Welcome today's webinar hosted by Diabetes Technology Interest Group. I am Dr. Blake Cooper, I'm a vitro retinal surgeon in Kansas City, and I'll be co-moderating with my colleague, Dr. Risa Wolf. Hi, good afternoon. My name is Dr. Risa Wolf. I'm a pediatric endocrinologist and associate professor of pediatrics at the Johns Hopkins Children's Center in Baltimore, Maryland. So here's a glance at today's agenda coming up next on the next slide. And we're going to provide first a few announcements and then we'll introduce our expert speaker today in a few moments. The presenter will take questions from the audience at the end of the event. Please do not wait until the end of the session to send in your questions. Instead type them into the Q&A box in your control panel. Please use the Q&A box and not the chat function for questions. During this announcement segment, we will use the chat box to send you important information links and can also use this place to chat with other attendees. And if you missed last year's awesome webinar, which was on diabetic retinopathy screening trials and treatment from an equity lens, don't worry. You can still find the recording and all of the other ADA webinars at the ADA's Institute of Learning. This is an ADA member exclusive benefit. So see the link in the chat to view these prior webinars. The iHealth interest group is seeking members interested in being involved in the leadership team, specifically the chair elect, early career representative, and advisors. Scan the QR code for more information and please play a key role in shaping the next wave of diabetes leaders. And another benefit of ADA membership is connecting with members of the iHealth interest group on the diabetes or other interest groups on the Diabetes Pro Member Forum. You can continue the conversation about the topics covered in this webinar and others that you're interested in and see the link in the chat now. Finally, I'd like to introduce today's speaker, Dr. Andrew Barkmeyer. Dr. Barkmeyer is an ophthalmologist at the Mayo Clinic who specializes in disease and surgery of the retina and vitreous. His clinical and research interests include diabetic retinopathy, age-related macular degeneration, retinobascular disease, telemedicine, and complex vitreous retinal surgery for complications of diabetic retinopathy, ocular trauma, retinal detachment, and proliferative vitreous retinopathy. Dr. Barkmeyer. Thank you very much. So I'll share the screen. And can you see my screen okay? Yes. Okay, fantastic. So thanks for the opportunity to discuss the impact of these novel diabetes medications on diabetic retinopathy. I don't have any relevant financial interests. Just adjust my screen here. So the story with these medications is extremely impressive. We all know what the benefits of these medications are. And it started with this series of these cardiovascular outcome trials that all of a sudden we started studying these medications to see what the impact on cardiovascular outcomes was. And as a result of these series of trials, as this community knows well, there is a rapid evolution of the clinical guidelines where now patients were receiving GLP medications for indications that were independent of the glycemic control status. And as of the most recent, even the 2025 guidelines, these medications have a number of indications that have rapidly expanded the use of the medications. And now we're trying to harness all the benefits for systemically while still paying attention to some of the information that we don't quite have yet. So the GLP-1 medications, as we know, mimic GLP-1 and have a number of impacts on systemic health. SGLT2 medications have also risen rapidly. And the question is, what is the impact on diabetic retinopathy from these clinical trials that have driven all these practice patterns? So the SUSTAIN-6 trial was obviously critically important in identifying the positive benefits that we see all with these green boxes in the primary study. However, we identified an increased risk of diabetic retinopathy complications when they looked at the incidence of vitreous hemorrhage in injections for treatments of diabetic retinopathy laser and blindness. Now, these changes that were identified in this trial with respect to retinopathy outcomes were in the context of rapid lowering of hemoglobin A1c, where within the first 16 weeks, patients went from in the high eights of hemoglobin A1c down to near seven. And there's also in the context of the rapid improvement of BMI. So when we look at those systemic impacts and we think back to prior studies that have looked at similarly impactful systemic outcomes, think back to the DCCT study, where there was very similar levels of lowering of hemoglobin A1c within the first several months. And within the DCCT, what they identified was for primary prevention of diabetic retinopathy, there was a significant decrease in the development of diabetic retinopathy outcomes. And these were measured very, very carefully in the outcomes and the methodologies that these studies were rigorous, looking at standardized photography. And there were some pre-specified outcomes by the eye study group. However, in the secondary intervention group, so the patients who already had some degree of retinopathy, there were initially some worsening retinopathy outcomes. So when they look, when we talk about ETDRS outcomes, that refers to the standard way that we photograph and have clinical grading of retinopathy. And what we showed is within the first 12 to 18 months, actually retinopathy worsened in the patients who had this very significant intensive insulin treatment. However, the long-term benefits of the intensive insulin treatment were greatly outweighed by the risks of these early worsening. When we saw these patients who did have early worsening of their retinopathy in the first six to 12 months, the patients had significant improvement in the longer term, even though they had this early worsening. And I apologize for my screen here. And the impact of these, the impact of this initial very aggressive treatment where we lowered hemoglobin A1C early, right away, the benefits with respect to retinopathy outcomes, even in the patients who had early worsening were sustained for many years. So within the EDIC study, you can see that in the conventional treated group up on the top right, the patients who had conventional versus the insulin, intensive insulin management, there's a rapid convergence of the hemoglobin A1C numbers at the end of the DCCT study. However, looking forward throughout the years, the benefits in the intensively treated group were sustained for decades longer. So as a result, so as a result of all of these very well-documented DCCT findings, we have a significant amount of confidence that if you rapidly improve the diabetic control, that these patients will benefit in the long term. Looking at these specific trials for the GLP-1 medications, the meta-analysis of these trials had not shown a consistent increased risk across all the other trials outside of the semaglutide sustained six trial. And what's really important to notice in these trials that approved these medications, these GLP and SGLT2 medications, these cardiovascular outcomes trials were designed to look at a very specific subset of patients, and they also had a very short clinical trial follow-up. So to look at diabetic retinopathy outcomes as well as we'd like to in a very rigorous manner, you really need to look over several years. In these trials, we're looking at really at the first two years for the most part. So they're very short follow-up. They also had very narrow systemic inclusion criteria. So we wanted to look in these cardiovascular outcome trials as patients who are more likely to have significant number of events. And in that higher risk cardiovascular population, what they showed is all of the benefits that we've come to get these approvals to use these medications and the rapid expansion of their use. However, the majority of patients who are potentially eligible for these medications out in the population at large are at more of a moderate risk. These trials also have very limited retinopathy assessments. So they're heterogeneous. Some of them were based on eye exams, and we know that looking just dilated eye exams, when you look at retinopathy levels, it's very variable from provider to provider. And also, it's very difficult to take what people say just on these exams or limited photos and extrapolate that to high quality data. There's also no direct comparison between medication classes. So when the U.S. label, the FDA, looked at all the information for the SUSTAIN-6 and somaglutrite trials, what they said is the processes in place for capturing these DR events in the SUSTAIN-6 trial were not adequate to appropriately capture and analyze these clinically significant events. So based on the trials such as the DCCT, it's better to reduce the hemoglobin A1c as soon as possible, regardless of whether or not the results in an initial increase in the progression of diabetic retinopathy. So when this trial was run, the European Medicines Agency required a post-authorization safety commitment to look further into these retinopathy outcomes with somaglutide in a very appropriately done study. So the FOCUS trial is going to be a five-year study with rigorous photography and pre-specified ocular and retinopathy outcomes. So we're going to get some very high quality data on somaglutide versus placebo, but these results aren't going to be available for another couple years, probably in the 2027-2028 range. So when we think about these retinopathy risks in the context of having a number of new glucose lowering medications for type 2 diabetes, we can look at the preclinical investigations and there's a wealth of preclinical basic science information that looks at the different impacts of SGLT2 medications, GLP-1, DPP-4, and there's some distinct retinal microvascular inflammatory and neuroprotective findings that we've seen in the preclinical findings. These are predominantly favorable and they potentially are independent of the glucose lowering effects of the medications. So when you think of these potential direct tissue effects on the retina and with the known interclass differences in glucose lowering and these other broader effects on weight loss, etc., it's very plausible that there could be meaningful interclass differences in the risk of diabetic retinopathy complications over time. So we worked with a group led by Dr. Rosalina McCoy to look at the question of does the choice of these glucose lowering medications for type 2 diabetes impact the risk of developing DME, diabetic macular edema, or proliferative diabetic retinopathy, which are the two prominent causes of site-threatening diabetic retinopathy. And in this study, what we did is we looked at patients in U.S. commercial Medicare Advantage and fee-for-service plans over the 2014 to 2021 time period in a diverse population of patients from the OptumLabs database that this was geographically diverse across the U.S. and it was also racial, ethnic diversity, age diversity, income diversity. And we looked at patients who are initiating treatment with either GLP medications, SGLT2, DPP4, or sulfonylureas and looked at patients who didn't have any of these medications in the prior year prior to starting these medications and they had no prior treatment within that time period for DME or PDR. And then what we wanted to look at is because these coding-based outcomes are not very good at differentiating between subtle levels of retinopathy, we just looked at patients who met the threshold for treatment, which was diabetic macular edema or proliferative diabetic retinopathy. And when we queried this database, we found over 370,000 patients and large numbers of patients initiating treatments with each of these different medication classes. And when we looked at it, over time, some of the rates of these site-threatening diabetic retinopathy outcomes started to spread a little bit where patients with starting sulfonylurea medications started to have an increased number of treatments for these site-threatening retinopathy outcomes. And there was a slightly lower rate of these treatments for patients with SGLT2 medications and there was not a difference with patients starting the GLP-1 meds. So this is busy, but to summarize here, when we looked at the comparison between these classes of medications and then over time, the likelihood of having treatment for either diabetic macular edema or PDR or any either of those outcomes independently, there was a consistent pattern where SGLT2 medication starting patients did not have slightly lower risk of developing these primary outcomes compared to the other classes. But it was very, very important that GLP-1 medications had a similar risk as the DPP-4 and the sulfonylurea medications, which was very encouraging. This is very busy as well, but just knowing that there's a possibility of someone having an early increase in the likelihood of some of these diabetic retinopathy complications in the first year or so from the information from the DCCT, etc., we also wanted to look at these different time periods after starting the medications. And in summary, there was no significant difference in any of these time periods between these classes of medications. So that was very reassuring in that both the SGLT2 medications and the GLP medications did not confer an increased risk relative to some of the older classes of medications, DPP-4, sulfonylureas, and the relative interclass risks were similar at these shorter and longer durations of use. So the story between what the impact of these powerful systemic medications is on diabetic retinopathy is critically important because several of these different systemic effects can be very different on retinopathy. And we do not have adequate data at this point to confidently know how or counsel patients how they might be impacted by starting these medications. But what we do know is that because there are these very substantial systemic impacts in the short term, this is an important time period for patients to have eye exams. And if you are starting a patient on a new medication, both physicians and patients might have some concerns when you see some of these studies and outcomes that say, oh, this is an increased risk, but I have some retinopathy. What should I do? I think there's a consensus at the point that the most important thing is that patients do have maybe perhaps a little closer together eye exams just to be watched for some of these outcomes because we know that the long-term impact on their systemic health is going to be very favorable. So this is an evolving field. So then it goes to other impacts on the eyes as well, where we have rapid increase in these powerful medications and we need to learn how the rest of the ocular impacts will shake out over the next five years or so. Over this time period, we're going to see a number of studies like this one that this one gained very significant popular lay press attention where there was an increased risk of the non-arteritic ischemic optic neuropathy in this study that was published last year by Hathaway et al. And it's important to understand some aspects of this study to sort of contextualize what it said and what we should use this study for. So non-arteritic ischemic optic neuropathy is a relatively rare event. So what they did here is they looked at a population at a large referral center of patients who are seen in a neuro-ophthalmology practice. Neuro-ophthalmologists are who see patients typically with non-arteritic ischemic optic neuropathy. And they found within this subspecialty practice referral registry study that there was an increased hazard 4.28 for patients with type 2 diabetes who received semaglutide versus the non-GLP-1 cohorts. So this information was widely publicized and it's very important to contextualize it. So taking a step back, what is non-arteritic ischemic optic neuropathy? Well, it's a condition that is relatively rare, but it affects about 10 per 100,000 patients over age 50. And what happens is the optic nerve is supplied by some microvasculature and the optic nerve takes information from the retina and transmits it back to the brain so you can see. Now, if there's a microvascular insult to the tissues that connects the optic nerve and the retina to the brain, you can have an ischemic event and then you can lose vision. And what often happens is patients have a decrease in visual acuity abruptly, most commonly right upon waking in the morning. And often it's what we call an altitudinal visual field defect. So in other words, the lower half of the visual field or the upper half of the visual field is lost or partially lost. And when this happens, many of these patients have this vision loss that will be longstanding. Sometimes it'll improve a little bit after the acute event. Sometimes it'll worsen a little bit after the acute event. But it's a very important insult to the vision that's typically not recovered. And what's important to know is who gets this non-arteritic ischemic optic neuropathy and what are some of the risk factors? So one of the most important things to know is that there's actually a very important anatomic risk factor. It's called the optic nerve cup-to-disc ratio or a disc at risk where the cup-to-disc ratio is very small. If you look at this image below on the left photo, you see an optic nerve where in the central there's the yellow portion. We call that the optic cup. And then around the disc, the sort of the peach colored portion of the disc, that's the entire optic disc. And sort of the ratio of that central portion to the whole disc, we call the cup-to-disc ratio. So on the left, we would call that a cup-to-disc ratio of maybe 0.3. And on the right, we'd call that a cup-to-disc ratio of 0.0 because you don't even see the optic cup. And this is important because about 89% of patients who get non-arteritic ischemic optic neuropathy have a cup-to-disc of 0.3 or less. And most patients have a cup-to-disc ratio of 0.3 or more. So it's a small subset of patients who are cup-to-disc of 0.0, 0.1, 0.2. So this is important to know that there's a very specific anatomic predisposition. There's also systemic risk factors for it. And about 92% of patients are over age 50 who developed this condition. And 94% of patients have significant cardiovascular risk factors. So all patients with type 2 diabetes would have potential risk factors for this condition. When we think about this literature that's starting to come out about this risk, we have to how do we interpret this literature? Well, this is a very unique subset of population looking at this neurophthalmology clinic and what the outcomes were there. But it's very difficult to study these types of conditions that are serious but rare because any individual clinic is underpowered to look at these. So the additional challenge is with NAION, this does not have a specific ICD code. So our go-to for large, where you need a large patient population to look at these rare but serious events, if that's even a bit challenged in this population because they don't have a specific ICD code. So when we've looked at ICD coding compared to the chart reviews in the past, it's not a very reliable way. The codes do not necessarily relate to what's going on with the patient. So to look at this, we're going to have to look at this through large administrative databases. That'll be one way. And one administrative group, the Odyssey Network, has looked at that and there's some pre-published data that does suggest that there could be a slightly increased risk, but it's much lower than what was previously reported in this Hathaway group. And we have to look at it with the coding in a number of different ways. And some of that information is going to be forthcoming. So the bottom line with NAION is it is possible that there could be a small increased risk, but this is a small increased risk in a very, very rare condition in the overall context of having very positive impact on systemic health and the eye in general. And there's going to be a number of these papers that are going to continue to come out and inform our understanding. For example, just in the last month or so, another paper came out looking at a Danish database that showed there might be a protective effect of these medications on the likelihood of developing glaucoma. When we look at retinopathy, glaucoma, all these important eye conditions, I think the most important thing to summarize is that this data is continuing to evolve and continuing to come out. Our recommendations is to, if there are any patients that have specific questions and concerns on their risks related to their eyes and starting these medications, I think it's important to sort of risk stratify what we know about the systemic benefits, but also have people have an eye exam. They can talk to their ophthalmologist, but as of right now, there's really no specific limitation. There's no contraindication for starting these medications from the ocular perspective. It's just reasonable to have eye exams at a slightly increased frequency afterwards and counsel patients that if they do notice any changes in their vision, any changes in how they're functioning with respect to their activities of daily living in their vision, that they should go have an eye exam right away. At this point, I can open this up to questions. Also have a little bit more information that we can share about some exciting new developments and ongoing developments with respect to fenofibrate treatments and retinopathy. I think that would be great if you could share some novel insights on that as well, before we do questions. I would love to do that. That's fantastic. So we know that the partnership between systemic health management and ocular health management is critical for patients with diabetes, glycemic control, hypertension management, and serum lipid management. And we've had a number of findings to quickly summarize over the years that throw hints that treatment with fibrate medications may be beneficial to the relative risk of developing more advanced diabetic retinopathy over a longer term. But we haven't known exactly what to do with that information. For example, the ACCORD trial showed that among patients taking statins, those who were randomized to fenofibrate versus placebo had a lower likelihood of developing these negative ocular outcomes. We also know from the field study that patients randomized to fenofibrate versus placebo were much less likely to need laser treatment for diabetic retinopathy. And most importantly, in this ISUB study of the field study, a large percentage of patients had no retinopathy or very questionable retinopathy. But when you looked at the smaller subset of patients who already had some established retinopathy, the likelihood of needing treatment, of progressing to needing treatment for diabetic retinopathy, was significantly lower for those patients who were taking fenofibrate. It was about 0.3% versus 3.8%. And now this is important because diabetic retinopathy progresses over time. And over the time period of this type of study, you're very unlikely to have the progression all the way from zero retinopathy all the way to a very serious outcome. So in the past six months, the LENS study coming out of the UK also looked at a large screening population where they took retinal photos and looked at patients randomized to fenofibrate versus placebo. And they also found a protective effect for the progression of diabetic retinopathy. This is something we still don't know exactly what to do with this information because on the ophthalmology side, ophthalmologists are less comfortable prescribing this type of systemic medication if they don't know exactly what the potential monitoring requirements will be. They do not want to interfere with the systemic treatment that endocrinologists, primary care physicians are employing for these patients. And on the primary care diabetic control side, providers don't necessarily know what the retinopathy status is, who might benefit, how someone's doing. So the Diabetic Retinopathy Clinical Research Network is currently in the midst of a large study that should really help this to look at the impact of randomizing to fenofibrate versus placebo. And what we're looking at in this study is to determine if patients with a very specific amount of diabetic retinopathy, sort of the mild to moderate diabetic retinopathy, if you start someone at that point on fenofibrate, over the next five to six years, what will the very granular progression rates be of diabetic retinopathy? What will the progression to be to site-threatening retinopathy? And by setting these specific criteria on the ophthalmology side for if you have this level of retinopathy, this has been shown to benefit you. This will provide a model for ophthalmologists to prescribe or collaborate with internists to prescribe these medications. We also want to disseminate standardized prescribing guidelines if this does show what the other studies have shown, that this fenofibrate is protective. We want to collect information on other protective biomarkers through a number of routes that we're doing blood sampling, functional structural testing, and continuous glucose monitoring. So this is a very exciting time if we could potentially have another medication that is relatively cheap. It's inexpensive, potentially very well tolerated for patients in the long term, and in patients in areas who do not have as much access to the current very expensive injections and laser-based treatments, whether we'd be able to offer something that can impact the risk of developing site-threatening retinopathy in the long term. So thank you very much. I'd be happy to discuss any of this further and answer questions. Dr. Barkmeyer, thank you. There's a wonderful overview and presentation. I was hoping you could maybe just comment a little bit for the audience, because I think it'd be important for them to understand sort of current treatment of retinopathy. I know it's a broad topic, but as we have better anti-VEGF therapies and potential other medications, I mean, the fear of losing vision is great among those who live with diabetes. But I also feel, you probably feel this way as well, that we have wonderful treatment nowadays that can either halt, reverse, or improve levels of retinopathy. And if you can just sort of share a little bit about treatment, that might be helpful. Yeah, it's really been amazing over the past, really the past 15 years, there's been a complete paradigm shift in how we take care of patients who have both diabetic macular edema and proliferative diabetic retinopathy. And that's really been driven by these new injectable medications, these anti-VEGF medications. And the anti-VEGF medications have been shown to very significantly improve vision and maintain vision in patients who have diabetic macular edema and proliferative diabetic retinopathy over time. Over the past 15 years, the number of patients who have benefited from this has have been substantial. And the most important thing from a primary care and endocrinology side is to make sure that patients are getting the eye exams they need, because many times patients who can benefit in very strongly evidence-based ways do not even have vision loss yet. So they're patients who have sight-threatening retinopathy who might benefit from these anti-VEGF treatments and benefit from laser treatments to reduce the risk of further vision loss. But we know that still as a community in this country, maybe about 60% of patients are getting their annual eye exams that are recommended. And catching any of these conditions early rapidly improves the likelihood that we can really benefit them in the long-term and preserve vision. But for patients who do have vision loss, these treatments are better than what we've ever had before. And sort of the next phases are really working towards ways to better understand how to really optimize the chances of improving vision, but also developing new therapies that can also reduce the treatment burden, the number of trips back, the expense to patients, and just like gradually fine-tuning the ability to really improve vision in the short-term, but also like long-term vision outcomes to protect their vision. I would just add that I think one of the things you definitely provided in this talk is a lot of reassurance, because I think there's definitely concern, at least in the endocrine world, that if we're starting these medications and the patient potentially does have some mild or some form of retinopathy that we could potentially be making worse with these new drugs, but really the benefits of lowering A1C and the other sequential benefits definitely outweigh that. So it's great to sort of have your thoughts on that. We do have one question left in the Q&A. And of course, if anybody else wants to send questions, please do. I'll just read it out to you. It says, even though use of GLP-1, semaglutide, et cetera, may improve diabetic retinopathy over the long-term, there is concern that the initial worsening of macular edema, retinal integrity with the use of these meds may damage photoreceptors of the cellular or subcellular levels that are irreversible. Do you agree? Or what are your thoughts on the potential damage to photoreceptors? Well, it's a great question. And I would make it very narrow that there may be a small subset of patients who have if you look at the bottom right corner here with this image, these two images on the right, there could be a patient who has substantial amount of diabetic macular edema, and they have a lot of these sort of yellow lipid exudates that perhaps if you could start an ocular treatment first before doing these very impactful systemic therapies, could that potentially be better in the long-term? It is absolutely possible. However, we don't have any data to suggest that. And we have very, very strong data that at whatever stage of diabetic macular edema and proliferative diabetic retinopathy someone might have, we have very clear guidelines on how these patients can benefit from our current therapies. And we know that because of this long-term horizon of benefit and the cardiovascular benefits, I'm personally not recommending anything different for any, there's really no specific patient that I would say, do not start these medications yet. There are some people who might say sort of at the expert opinion level of recommendation that we might want to start treatment if you have a certain threshold of diabetic macular edema or risk to developing that. But this would still all go back to referring someone back to their ophthalmologist or retina specialist. And if someone has a question of a very specific question, is there some treatment I should have before starting these medications, they should be evaluated by a retina specialist. But from my perspective, I think that these medications should be started when they're systemically indicated and we need to follow them very, very closely. Could there be some select patients that have damage? I think it's very unlikely that in the entire group of patients who would be starting these medications that we should do anything other than starting the medications and have a prompt eye exam. Thank you. So I think part of what you've also touched on is the importance of communication between eye care professionals, primary care physicians, endocrinologists, and cardiologists, anyone who's really prescribing these medications. I guess as a retina specialist, the level of retinopathy, does that concern you when patients start medications? So if they have, let's say level 47 or 53, that moderately severe or non-proliferative disease or central involved retinal edema, are you going to want to communicate back with the primary care physician starting those medications? Patients need to be followed more frequently, or if they do start the medications, will you watch them to see if the retinopathy does progress and potentially stabilizes over time? I think that communication is always appreciated in both directions. And I think communicating as much as we can is very important. Or, you know, as far as if someone is at a point of retinopathy and they will tell me, like you said, that 47 or 50, let's say someone has moderately severe diabetic retinopathy, and they come and ask a question about, should I start these medications, or do you have any specific recommendations that we should pass to the endocrinologist or primary care provider? My recommendation for them is the same, that if you clearly have some ocular end organ damage at this point, we know that this diabetes has significantly affected your retina. And looking forward, your risk is elevated in the coming years. I need to see you more frequently as you have increasing severity of your diabetic retinopathy. And if you start one of these medications, I will see you even closer together. You treat it very similarly to someone who comes and tells you that they've recently become pregnant, or recently have some other rapid change, whether they undergo bariatric surgery or some other impact on their systemic health that's going to be very important in the coming time. You know, we can apply what we know from some of these rapidly changing systemic impacts to populations of patients that statistically they're more likely to have progression. We just don't know if that individual patient will, so our response is just to follow them more closely. I don't have any recommendation to, I personally do not ever recommend delaying these treatments, because I feel that as long as I have someone under my care, and I can follow them as closely as I need, that we can address the complications if they arise, and we can put them in a good spot. My biggest concern is always if there's a gap in care, and they have a delay in access to some of their retinal treatments and evaluations, that's my biggest concern. As long as they're under my care, I recommend following the systemic evidence-based guidelines that we know will reduce the risk of heart attacks, death, and all the other benefits that are very well established. The one other thing that I was going to mention to this community as well is, we've really never had good systemic treatments for specific ocular complications like diabetic macular edema and proliferative diabetic retinopathy, but over the next couple of years, we're actually probably going to be interacting a little bit more often on that front as well, because there are a number of medications within clinical trials that we're going to have results on relatively soon that look at systemic oral treatments specifically for diabetic macular edema, and that's going to be something that's really going to probably, if these studies show very promising systemic benefits, ocular benefits, there's probably going to be an increase in the amount of questions and collaboration back and forth, because as ophthalmologists identify patients who can benefit in their eyes from starting these systemic medications, and this goes for the phenofibrate-based treatments too as data continues to come in, we will be rapidly increasing our amount of communication for collaborating on what are the potential concerns that you might have for this specific patient starting this medication. There are several medications such as Tanaverset, which is a new medication that impacts the inflammasome. There are medications that are in a couple of industry-based trials that we should have more information over the next year or two as well. So I think that the collaboration between the retina and the endocrinology in primary care communities is only going to increase in the coming years. Thank you. There is one more question about, given the risk-versus-benefit ratios, can an argument be made in using GLP-1s in those with diabetic retinopathy, whether they're type 1 or type 2? And I know that's a little bit more of like an endocrine sort of question, but I don't know if you guys on your side in ophthalmology have started to see that. Obviously, in the endocrine world, we're definitely starting to see more patients with type 1 also use GLP-1s when they have significant insulin resistance. I'd say from my perspective, if I had a patient with type 1 diabetes versus type 2 diabetes, and I were told that we were considering this based on this data to support our systemic treatment, that we now think that this might be beneficial for you as someone with type 1 diabetes, I have nothing that would make me guide them any differently from my perspective. We're still going to be looking at their retinopathy levels. We're going to be looking at what we sort of assess as their likelihood of progressing over the coming years based on their glycemic control status, hypertension, all of the known risk factors. That type 1 versus type 2 starting GLP-1 medication, that would not impact the way I would discuss with patients because I don't think we have enough information to inform any potential differential impact on retinopathy. Great. Quick question as far as in your institution, holding GLP-1s prior to surgery and particularly vitro retinal surgery in your cataract surgery as well. Absolutely. We've had a fairly rapid practice shift in that where now every patient, it's one of the first things we discuss. The GLP medications, we're holding them a week in advance of any elective surgery. There are times where if someone has a retinal detachment or some other urgent emergent indication for surgery, sometimes in that context, we'll just communicate with the anesthesia teams and they'll do their evaluation. We haven't delayed surgery for any patients who need emergent surgery, but all of the elective surgeries, we're communicating early and often with them, both from our side when we see them in clinic and we're setting someone up for surgery, but also in our anesthesia pre-surgical evaluations, they'll discuss it with them. Then on the day of surgery, we check again. One of the things that we've done at times as well is we've sent reminders a week and a half in advance or so because it's one thing to think of stopping a medication the night before surgery or the morning of surgery, but it's a little trickier to remember if you're taking injection that's a once a week medication to hold it, whether it's five days before or eight days before or 10 days before. That can be a little bit trickier for patients to remember sometimes. We're looking into communicating people early and often to hold these medications to make the elective surgery as safe as possible. Thank you. I think that this is really an amazing talk. Thank you for presenting today. We hope it was valuable to all of the attendees for the webinar. Dr. Barkmeyer, I really appreciate your time and you're sharing your expertise with us. We'll at this point wrap up for the afternoon. Thanks again for leading us and also for our participants. Thanks so much, everyone. Have a good afternoon.

Diabetes Technology

GLP-1

SGLT2

Diabetic Retinopathy

Cardiovascular Benefits

Fenofibrate

Ocular Conditions

Medical Communication