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November 18, 2002

Complications

Question from Seaside, California, USA:

I have aggressive proliferative retinopathy with refractory macular edema first identified about seven months ago, and my vision is variable on a day to day basis. I've had improvement with hyperbaric oxygen and heavy metal chelation as well as supplements to decrease my insulin demand. The next step may be stem cells and, as time is of the essence, I am wondering about any stem cell studies for proliferative retinopathy with macular edema. I am willing to consider all options to retain and restore vision.

Answer:

You did not say if you have had the standard treatment of laser intervention.The Early Treatment and Diabetic Retinopathy Study (ETDRS) established the efficacy of laser surgery for both proliferative diabetic retinopathy and macular edema. It has been established that laser surgery decreased the risk of severe vision loss by 50%.

You are correct that time is of the essence, and this well documented, time tested treatment modality is the standard of care for these two conditions at this time. You would be taking a high risk of blindness if you are searching for an alternative for this procedure.

There is no stem cell research for possible future treatment options at this time or even research planned for the future that I’m aware of. I walked across the hall and asked a colleague who is a retina specialist aware of current topics in retinal treatment, and he concurs that there is no study that he is aware of either.

Again, you did not say if you have had laser treatment already. Your current option to consider is laser intervention to retain and preserve useful vision. Once vision is destroyed it can not be restored.

CAG
Additional comments from Dr. Dilogen V de Alwis:

There are, as far as I am aware, no specific reports on retinopathy and stem cell treatments. However, from our previous experience with tight control and retinopathy, it is likely that, if this leads to a sudden change in control, there will be initial worsening of retinopathy. Whilst on the long term, this worsening improves to the extent that, at about two years, even those with sudden tightening of control do better than those with poor control, it is now recognised that there are some things that can be done to prevent the initial worsening.

My recommendations, based on my own practice for those with poor control where tighening is planned:

If control is poor, improvements should be carried out in a progressive manner, over a period of at least 6 months, preferabbly longer. This might not be possible with stem cell treatments. It might be possible, however, that gradual tightening with insulin could be attempted prior to the stem cell treatment.
If there is any degree of maculopathy, or proliferative retinopathy, further laser treatment should be carried out at least three months prior to stem cell treatment. If retinopathy is not stablised following this, delaying stem cell treatment until further laser is carried out needs to be considered.
All other potential risk facotrs such as blood pressure, cholesterol and lipids etc. should be controlled.

DVdA
Additional comments from Jane Seley, diabetes nurse specialist:
It is not uncommon to experience eye or other complications after
achieving good control and it would seem like the good control led to the
complication or at least couldn’t stop it, but that is not the case. The complication
is most likely from poor control in the past and it was too late for the good control to stop it. I don’t want you to think that good control will not
help you, because it will help you delay or prevent future complications.
I wish I could offer you more encouragement about what is happening now, but unfortunately only time will tell and it sounds like you are receiving excellent care.

JS