Diabetic maculopathy in community practice:
A thirty year perspective
William V. Aldred (Pensacola)
The history of treatment philosophies for diabetic macular disease is characterized by periods
of gradual evolution interrupted by several radical paradigm shifts. The laser was an epochmarking
development in the history of our specialty, and its ability to influence vascular pathologic
processes became especially evident in diabetic eyes. Accordingly, laser methodologies
dominated the early years of diabetic retinal practice. The laser era can be considered as
consisting of three cycles: the pre-ETDRS, the ETDRS, and subsequent refinements and
variations on the ETDRS protocols. With the passage of time, however, shortcomings in laser
treatment outcomes relative to patient and physician expectations became evident.
Additionally, demographic changes in the diabetic retinopathy patient profile have gradually
occurred during this time interval. Treatment models for diabetic macular disease based
predominantly upon the laser are therefore now being reevaluated by community retinal specialists.
Two additional revolutions in diabetic macular disease treatment have occurred concurrently with the above. First, surgery
to address vitreomacular interface abnormalities has come into its own, and continues to expand. Sutureless vitrectomy
techniques are at the forefront of this movement, and continue to play an enlarging role in our treatment armamentarium.
Second, pharmacologic treatments have burst upon the scene in the last several years. Steroids such as triamcinolone
acetonide, VEGF inhibitors, and long acting forms of these classes of medications have captured the attention of the retinal
community, and offer further hope of future progress.
It is the responsibility of community retinal specialists to evaluate new possible therapies as reported by published studies,
discussions with colleagues, and presentations at conferences, in order to assess the value of each treatment modality for
the individual patient. This paper outlines the evolution of a current diabetic maculopathy treatment algorithm by one retinal
surgeon. Thirty years of experience are combined with a view to possible future developments in this ever changing and
challenging struggle on behalf of our diabetic maculopathy patients.