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Effect of Multifactorial Intervention on Diabetic Macular Edema

¹ Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
² Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Address correspondence to Amod Gupta, Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India. E-mail: eyepgi{at}sify.com

Clinical trials (1, 2) have shown that intensive control of blood glucose and hypertension reduce development of clinically significant macular edema (CSME). Elevated HbA_1c (A1C) is a risk for persistent CSME (3). Gross proteinuria is associated with a 95% increase in the incidence of macular edema (4). However, the effect of control of systemic factors before focal laser photocoagulation is not known. We aimed to determine whether multifactorial intervention over 4–6 weeks before focal laser photocoagulation would reduce macular thickness.

In a prospective nonrandomized pilot study, 14 consecutive patients (10 men and 4 women, aged 44–65 years) with type 2 diabetes presenting with nonproliferative diabetic retinopathy and CSME underwent multifactorial interventions including single or multiple modifications in oral hypoglycemic agents (n = 10), atorvastatin (n = 11), antihypertensive drugs (n = 12), and losartan (n = 4) to control A1C, fasting and postprandial blood glucose, systolic and diastolic blood pressure, lipid profile, and 24-h urinary proteins. Detailed ocular examination at recruitment and 6 weeks after interventions included fundus fluorescein angiography and measurement of macular thickness using stratus optical coherence tomography done between 12:00 P.M. and 3:00 P.M. Quantitative data are shown as means ± SD. Intergroup comparison was performed by unpaired t test.

At 6 weeks postintervention, we found a statistically significant decrease in mean A1C (8.3 to 7.62%, P < 0.01), LDL (125.14 to 99.5 mg/dl, P < 0.001), fasting blood glucose (142.07 to 117.5 mg %, P < 0.01), systolic blood pressure (141.43 to 126.43 mmHg, P < 0.002), and diastolic blood pressure (87.14 to 81.54 mmHg, P < 0.001). There was significant decrease in mean retinal thickness in both central 1 mm (244.20 ± 64.30 to 220.30 ± 59.68 µm, P < 0.001) and 6 mm (282.87 ± 51.09 to 261.65 ± 40.08 µm, P < 0.001) of the macula that resulted in a trend toward improvement in visual acuity (logarithm of minimal angle of resolution 0.53 ± 0.29 to 0.52 ± 0.27).

Decreasing macular edema on optical coherence tomography with multifactorial control before laser photocoagulation is encouraging in the management of CSME. Reducing macular thickness facilitates application of a low-energy laser beam. Previously, we found that atorvastatin 6 weeks before focal laser photocoagulation reduced subfoveal migration of lipids in patients with macular edema and dyslipidemia (5). We propose larger studies to determine the role of optimizing systemic factors before laser in CSME.

References

1. The UK Prospective Diabetes Study Group: Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 352:837–853, 1998[Medline]
   
2. The UK Prospective Diabetes Study Group: Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 317:703–713, 1998[Abstract/Free Full Text]
   
3. Do DV, Shah SM, Sung JU: Persistent diabetic macular edema is associated with elevated hemoglobin A1C. Am J Ophthalmol 139:620–623, 2005[Medline]
   
4. Klein R, Klein BEK, Moss SE, Cruickshanks KJ: The Wisconsin Epidemiological Study of Diabetic Retinopathy XVII: the 14-year incidence and progression of diabetic retinopathy and associated risk factors in type 1 diabetes. Ophthalmology 105:1801–1815, 1998[Medline]
   
5. Gupta A, Gupta V, Thapar S, Bhansali A: Lipid-lowering drug atorvastatin as an adjunct in the management of diabetic macular edema. Am J Ophthalmol 137:675–682, 2004[Medline]
   

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				R. Singh, V. Gupta, A. Gupta, N. Sachdev, M. R. Dogra, and A. Bhansali Multifactorial Interventions Before Laser Photocoagulation Improve Outcome of Diabetic Macular Edema Diabetes Care, December 1, 2006; 29(12): 2758 - 2759. [Full Text] [PDF]

This Article Extract Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Singh, R. Articles by Bhansali, A. Search for Related Content PubMed PubMed Citation Articles by Singh, R. Articles by Bhansali, A. Social Bookmarking                What's this?