Decreasing the Risk of Diabetic Retinopathy in a Type 2 Diabetes Study: Part 4

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Case management may also have played a role in attendance at sessions when the photographs were taken and the immediate feedback that nonmydriatic photography can give to the health care team and thus facilitate the follow-up of patients with documented retinopathy. Whether it is the support associated with case management and the resultant adherence to nonglycemic targets such as hypertension that led to the improved retinal status, independent of improved glycemic control, cannot be addressed by this study. However, perhaps because case management clearly improves glucose control in a Medi-Cal–type population and is associated with decreased risk of new-onset retinopathy, comprehensive case management may be justified in similar health care settings.

Limitations of this study include the fact that it was not of sufficient duration to address whether case management may have also prevented progression of previously recognized retinopathy, which may have required more time or larger numbers to see an effect. Another limitation is the fact that we only used a single field for evaluation of the retina rather than the seven fields used in other studies of retinopathy, although in previous reports, this technique for diabetic retinopathy screening has been shown to be effective. In this way, minimal retinopathy may have been missed in the periphery at baseline and at the follow-up study. However, since both baseline and follow-up retinal fields were identical, it is most likely that our findings reflect a clinically meaningful decrease in the development of retinopathy over the 2-year time span that was tested. Furthermore, seven-field photography was not practical in this case management setting. Although all participants were urged to visit an ophthalmologist, those subjects with evidence of any retinopathy on the photograph were personally followed by the case management team to facilitate the consultation.

Although other studies show that improved glycemic control decreases the risk of retinopathy, this study is the first to show that even a relatively short duration of improved control (?2 years) instituted before the onset of clinically identifiable retinopathy can decrease the risk of developing new retinopathy. This study also underscores the risk of retinal disease in type 2 diabetes in that progression of retinopathy occurred within a relatively short time when glycemic control was not achieved. Further studies are necessary to determine whether early intervention to achieve glycemic control in established diabetes has a greater effect to reduce diabetic retinopathy than its introduction at a later stage of the disease.