Defining Best Practice Standards for the Diagnosis and Management of Diabetic Retinopathy and Diabetic Macular Edema in Latin America

• Main Authors: Patricio Schlottmann, Claudia Acosta, Arturo Alezzandrini, Joaquin Bafalluy, Laurentino Biccas, Rene H Cano, Francisco Max D'Amico, Gabriel Dib, Jans Fromow-Guerra, Rodrigo Jorge, Daniel Lavinski, Virgilio Morales-Canto, Jose A Roca, Michel Eid Farah
• Format: Article
• Language: English
• Published: Pan-American Association of Ophthalmology 2014-10-01
• Series: Vision Pan-America
• Subjects: diabetic retinopathy; diabetic macular edema
• Online Access: http://journals.sfu.ca/paao/index.php/journal/article/view/217
• ISSN: 2219-4665; 2219-4673

Purpose: To provide evidence-based recommendations and guidance for the management of diabetic retinopathy (DR) and diabetic macular edema (DME) based on recently published clinical evidence and clinical experience. Methods: A literature search using PubMed and the Cochrane Library was performed with the terms “diabetic macular edema” or “diabetic retinopathy” to identify studies published from January 2008 to November 2013. This was followed by a manual search of references cited in selected papers published in peer-reviewed journals. The references identified in these literature searches were reviewed and presented by members of the Latin America DME expert panel to the entire group during the 2-day consensus meeting. During this meeting,the experts formulated recommendations with consideration of the health benefits, risks, and adverse effects of interventions. References used to support recommendations were assigned a level of evidence based on the Strength of Recommendation Taxonomy (SORT) evidence rating system. Results: Thirty-one consensus recommendations were formulated. These include the recommendation for early glycemic control in diabetic patients in order to reduce the risk of progression of ocular disease. The expert panel also recommended the collection of epidemiological data to further define the prevalence of DR and DME in Latin America and to establish management and treatment algorithms for various stages of the disease. The need for early screening and development of infrastructure to ensure appropriate followup and treatment of those in need is further emphasized. Both fluorescein angiography (FA) and optical coherence tomography (OCT) are needed for proper assessment of disease progression and response to therapy. Based on available high-level evidence, we recommend ranibizumab as the gold standard for the treatment of DME and panretinal photocoagulation (PRP) as the gold standard for proliferative DR. Vitrectomy should be considered in the presence of macular traction or if edema is not responding to pharmacological therapy. As intravitreal steroids provide a reduction in edema, they can be used to ameliorate the effects of other therapies as well as in pseudophakic eyes. Finally, when selecting a therapy for DR and/or DME, it is of particular importance to consider the general health status of a patient. Conclusion: Although these guidelines are not intended to be a replacement for clinical judgment, they should help to streamline the management of DME across Latin America and ensure that patients receive the best available care in a timely manner.