ATLANTA – Here at SECO 2010, presenter Clement Trempe, MD, urged
attendees at a PCON-sponsored course to determine the cause of the inflammation
in patients with diabetic retinopathy and then proceed with medical treatment.
“Diabetic retinopathy is not an eye disease, but part of a chronic
systemic inflammatory disease process that shares the same risk factors and
elevated biomarkers associated with coronary vascular and neurodegenerative
diseases such as age-related macular degeneration, glaucoma and
Alzheimer’s,” he told nearly 200 attendees.
“Prevention is best,” Dr. Trempe said. “Encourage a
healthy lifestyle, proper dental care, good nutrition, no smoking, weight
control, multiple vitamins and minerals (no iron; it creates more
inflammation), 2,000 U of vitamin D3, vitamin A, fish oil (one tablespoon of
cod liver oil will give you vitamins D3 and A and fish oil) and stop all eye
drops that cause inflammation.”
All patients with high-risk characteristics should be started on 100 mg
of minocycline twice daily. “It provides good antiangiogenic and
neuroprotective action,” he said. “Minocycline exerts multiple
inhibitory effects on VEGF-stimulated angiogenesis.”
Therapy should begin when intraretinal hemorrhages are seen, he said.
Dr. Trempe believes that current treatments for diabetic retinopathy such as
photocoagulation, vitrectomy and intraocular injections are “destructive
Instead, he supports medical therapy for patients with the condition.
“Prescribe diclofenac sodium 0.1% twice daily at first, then increase to
four times daily if no response,” he said. “Timolol 0.5% (a
beta-blocker) twice daily protects ischemic tissues. If high risk, prescribe
Cosopt (dorzolamide HCl, timolol maleate, Merck) and prednisolone acetate twice
daily and increase to four times daily if needed.
“Timolol, a nonselective beta-blocker, decreases the expression of
VEGF and bFGF genes through down-regulation of the Raf-mitogen-activated
protein kinase pathway in abnormal vessels,” Dr. Trempe continued.
“It triggers apoptosis of abnormal capillary endothelial cells. Long-term
use of beta-blockers decreases mortality in hypertensive patients by
stabilizing the vasa vasorum angiogenesis in atheromatous plaque.”
These patients should also have a medical work-up, Dr. Trempe said,
including ESR, C-reactive protein, complete blood count, homocysteine,
25-hydroxy vitamin D, 1,25-dihydroxy vitamin D, Chlamydia pneumoniae antibody
titer and toxoplasmosis antibody titer. Chronic infections such as ulcers, gum
disease, gastritis and urinary tract infections should be ruled out or treated.
All patients with retinopathy should also be placed on systemic
medications, Dr. Trempe said. “Start ACE inhibitors or angiotensin II
receptor blockers and magnesium chloride 150 mg daily. Stop diuretics in
patients with proliferative retinopathy.”
Primary Care Optometry News will be sponsoring another
2-credit continuing education course during Optometry’s Meeting in
Orlando. PCON Editorial Board members Ron Melton, OD, FAAO, and Randall Thomas,
OD, FAAO, will present “Clinical Grand Rounds” June 19 at the Gaylord
Palms. Go to www.PCONSuperSite/AOA.com for more information.