Dana M. Deupree, MD, FACS, a vitreo-retina physician and surgeon at The Macula Center in Tampa, Florida, talks about new treatments for treating diabetes-related vision problems.
Interview conducted by Ivanhoe Broadcast News in February 2017.
Tell us a little bit about your background.
Dr. Deupree: I am a vitreo-retina specialist. I’ve been in Pinellas County and practicing full-time ophthalmology in the vitreo-retina specialty field since 1991. One of the principal things we do is take care of diabetic and macular degeneration patients. We also fix macular puckers, retinal detachments, we deal with trauma (sometimes through the emergency rooms) but our principal focus is diabetic retinopathy, and macular degeneration.
How does diabetes affect the eye?
Dr. Deupree: Diabetes affects the capillaries, the tiniest blood vessels in your body. They get affected by blood sugar that is consistently too high. Then, some of the smaller capillaries will close off and that creates damage to the tissue in that particular area in your body. It could be the kidneys or it could be the feet where patients can develop neuropathies. What doctors are trying to do is improve and increase good blood flow to whatever area of your body diabetes is affecting and, in my case, I’m focused on taking care of the retina and the back of the eye. What we see with diabetes is if those little closures occur, there’s damage to that area that causes certain proteins to be produced and other inflammatory things that we can now control with some of these drugs that we’re going to talk about. Basically, that damage can lead to swelling, bleeding, or new blood vessel development. Blood vessels can develop in the body’s effort to try to heal the damaged area. Unfortunately, these newly-formed vessels can bleed. Those hemorrhages in the eye are what can often dramatically reduce the vision for patients.
It can lead to loss of sight?
Dr. Deupree: Yeah, it often can be very subtle, and that’s a little bit of the problem. It can be a very silent disease where a person with diabetes may not really recognize that their vision is off. Maybe they have 20/20 vision in both eyes but they could have small leaks scattered throughout the retina and at some point that swelling is going to start causing them blurred vision. My challenge is really about trying to stay ahead of that whole process and not allowing it to get to the point where the eyes bleed out and vision is totally blocked. But if left untreated, diabetic retinopathy can blind you. With great care in the hands of our ophthalmologists, optometrists and the retina specialists, and with its early detection, we can stay ahead of it diabetic retinopathy damage and patients do very well if they’re looking after it.
Let’s get into some of the traditional treatments and some other more newer treatments.
Dr. Deupree: Okay. You commonly start with the more traditional laser treatment, which was invented in the 70s: lasering the retina. It was a little cruder process then. The lasers now are much more refined, they’re kind of in the “sub-threshold” category – meaning less burning to the tissue and better effectiveness. But eyes with diabetes, without laser, can go on to bleed and become blind. Through a lot of very well-constructed studies, we know a certain amount of lasering in the eye usually stabilizes things. Laser shuts the disease process down by getting more oxygen into the eye, decreasing some of these inflammatory proteins and just increasing the oxygen content to the retina in general. Then, with that “peripheral”, “scattered” laser in place, we need to laser less in the sensitive central vision area called the macula. Using fewer lasers in the macula means less scarring and less damage. Along with laser treatment we can reduce the edema which is blurring vision with some of these new pharmaceutical agents. Some of these drugs were developed and co-developed for cancer therapy because they block these proteins that cause inflammation and new blood vessels. They’re given by an injection in the eye, which sounds horrible, but patients need to understand that it can be done painlessly. We numb the eye up completely and the whole process takes just a couple minutes. This method delivers the drug directly on-site. We can get rid of the leakage and the bleeding with these injectables to help the swelling in the macula improves. Now, these are called anti-VEGF medications. VEGF is vascular endothelial growth factors. These drugs were custom-designed and brought to the market about twelve years ago at great expense, predominately for wet macular degeneration. But then they crossed over and became very helpful for diabetic macular edema cases — this is a very common problem. We may start with the traditional laser to get the patient stabilized but then the finish work is done more with these injectables. We have one medication that directly blocks the proteins and then we also have these newer implantable devices with the slow release of steroids. These devices use the more traditional steroids. The one called Ozurdex delivers the steroid for about three and a half months after it’s injected into the eye. We have to monitor pressure inside the eye throughout the treatment. We may also go with the newest injectable, which was recently approved, called Iluvien, which slowly releases a different steroid into the eye for three years.
It’s injected?
Dr. Deupree: Yes, it comes in its own injector that slowly releases the medication for about three years. It’s a very tiny implanted device, smaller than a grain of rice; it stays in your eye, delivers the drug and it helps stabilize these eyes. It gets the inflammation in the retina down. We still may have to do some other treatments now and then, but as a rule, it’s much less intervention when using these long-term injectables. You end up seeing the patients less frequently and the system starts saving money on the back-end because the patients are doing better. They are seeing better, they’re back to work and so we’ve really impacted their lifestyle to the point that I think the overall cost of these treatments actually gets mitigated by how well the patients are doing
That’s maybe your first line of defense to go to for implants?
Dr. Deupree: Well the first line probably is going to be a laser treatment. We usually kind of start with the laser, and then we consider the other medications. I think of them more like “finish work”. It’s kind of the stabilizer, a long-term stabilizer.
You’ve been doing this for a while. How would you say things have changed over the years as far of treating this?
Dr. Deupree: I’ve been doing this for twenty-five years and it was primarily laser and steroids back in the day. We had to get very courageous with the laser, sometimes getting very close to the central vision, trying not to create scarring in the central vision of the macula which could do harm. But other times it was the only way we had to stop those leaks. If we didn’t, the vision would just continue to deteriorate to the point of blindness in many cases. Sometimes we get very close to the central vision just trying to touch the edge of the vessel and “cauterize” it essentially. Now we’re able to back off with the laser and utilize these injectable drugs in a much safer way for the patient. I think we’re getting much better visual results. Surgery is also a component to treatment here. If the retinopathy is too advanced and there is scar tissue membranes from bleeding inside the eye, we have to go and peel off the membranes to help stop the bleeding. Then, usually laser, and finally come back to these drugs to stabilize and optimize the vision.
It’s too late to do injections with this kind of case?
Dr. Deupree: I can inject the drug before surgery and that helps stop the bleeding and it actually enhances my surgery because I don’t have to fight the bleeding while I’m working through removing the scar tissue. We’re better at our surgical process too with these medications. A little note on the drug companies they spend a half a billion dollars developing a drug and they come to market very expensive but they save peoples’ vision and saving peoples’ vision is very cost-effective to the overall healthcare costs. People that go blind, it’s a horrible thing. They also become much more dependent because there are a lot of things they can’t do any more. Other disability-types of services and things have to come in to play. They get depressed, there’s just so much impact on a person’s life when they lose their vision. We keep them seeing and active and participating. Like the young lady that we’re going to work on today. She is thirty years old and she’s starting a new job on Monday. But she’s got to be able to see to do that job. I think for her, for the rest of her life, we can keep her vision stable but it takes some pretty aggressive intervention. The best thing is the prevention; regular eye exams (at a very minimum once a year) for any diabetic, because they could show diabetic signs at their first diagnosis or they could go twenty years without them. But you can’t predict that. You need to be checked once a year. This is the safest and best way to keep your vision stable.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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