Patient with severe proliferative diabetic retinopathy and comorbidity: analysis of solved and unsolved problems in diabetic retinal involvement diagnosis and treatment from the point of real-world clinical practice and clinical guidelines

BACKGROUND: Diabetic retinal involvements as proliferative diabetic retinopathy (PDR) and diabetic macular edema (DME), revealed in most cases of PDR, are main causes of best corrected visual acuity (BCVA) loss in diabetic patients. PDR represents late diabetes mellitus (DM) complication, in severe cases it requires vitreoretinal surgery (VRS). Given high risk of vision loss and comorbidity of PDR patients, optimal choice of ophthalmological treatment strategy is still actual.

AIM: to compare clinical guides’ recommendations accomplishment and real clinical practice, analyze main retinal diabetic involvement diagnosis and management problems, on diabetic patients, presented to Endocrinology Research Center of the Ministry of Health of the Russian Federation for VRS.

MATERIALS AND METHODS: Study subjects: data of medical records and endocards (Endocrinology Research Center diabetic patients clinical statistical registration cards) of 252 patients (260 eyes) with type 1 (n=168) and type 2 (n=84) DM, undergoing VRS from 2019 to 2023. We analyzed reasons for PDR deterioration, VRS results, frequencies of cardiovascular (CV) and diabetic complications, that heighten risks of cardiovascular events (CVE), such as atherosclerotic diseases, ischemic heart disease (IHD), chronic heart failure (CHF), cerebrovascular accident (CVA), chronic kidney disease (CKD), and diabetic foot syndrome (DFS). Inclusion criterion was presence of PDR complication, requiring VRS, irrespective of its severity. Standard ophthalmological investigation, ultrasound B-scan of the eyes, retinal optical coherent tomography (OCT), and fundus photography were carried out. BCVA evaluation was made before VRS and one month after the procedure. Proliferative process stabilization was checked up in one month to five years.

RESULTS: Median age of patients with T1DM/T2DM was 39/63 years, DM duration before VRS was 19/17 years, females constituted 63%/57% of patients, respectively. In 258 eyes of 260 (99,2%) retinal photocoagulation (PC) before VRS procedure was not accomplished or was not performed at all. In all patients one month after procedure BCVA grew higher, but it strictly depended on baseline BCVA, which was determined by PDR complication severity. Before/after VRS in 76 eyes (29%) it constituted between light perception with projection and 0,05/0,01–0,08; in 68 eyes (26%) — 0,06–0,1/0,08–0,3; in 62 eyes (24%) — 0,2–0,3/0,3–0,5; in 54 eyes (21%) — 0,4–0,8/0,5–1,0 in decimals, respectively. Concurrent conditions frequencies among DM1/DM2 patients were for atherosclerosis — 47%/67%, for IHD — 9%/32%, for CVA — 4%/9%, for CHF — 5%/30%, for CKD — 71%/63% (including CKD stage C5 24,7%/13,6%), for DFS — 29%/17%, for amputations — 13%/17% of cases, respectively.

CONCLUSION: In the studied cohort of patients with severe PDR, frequent concurrent conditions and high CVE risks in 99,2% of cases retinal PC extent was improper, that lead to complications and need for VRS. In patients with PDR and comorbidities panretinal PC should be carried out without delay, as it is required by clinical guidelines. To avoid severe visual loss panretinal PC must be the treatment of high priority.

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