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

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.

Episode Transcript

SPEAKER_00 (00:00):
Welcome to ASRS's Journal of Veterinal Diseases
Authors Forum.
I'm your host, Dr.
Timothy Murray, editor-in-chiefof JVRD.
On each episode of the JVRDAuthors Forum, I will interview
innovative retinal researcherson their studies featured only

(00:22):
in JVRD and how these studieswill impact our patients' care
in our clinics.
Tune in to hear directly frominvestigators about the clinical
implications of the newest andhighest quality research in the
field of retina.
It's my pleasure to be joined byDr.
Catherine Talcott from the ColeEye Institute at the Cleveland

(00:45):
Clinic.
We're going to discuss yourmanuscript, Predictors of Vision
Loss After Lapses inAntivascular Endothelial Growth
Factor Treatment in Patientswith Diabetic Macular Edema.
I loved your manuscript becauseI think this is one of those
clinical issues that drives theclinician crazy.
And I would like you to take usthrough how you developed the

(01:09):
approach for the manuscript andthen how you were able to look
at your data.

SPEAKER_01 (01:13):
Yeah, thank you so much for the kind words and
thanks so much for including ourmanuscript in your journal.
As a retina specialist, I thinkone of the most challenging
patient populations that we takecare of is our diabetic
patients.
As we know, they face a lot ofchallenges with regard to being
able to attend our retina clinicappointments.
They tend to be youngerpatients, have a lot of other

(01:34):
medical problems.
They have to hold jobs, takecare of other people, and
they're sick individuals aswell.
Fortunately, we know based onthe literature that a lot of our
diabetic patients, if they havediabetic macular edema, if they
have a lapse in treatment wherewe want them to come back and
they don't come back, theyactually do okay.
But there's a number of thosepatients who don't do well.

(01:54):
And if they sort of have a lapseof treatment, their vision
actually drops.
So we wanted to explore that alittle bit more.
So we looked at our patients atthe Cleveland Clinic E.
coli Institute who had diabeticmacular edema and had gotten at
least one injection.
And then we looked at thoseindividuals who actually had a
lapse of treatment.
So they had sort of a lapse ofthree months.
And that was more than what wasintended by their treating

(02:17):
retina specialists.
And we separated out thosepatients who had a vision
decline.
And so we put that out that theyhad to lose at least 10 letters
of vision compared to those whodidn't lose any vision.
And then we look back at theirsort of baseline characteristics
to be able to sort of see likewhat were the predictors there.
And the predictors wereactually, I think, pretty
interesting that we found.

(02:38):
So we found that if you,probably not surprisingly, if
you had a longer lapse intreatment, you were more likely
to have a visual loss.
but also if you had diabeticfoot disease.
And if you had Medicaidinsurance, then you were more
likely to have vision loss.
A protective factor that wefound was actually the length of
time since you had beendiagnosed with diabetes.
So, you know, obviously, youknow, our study is limited by

(03:01):
the numbers that we hadavailable at our sort of medical
center.
But I think it sort ofhighlights some of the things to
sort of think about when you'retaking care of patients with
diabetic macular edema.
You know, I think the largerpicture is, If we can better be
able to isolate which patientsare at risk for having vision
loss, if there's a lapse oftreatment, then maybe we could

(03:22):
think about sort of resources interms of sort of more counseling
for those patients, you know, orif there was someone in your
clinic who could call to checkin on patients if they miss an
appointment, then those are sortof the clinical things that I
think is important to sort oftease out in this work in
general and in this field.

SPEAKER_00 (03:39):
So I think that we all thought this made sense.
And for me, this really cameinto clear perspective with the
COVID pandemic where in manycases, patients were unable to
come to us, even if they wantedto.
And we've seen from yourinstitution and others that
there was vision loss in thesepatients, and some of that

(03:59):
vision loss was permanent.
So, I mean, I like to alwaysthink every patient will come
back every time, but the longerthat I practice, the more I
realize that that is, you know,that's a hopeful wish.
And we try to convey that to ourpatients, but many patients have
really good reasons that theycan't get to our office.

(04:21):
They were admitted to thehospital.
They had no transportation.
They had a family member.
So I do think it's important tothink of what can be better
predictors.
So how do you use that, Dr.
Talcott, day to day?
Do you look at your patientswith these issues and more
aggressively counsel them?
How do you actually manage?

SPEAKER_01 (04:40):
Yeah, I think it's hard to do, right?
And then we're all busy retinaspecialists, right?
So in the context of like a busyclinic, you know, how do you
slow down, try and figure outthe patients who are at risk and
then try and make a differencethere?
Some of the things that I findreally helpful, especially for
my diabetic patients, is toreally sort of orient to sort of
the imaging and to slow down andspend some time.

(05:01):
For this case, obviously, in thecase of diabetic macular edema,
it's important to sort of showthem why the scans look the way
they do and why that correlateswith their vision.
But especially in the cases ofpatients who have prolificative
diabetic retinopathy, if you areable to get wide field imaging,
I think that can be reallypowerful.
Also, if our patients come inwith other family members or

(05:23):
other support people, I thinkit's really important to engage
them as well, since they'regoing to be incredibly important
in that patient's journey, beingable to make it to clinic in
case something happens.
So those are the sort of thingsI try and do.
And then if some of thesepatients miss an appointment,
they message us trying to getback in Like our staff tries to
be very conscientious of tryingto get them back in and not have

(05:44):
them wait even longer.

SPEAKER_00 (05:45):
Yeah, I think that's important to understand the
importance of your staff, right?
Because routinely patients willcall and will be counseled that
there's a delay in theirappointment time.
But we have discussions that ifyou've had an emergency and
missed an appointment, we have acategory to move you rapidly
into the clinic so we don'tcompromise further the vision

(06:06):
going forward.
You know, the other thing whereI think this becomes important
is, you know, we're looking nowat drugs that potentially have
longer duration for ourpatients.
So maybe those more expensivedrugs have a greater utility in
patients that we're concernedmay be lost to a follow-up.
Do you have any thoughts aboutthat?
Does that influence yourdecision in treatment?

SPEAKER_01 (06:28):
Yeah, I think that's a really great point.
You know, we often think aboutsort of newer generations of
medicines as being very helpfulfrom a drying perspective, but I
think the durability piece meansa lot too, especially for
patient populations where, youknow, they're more of us for
having sort of a loss to followup.
We looked at in our study,actually, if medication type
made a difference in terms ofpredictors, and we did not find

(06:50):
that to make a difference.
But again, like our sample sizesare sample size.
But intuitively, I think itmakes sense that if we're able
to for these patients who arethinking are more of us for
having sort of a loss to followup.
If you can get them on a moredurable treatment, then even if
there is a delay in care, thatthey're more covered.
The challenging piece is, youknow, as we both know, is that,

(07:13):
you know, insurance approval forsome of these longer acting
medications is difficult andstep therapy is becoming more
like rampant.
So it can be harder in somecases to be able to access those
medications.
Like, for instance, like I'm atan academic center and we're not
allowed to give any samples toany patients.
So, you know, we really have tosort of follow the book.

(07:35):
And it often means starting withBevacizumab and then sort of
switching over.
And if these patients do have adelay in care, then sometimes
their authorization will expireor they come back and they're on
different insurance.
But I agree that having tools inour toolbox that are allowing
patients to be able to gettreatment that works for longer
would be able to provide sort ofa safety net for these patients

(07:58):
in case there's a lapse in care.

SPEAKER_00 (07:59):
And then I know that you do also what we do.
You spend time talking to thepatients about their general
health care management, theimportance of their blood sugar
and blood pressure, along withtheir return to the clinic.
And you've suggested that one ofthose markers may be a variable
for socioeconomic class, whichalso independently predicts for
potentials for loss to follow upor vision loss independently.

(08:23):
So do you have any otherstrategies?
It sounds like you're spendingtime with your patients.
You're taking them througheducation about their disease.
You're offering alternatives toget them in if they've been lost
to follow up.
But it still makes my heartbreak a little bit when I see
somebody lose vision that Ican't recover because we didn't

(08:43):
get them back for a treatmentthat we know that works.

SPEAKER_01 (08:47):
Yeah, I think that's a really good point.
And sometimes, I don't know ifyou experienced this, but my
patients with diabetes,sometimes we're the people as
retina specialists who see themthe most frequently, and they'll
often come to us and be like, Ireally need an endocrinologist.
Can you get me anendocrinologist?
you know, it can be reallychallenging.

(09:08):
We're so used to existing in ourown bubble of just
ophthalmology.
But, you know, I think one ofthe fortunate things of where I
practice is being at a largemedical center.
If someone has like being anendocrinologist or someone
before, I can at least messagethem through our system pretty
easily.
But these are the sort ofsituations where you would
really love to be able to have asocial worker to be able to get

(09:30):
involved and to be able to helpyou.
We actually as a departmentjust, we just hired or engaged
with a social worker, but herfocus is really mainly on sort
of people who have legalblindness, giving them the
resources that they need.
It just really highlights thatthe care of these patients is
complex, you know, and How wepractice in the real world is so

(09:51):
different than what we see inclinical trials where someone
has a research coordinator tocall them and make sure they're
doing okay and can helpfacilitate care.
It almost makes you wish that wehad that for sort of all of our
patients.
I think moving forward, it wouldbe great to have more resources.
You know, we like, you know, allof us try to do what we can for

(10:13):
these patients, but it'schallenging for sure.
And I always feel bad for thesepatients about all the demands
on them from a healthcareperspective and also just a
social perspective.

SPEAKER_00 (10:25):
Thank you for speaking with us.
We're going to direct ourlisteners to your manuscript,
Predictors of Vision Loss AfterLapse in Antivascular
Endothelial Growth FactorTreatment in Patients with
Diabetic Macular Edema.
Thanks for joining us.

SPEAKER_01 (10:39):
Thank you so much for having me.

SPEAKER_00 (10:40):
Thanks for tuning in to the JVRD Authors Forum.
You can watch and listen to moreepisodes on the ASRS YouTube
channel and on popular podcastdirectories, including Apple
Podcasts and Spotify.
Visit www.asrs.org forward slashJVRD forum on the ASRS website

(11:07):
to learn more.
See you soon.