P ERSPECTIVE Systemic Considerations in the Management of Diabetic Retinopathy LLOYD PAUL AIELLO, MD, PHD, MARK T. CAHILL, FRCOPHTH, AND JUN S. WONG, FRCOPHTH ● PURPOSE: To highlight the systemic factors which affect onset and/or progression of diabetic retinopathy (DR) and to emphasize the role and responsibilities of ophthalmologists and other eye care providers to ensure that appropriate systemic medical evaluation of the pa- tient with diabetes is being pursued. ● DESIGN: Literature review of publications relevant to diabetic retinopathy, blood glucose control, diabetes mel- litus type, hypertension, renal disease, elevated serum lipids, exercise, pregnancy, anticoagulation, thromboly- sis, smoking, anemia and antioxidant ingestion. See also pp. 648 – 658 and 659 – 667. ● FINDINGS: Intensive blood glucose control and control of systemic hypertension reduce the risk of new onset DR and slow the progression of existing DR. Severe DR may be an indicator of renal disease while severe renal disease and its treatment can affect the progression of DR. Elevated serum lipids are associated with macular exudate and moderate visual loss. Certain types of exces- sive exercise in patients with advanced stages of retinop- athy may aggravate vitreous hemorrhage. During pregnancy, DR should be monitored closely as transient progression of DR can occur. Therapeutic anticoagula- tion and thrombolysis are not contraindicated at any stage of DR. Anemia can result in progression of DR, smoking in general should be discouraged, and the role of antioxidant therapy requires further study. ● CONCLUSIONS: Blindness from diabetic retinopathy is now largely preventable with timely detection and appro- priate interventional therapy. Routine, repetitive, life- long, expert clinical retinal examination is essential for the fundamental ophthalmic care of the patient with diabetes. However, diabetes mellitus is a systemic disease and thus optimal ophthalmic care must include diligent evaluation and treatment of concomitant systemic disor- ders that influence the development, progression and ultimate outcome of diabetic retinopathy. Optimization of these systemic considerations through an intensive, multi-disciplinary, healthcare team-based approach will maximize the ophthalmic and general health of these patients. Ophthalmologists and other eye care providers are critical members of this team with unique responsi- bilities to ensure that appropriate systemic medical eval- uation is being pursued. (Am J Ophthalmol 2001;132: 760 –776. © 2001 by Elsevier Science Inc. All rights reserved.) D IABETIC RETINOPATHY (DR) REMAINS A SIGNIFI- cant cause of acquired visual loss in working age adults worldwide. The medical, social and finan- cial impact of this disease is substantial. In the United States, diabetes mellitus (DM) affects over sixteen million people, and retinopathy is present in nearly all persons with duration of diabetes of 20 years or more. Severe vision loss from diabetes primarily results from intraocular angio- genesis (proliferative diabetic retinopathy, PDR) and mod- erate visual loss principally occurs from leakage of the retinal vessels (diabetic macula edema, DME). Diabetic macular edema is more common than PDR in type 2 DM and, since 90% of the American diabetic population has type 2 diabetes, more persons have vision loss from DME than from PDR. 1 The risk of severe visual loss (best corrected visual acuity 5/200 or worse at two consecutive visits 4 months apart) from PDR is approximately 40% after 6 years if not treated with laser panretinal (scatter) photocoagulation (PRP). 2,3 The risk of moderate visual loss (doubling of visual angle at two consecutive visits four months apart) from clinically significant macular edema (CSME) is approximately 33% after 3 years. 4 Legal blindness (best corrected visual acuity of 20/200 or worse) has been estimated as 25 times more common in the diabetic population than in those without the disease. 5,6 Appropriate and timely laser photocoagula- Accepted for publication Jun 12, 2001. From the Beetham Eye Institute, Joslin Diabetes Center, 1 Joslin Place, Boston, MA 02215 (L.P.A., M.T.C., J.S.W.) and Department of Oph- thalmology, Harvard Medical School, Boston, MA 02215 (L.P.A.). Reprint requests to Lloyd Paul Aiello, MD, PhD, Joslin Diabetes Center, 1 Joslin Place, Boston, MA 02215; fax: 617-735-1960; e-mail: LPAiello@joslin.harvard.edu © 2001 BY ELSEVIER SCIENCE INC.ALL RIGHTS RESERVED. 760 0002-9394/01/$20.00 PII S0002-9394(01)01124-2