ASRS’s Journal of Vitreoretinal Diseases (JVRD) Author’s Forum

Predictors of Vision Loss After Lapse in Antivascular Endothelial Growth Factor Treatment in Patients With Diabetic Macular Edema

• American Society of Retina Specialists (ASRS)

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On this episode of the JVRD Author’s Forum podcast, Dr. Katherine E. Talcott of the Cole Eye Institute at the Cleveland Clinic discusses ‘Predictors of Vision Loss After Lapse in Antivascular Endothelial Growth Factor Treatment in Patients With Diabetic Macular Edema,’ published in the March/April 2025 issue of JVRD.

Host Dr. Timothy Murray and Dr. Talcott discuss the clinical implications of treatment lapses in patients with diabetic macular edema and the importance of identifying individuals at higher risk for vision loss. Dr. Talcott highlights key predictors of vision loss, such as longer lapses, diabetic foot disease, and Medicaid insurance, and discusses how these insights can guide personalized care, improve patient counseling, and support proactive interventions to preserve vision in this vulnerable population.

For more information, visit www.ASRS.org/JVRDForum.

Welcome to ASRS’s Journal of Vitreoretinal Diseases (JVRD) Author’s Forum. JVRD is the official scientific peer-reviewed journal of the American Society of Retina Specialists (ASRS), offering the highest quality and most impactful research and clinical information in the field. Join host Dr. Timothy Murray, Editor-in-Chief for JVRD, as he discusses cutting-edge developments featured in JVRD with the lead authors who share clinical pearls and explore their significance for advancing patient care.

SPEAKER_00:

Welcome to ASRS's Journal of Veterinal Diseases Authors Forum. I'm your host, Dr. Timothy Murray, editor-in-chief of JVRD. On each episode of the JVRD Authors Forum, I will interview innovative retinal researchers on their studies featured only in JVRD and how these studies will impact our patients' care in our clinics. Tune in to hear directly from investigators about the clinical implications of the newest and highest quality research in the field of retina. It's my pleasure to be joined by Dr. Catherine Talcott from the Cole Eye Institute at the Cleveland Clinic. We're going to discuss your manuscript, Predictors of Vision Loss After Lapses in Antivascular Endothelial Growth Factor Treatment in Patients with Diabetic Macular Edema. I loved your manuscript because I think this is one of those clinical issues that drives the clinician crazy. And I would like you to take us through how you developed the approach for the manuscript and then how you were able to look at your data.

SPEAKER_01:

Yeah, thank you so much for the kind words and thanks so much for including our manuscript in your journal. As a retina specialist, I think one of the most challenging patient populations that we take care of is our diabetic patients. As we know, they face a lot of challenges with regard to being able to attend our retina clinic appointments. They tend to be younger patients, have a lot of other medical problems. They have to hold jobs, take care of other people, and they're sick individuals as well. Fortunately, we know based on the literature that a lot of our diabetic patients, if they have diabetic macular edema, if they have a lapse in treatment where we want them to come back and they don't come back, they actually do okay. But there's a number of those patients who don't do well. And if they sort of have a lapse of treatment, their vision actually drops. So we wanted to explore that a little bit more. So we looked at our patients at the Cleveland Clinic E. coli Institute who had diabetic macular edema and had gotten at least one injection. And then we looked at those individuals who actually had a lapse of treatment. So they had sort of a lapse of three months. And that was more than what was intended by their treating retina specialists. And we separated out those patients who had a vision decline. And so we put that out that they had to lose at least 10 letters of vision compared to those who didn't lose any vision. And then we look back at their sort of baseline characteristics to be able to sort of see like what were the predictors there. And the predictors were actually, I think, pretty interesting that we found. So we found that if you, probably not surprisingly, if you had a longer lapse in treatment, you were more likely to have a visual loss. but also if you had diabetic foot disease. And if you had Medicaid insurance, then you were more likely to have vision loss. A protective factor that we found was actually the length of time since you had been diagnosed with diabetes. So, you know, obviously, you know, our study is limited by the numbers that we had available at our sort of medical center. But I think it sort of highlights some of the things to sort of think about when you're taking care of patients with diabetic macular edema. You know, I think the larger picture is, If we can better be able to isolate which patients are at risk for having vision loss, if there's a lapse of treatment, then maybe we could think about sort of resources in terms of sort of more counseling for those patients, you know, or if there was someone in your clinic who could call to check in on patients if they miss an appointment, then those are sort of the clinical things that I think is important to sort of tease out in this work in general and in this field.

SPEAKER_00:

So I think that we all thought this made sense. And for me, this really came into clear perspective with the COVID pandemic where in many cases, patients were unable to come to us, even if they wanted to. And we've seen from your institution and others that there was vision loss in these patients, and some of that vision loss was permanent. So, I mean, I like to always think every patient will come back every time, but the longer that I practice, the more I realize that that is, you know, that's a hopeful wish. And we try to convey that to our patients, but many patients have really good reasons that they can't get to our office. They were admitted to the hospital. They had no transportation. They had a family member. So I do think it's important to think of what can be better predictors. So how do you use that, Dr. Talcott, day to day? Do you look at your patients with these issues and more aggressively counsel them? How do you actually manage?

SPEAKER_01:

Yeah, I think it's hard to do, right? And then we're all busy retina specialists, right? So in the context of like a busy clinic, you know, how do you slow down, try and figure out the patients who are at risk and then try and make a difference there? Some of the things that I find really helpful, especially for my diabetic patients, is to really sort of orient to sort of the imaging and to slow down and spend some time. For this case, obviously, in the case of diabetic macular edema, it's important to sort of show them why the scans look the way they do and why that correlates with their vision. But especially in the cases of patients who have prolificative diabetic retinopathy, if you are able to get wide field imaging, I think that can be really powerful. Also, if our patients come in with other family members or other support people, I think it's really important to engage them as well, since they're going to be incredibly important in that patient's journey, being able to make it to clinic in case something happens. So those are the sort of things I try and do. And then if some of these patients miss an appointment, they message us trying to get back in Like our staff tries to be very conscientious of trying to get them back in and not have them wait even longer.

SPEAKER_00:

Yeah, I think that's important to understand the importance of your staff, right? Because routinely patients will call and will be counseled that there's a delay in their appointment time. But we have discussions that if you've had an emergency and missed an appointment, we have a category to move you rapidly into the clinic so we don't compromise further the vision going forward. You know, the other thing where I think this becomes important is, you know, we're looking now at drugs that potentially have longer duration for our patients. So maybe those more expensive drugs have a greater utility in patients that we're concerned may be lost to a follow-up. Do you have any thoughts about that? Does that influence your decision in treatment?

SPEAKER_01:

Yeah, I think that's a really great point. You know, we often think about sort of newer generations of medicines as being very helpful from a drying perspective, but I think the durability piece means a lot too, especially for patient populations where, you know, they're more of us for having sort of a loss to follow up. We looked at in our study, actually, if medication type made a difference in terms of predictors, and we did not find that to make a difference. But again, like our sample sizes are sample size. But intuitively, I think it makes sense that if we're able to for these patients who are thinking are more of us for having sort of a loss to follow up. If you can get them on a more durable treatment, then even if there is a delay in care, that they're more covered. The challenging piece is, you know, as we both know, is that, you know, insurance approval for some of these longer acting medications is difficult and step therapy is becoming more like rampant. So it can be harder in some cases to be able to access those medications. Like, for instance, like I'm at an academic center and we're not allowed to give any samples to any patients. So, you know, we really have to sort of follow the book. And it often means starting with Bevacizumab and then sort of switching over. And if these patients do have a delay in care, then sometimes their authorization will expire or they come back and they're on different insurance. But I agree that having tools in our toolbox that are allowing patients to be able to get treatment that works for longer would be able to provide sort of a safety net for these patients in case there's a lapse in care.

SPEAKER_00:

And then I know that you do also what we do. You spend time talking to the patients about their general health care management, the importance of their blood sugar and blood pressure, along with their return to the clinic. And you've suggested that one of those markers may be a variable for socioeconomic class, which also independently predicts for potentials for loss to follow up or vision loss independently. So do you have any other strategies? It sounds like you're spending time with your patients. You're taking them through education about their disease. You're offering alternatives to get them in if they've been lost to follow up. But it still makes my heart break a little bit when I see somebody lose vision that I can't recover because we didn't get them back for a treatment that we know that works.

SPEAKER_01:

Yeah, I think that's a really good point. And sometimes, I don't know if you experienced this, but my patients with diabetes, sometimes we're the people as retina specialists who see them the most frequently, and they'll often come to us and be like, I really need an endocrinologist. Can you get me an endocrinologist? you know, it can be really challenging. We're so used to existing in our own bubble of just ophthalmology. But, you know, I think one of the fortunate things of where I practice is being at a large medical center. If someone has like being an endocrinologist or someone before, I can at least message them through our system pretty easily. But these are the sort of situations where you would really love to be able to have a social worker to be able to get involved and to be able to help you. We actually as a department just, we just hired or engaged with a social worker, but her focus is really mainly on sort of people who have legal blindness, giving them the resources that they need. It just really highlights that the care of these patients is complex, you know, and How we practice in the real world is so different than what we see in clinical trials where someone has a research coordinator to call them and make sure they're doing okay and can help facilitate care. It almost makes you wish that we had that for sort of all of our patients. I think moving forward, it would be great to have more resources. You know, we like, you know, all of us try to do what we can for these patients, but it's challenging for sure. And I always feel bad for these patients about all the demands on them from a healthcare perspective and also just a social perspective.

SPEAKER_00:

Thank you for speaking with us. We're going to direct our listeners to your manuscript, Predictors of Vision Loss After Lapse in Antivascular Endothelial Growth Factor Treatment in Patients with Diabetic Macular Edema. Thanks for joining us.

SPEAKER_01:

Thank you so much for having me.

SPEAKER_00:

Thanks for tuning in to the JVRD Authors Forum. You can watch and listen to more episodes on the ASRS YouTube channel and on popular podcast directories, including Apple Podcasts and Spotify. Visit www.asrs.org forward slash JVRD forum on the ASRS website to learn more. See you soon.