with AMD that they can often save their vision thanks to recent treatment advances, but early detection and ongoing monitoring across all of retina diseases remain a crucial first step. But Dr. Kim, to help our listeners connect the dots, a lot of confusion among patients that had not been diagnosed with either of these diseases. How do you describe AMD? How do you describe diabetic retinopathy? How are they similar in terms of visual impact potentially on vision, but how do they really differ in terms of which retina layers, vascular beds are primarily affected?
Judy Kim, MD:
Diabetic retinopathy tends to affect younger-age people, whereas age-related macular degeneration, as the name implies, is age-dependent, so, 50, 55, or older. Age is the big differentiating factor. Then, whether one has diabetes or not, because many people with…
Mario Nacinovich:
Big difference.
Judy Kim, MD:
… AMD might not have diabetes, but if one is older and has diabetes, then that’s where they intersect. I also talk about the different layers. Diabetic retinopathy is more due to damaging of the blood vessels within the retina, whereas age macular degeneration is age-related disease below the retina. Then, obviously, showing OCT is very helpful to patients. The pathophysiology is totally different between the two.
Mario Nacinovich:
Correct.
Judy Kim, MD:
OCT findings are totally different between the two. With just imaging, we can diagnose the two. But for laypeople, I would say if you have any vision change, and also, try to check your vision 1 eye at a time. When we have both eyes open, I tell my patients, “Our brain is so smart, it averages everything out and you don’t know that one eye hasn’t gone bad.” Make a habit of covering one eye and checking one vision, and then covering the other eye and checking the other vision. If you have any vision loss or blurriness, missing spots, scotoma, or waviness, metamorphopsia, or new onset of lots of floaters, which could be vitreous hemorrhage from diabetes, or peripheral vision visual field defect, which can be from a traction or rhegmatogenous retinal detachment from diabetic retinopathy, all these things, just call an eye doctor right away.
Mario Nacinovich:
Suffice to say the relationship between AMD and DR is extremely complex. These are very different things. Perhaps surprisingly, even though we’re dealing with a very, very small portion of the eye in the retina, sometimes inverse. Certainly, several studies suggest that even patients with AMD may reduce the risk or severity of developing DR. That is discussions that I think for laypeople for perhaps primary care that’s not happening every day, but certainly for us that are working in retina, I think these potential for changes in retina metabolism, oxygen demand that alters susceptibility to these microvascular damage needs to be understood, needs to be interpreted appropriately, and we need to continue to guide clinicians on what they should and should not conclude at any stage.
Judy Kim, MD:
Yes.
Mario Nacinovich:
That’s critical.
Judy Kim, MD:
Yeah, studies have shown that also, patients with vision impacting diabetic retinopathy, diabetic macular edema, one is seen by a retina specialist who are the experts at diabetic retinopathy and age-[related] macular degeneration. Following treatment, their visual acuity outcome is a lot better. Seeing retina specialists with these conditions for treatment is also important, and timely referral and access to a retina specialist should be emphasized as well.
Mario Nacinovich:
That is the key message to everyone that’s listening, whether you are a retina specialist, whether you are a patient, a family member, a part of the primary care team treating patients with diabetes. During AMD Awareness Month, we need to really think about coordinated care for these people who may be at risk for both AMD and diabetic eye disease.
Dr. Kim, I want to thank you for sharing your expertise with me, your perspectives on the evolving landscape here in terms of diabetic retinopathy and diabetic macular edema. Thank you for helping us think about how to better integrate screening these advanced technologies and therapies, the long-term management to protect vision or the short-term management to protect vision if in fact these products work quickly, and we need to be aware of the individualized therapeutic options that are available for patients.
But for our audience, please remember, as Dr. Kim has suggested and as the American Academy of Ophthalmology has professed for the AMD Awareness Month, think about proactive retina screening, not just for you, but for your entire family. Think about the timely referral to a specialist, in this case, to a retina specialist, think about sustained treatment and how that can make a profound difference for people living with diabetes and for those at risk of AMD and other diabetic retina diseases. Please see our show notes here for key references, key resources. I welcome you to also join us next time on The Spotlight Series for another deep dive into emerging clinical challenges in ophthalmology. Dr. Kim, thank you for joining us.
Judy Kim, MD:
Thank you, Mario. It’s been a pleasure.
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