✅ Medically reviewed by Dr Sharon Heng
Ms Sharon Heng has a deep interest in personalised medical treatment and in particular believes in and utilises appropriate imaging biomarkers to determine treatment prognosis, responses and as guidance to choosing appropriate first line therapy for patients with diabetic macular oedema.
She sits on the biomarker steering committee for AbbVie – the medical arm of the pharmaceutical company which manufactures ozurdex implant. Together with the rest of the committee, they have advised and given input to produce a clinical handbook for healthcare professionals as a guidance to the use of biomarkers in the management of DMO.
What is Personalised Medical Treatment?
Personalised medicine which is otherwise also known as precision medicine, is the individualising medical decisions and interventions suited to a particular individual- or customising treatment plans for the individual.
With personalised or precision medical treatment, we hope to be able to choose a treatment that is most suited for the patient, with the least side effect with likely best possible outcome. This would be based on an individual’s unique situation including clinical, medical and social.
Everyone is unique with different genetic make up and this may impact on how they manifest certain diseases, response to certain diseases, the severity of disease and response to treatment. For example, patients with genetic predisposition to age related macular degeneration such as ARMS 2 or CFH gene may have earlier onset of advanced stages of age related macular degeneration and may need closer monitoring.
When one has been diagnosed with an illness, the decision on treatment you’re offered will usually be based on average results from larger population from clinical studies, however, patients may respond differently at an individual level and that is where understanding the patient profile, make up, clinical profile, the drug side effects and potential outcomes is important in determining the best treatment for that particular individual.Further, personalised treatment is also about improving diagnosis and predicting the likelihood of someone developing a condition, and stopping a condition from getting worse just as in the earlier example of AMD.
What is DMO?
Diabetic eye disease encompasses several conditions that can affect the eyes of people with diabetes, including diabetic retinopathy, diabetic macular oedema (DMO), and cataracts. The most common is diabetic retinopathy, which occurs when high blood sugar levels cause damage to the tiny blood vessels in the retina.
DMO is a complex, multifactorial disease which may result in visual loss. In cases of high sugar or hyperglycaemia can result in the breakdown of the blood–retinal barrier (BRB), promoting oxidative stress and the release of inflammatory which leads to increased retinal vascular permeability. As a result, there is accumulation of intra- and subretinal fluid (IRF/SRF) fluid in the macular and visual impairment.
What are Biomarkers?
Biomarkers are traits that doctors measure in your blood, tissues, and clinical imaging. There are several categories of biomarkers, examples include:
Histological, e.g., BRCA1/2
Radiographic, e.g., radiographic evidence of tumor shrinkage
Physiological, e.g., blood pressure and hba1c
Biomarkers can be used for predicting and monitoring response to treatment.
How Do Biomarkers Help in the Management of DMO?
Physiological biomarkers such as hypertension, hypercholesterolemia, and blood sugar tests are important associated factors to optimise diabetic retinopathy control. Numerous studies over the decade have found the association of better sugar and blood pressure control in maintaining diabetic retinopathy status.
Up to 30% of patients with optimal sugar control may show improvements in their diabetic macular oedema. With the advancement in imaging and plethora of imaging modalities, there is an increase in interest in looking at imaging biomarkers and if certain signs may predict or prognosticate disease outcome, or response to treatment.
For example using certain findings on OCT scans, we can determine how severe or chronic the DMO may be and if treatment may improve vision and we may then base on the findings, advise patients on expectations accordingly.
Examples of Imaging Biomarkers?
This article is not exhaustive on all the biomarkers we review on a clinical basis. As examples, commonly known biomarkers include the following:
Intraretina cysts
In DMO, IRCs form secondary to fluid accumulation within the retina and are seen on OCT imaging. These cystoid spaces are characterised by their specific location within the retinal layers, as well as their reflectivity and size. For example, large cystoid spaces with minimal remaining retinal tissue are typically associated with chronicity.
Hyper-Reflective Foci
Hyper-reflective foci are small, dot-shaped, hyperreflective lesions visible on OCT images of the retina. In DMO, these are thought to represent lipid-laden macrophages or microglial cells which may indicate inflammation.
What Treatments are Available for DMO?
Laser Treatment (Laser Photocoagulation)
One of the most common treatments for diabetic eye disease is laser photocoagulation. This procedure uses a laser to target and seal off leaking blood vessels in the retina, which helps to prevent further damage and stabilizes vision.
Laser is used as a treatment for proliferative diabetic retinopathy and diabetic macular oedema. The procedure is typically done in an outpatient setting and has minimal side effects.
Anti-VEGF Injections - The Cornerstone of DMO Treatment
Anti-VEGF (vascular endothelial growth factor) injections are used primarily to treat diabetic macular oedema (DMO), a condition where fluid leaks into the retina, causing it to swell and impair vision.
Anti-VEGF therapy works by blocking the VEGF protein, which stimulates the growth of abnormal blood vessels in the retina.
These injections can significantly reduce the swelling in the retina, leading to improved vision. The injections are typically administered in a series, with the frequency of treatment depending on the patient’s condition.
Steroid Injections and Implants
In some cases, corticosteroids may be injected into the eye to reduce inflammation and control diabetic macular oedema. These injections help reduce swelling in the retina and can improve vision in certain patients. In addition, steroid implants, which slowly release medication over time, may also be used to manage DME.
Managing Diabetic Eye Disease Through Lifestyle Changes
While diabetic eye disease treatment focuses on medical interventions, managing blood sugar levels is equally important in preventing further eye damage. High blood sugar levels contribute to the deterioration of blood vessels in the retina, so maintaining a healthy glucose level can slow the progression of the disease.
Managing blood pressure, cholesterol levels, and quitting smoking can also help reduce the risk of diabetic eye disease. A balanced diet, regular exercise, and adherence to diabetes medications are key factors in maintaining overall health and preventing complications.
Ms Heng is an expert in diabetic retinopathy management, including screening, lasers, cataract surgery and antivegf therapy. She believes in providing a personalised treatment plan in accordance to the patient's individual medical profile, disease profile and needs.
Moorfields Private provides services such as an all-inclusive diabetic retinopathy screening package including advanced multimodal imaging and consultation.
Contact us now for further information
Email: Moorfields.sheng@nhs.net
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