Management of chronic diseases: Diabetic Macular Oedema and Uveitis

Diabetic macular oedema and uveitis: the numbers and pathogenesis

Among chronic eye diseases, we offer an in-depth look at diabetic macular oedema (EMD or DME) and uveitis. EMD is one of the most serious ocular complications associated with diabetes: 35% of diabetic patients develop diabetic retinopathy (DR) and, in 7% of cases it progresses to EMD, which untreated can severely impair central vision. Hyperglycaemia is a major contributor to the pathogenesis of EMD, leading to a state of neuroinflammation, oxidative stress and vascular dysfunction affecting the retina of the eye. Clinical evidence has shown that the state of chronic low-grade intra-retinal inflammation acts as a trigger for the development of oedematous diseases. In Italy alone, there are approximately 200,000 people suffering from EMD and therefore subject to a gradual decrease in vision and impairment of vision.

Uveitis, on the other hand, represents a heterogeneous group of inflammatory diseases that, starting from the uvea, are able to involve various structures of the eye, including the retina and optic nerve. Their frequency depends on geographical, genetic, social and environmental factors. In the Western world, uveitis accounts for 10% of eye diseases, affecting mostly young adults (20-50 years). Diagnoses of uveitis have increased significantly over the past 20 years due to a clearer classification and improved diagnostic methods. Depending on the site of the inflammatory process, uveitis can be: i) anterior, ii) intermediate, iii) and posterior. The latter can also be infectious and non-infectious in nature. In non-infective posterior uveitis, the decrease in visual acuity is often related to the presence of macular oedema, vitritis or inflammation of the optic nerve.

The therapeutic strategy for both eye diseases, EMD and uveitis - particularly for non-infectious posterior uveitis - involves reducing the inflammatory state with various long-term treatments, including anti-VEGF (vascular endothelial growth factor) and intravitreal injections of steroid anti-inflammatory drugs.

Impact of COVID-19 on the management of patients with chronic eye diseases being treated with long-term therapies

The impact of the COVID-19 pandemic on the management of individuals with chronic eye diseases - such as diabetic macular oedema and uveitis - was devastating. Patients and healthcare personnel were faced with an emergency situation that necessitated the use of significant precautions, which led clinical and hospital facilities to confine themselves to emergencies. The management of individuals suffering from chronic pathologies, such as EMD and uveitis, was, therefore, considerably slowed down due to a sharp decrease in medical visits, examinations, follow-ups, and above all treatment sessions. Early estimates indicate that in Italy alone, some 18 million healthcare services were suspended in 2020. The impact of the COVID-19 emergency has, therefore, significantly affected the compliance and on therapeutic adherence: the latter factors of fundamental importance in the management of chronic individuals. Recent literature data, therefore, urge the adoption of new opportunities for the management of chronic diseases, such as telemedicine. The latter, in fact, would allow many visits to be conducted by videoconference or through simple telephone calls.

Importance of compliance and adherence in the management of chronic eye diseases (diabetic macular oedema and uveitis) and impact on quality of life

As defined by the World Health Organisation, 'a chronic disease is any illness that leads to health problems and forms of disability requiring years of continuous management'. Poor adherence to treatment of chronic diseases is a global problem of the highest magnitude, the consequences of which result in poor health and significant health care costs. However, even today, adherence to long-term therapy for chronic diseases in developed countries averages 50%, reaching even lower rates in developing countries.

Poor adherence to long-term treatment severely compromises the effectiveness of treatment, reducing the quality of life of the affected patient. Non-infectious uveitis represents, for example, one of the main causes of visual loss due to its typically relapsing course and the high frequency of complications, which tend to increase with each new relapse with irreversible damage to the ocular structures. Therefore, apart from the COVID-19 pandemic emergency, one should consider the great risks related to the slowdown in the management of patients suffering from all chronic eye diseases, and especially from diabetic macular oedema and uveitis.

Bibliography

1. Martin Paez et al Considerations for the Treatment of Inflammatory Neuro- Ophthalmologic Disorders During the COVID-19 Pandemic. J Neuro-Ophthalmol 2020;40:305-314
2. Justine R. Smith et al. Managing Uveitis during the COVID-19 Pandemic. Ophthalmology Volume 127, Number 9, September 2020
3. Adherence to long-term therapies. Evidence for action. WHO. 2003

Dr. Carmelo Chines
Direttore responsabile