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Paradigm shift in understanding

EURETINA Lecture looks at 50 years of change in understanding of diabetic retinopathy

Dermot McGrath

Posted: Friday, September 6, 2019

Francesco Bandello delivering the EURETINA Lecture 2019

The past 50 years have seen a profound transformation in the understanding of the complex pathophysiology of diabetic retinopathy (DR), with the evolution of new treatment strategies that move beyond purely metabolic control to try to mitigate the sight-threatening ocular complications of the disease, according to Professor Francesco Bandello MD, FEBO, who delivered this year’s EURETINA Lecture as part of the official opening ceremony at the 19th EURETINA Congress.

“We have witnessed a paradigm shift in the interpretation of diabetic retinopathy in the last 50 years from a disease of pure microangiopathy to one of neurovascular coupling dysfunction in which all the microvascular districts such as the iris, optic nerve and macula are involved,” said Prof Bandello, Full Professor and Chairman at the Department of Ophthalmology, University Vita-Salute, Scientific Institute San Raffaele, in Milan, Italy.

In a broad overview of current knowledge pertaining to DR, Prof Bandello said that the integration of standard investigations with new diagnostic techniques will allow prompt recognition and personalised treatment of both retinopathy and maculopathy in the near future.

“In the future, integration of standard investigations with new diagnostic techniques will allow the prompt recognition of the DR even before clinical signs of the disease are ophthalmoscopically evident, and the development of personalised treatment for both retinopathy and DME on the basis of the disease features,” he said.

The early history of DR research was hampered to a significant degree by the celebrated ophthalmologist Albrecht von Graefe’s claim in 1856 that there was no proof of a causal relationship between diabetes and retinal complications, noted Prof Bandello.

“As long as ophthalmoscopy was the only tool available to investigate the retina in diabetic patients, DR was considered a pure microvascular disease, due to the evident capillary structural changes, fluid extravasation and lipid exudation,” he said.

With the advent of fundus fluorescein angiography (FFA), the concept of ischaemia and the correlation between peripheral non-perfusion and neovascularisation was introduced, which was eventually followed by the advent of new therapeutic strategies such as peripheral photocoagulation.

An intimate connection between DR severity and diabetes-related iris stromal changes was then elucidated, and a new disease entity secondary to the radial peripapillary capillary plexus involvement, called diabetic papillopathy, was described.

Nowadays, more advanced imaging techniques such as optical coherence tomography (OCT), OCT angiography and wide-field imaging have shown how other elements participate in the occurrence of DR and diabetic macular oedema (DME), including inflammation and neurodegenerative processes, he concluded.

A full report of Prof Bandello’s lecture will appear in a future edition of EuroTimes