Diabetes mellitus is a common systemic disease with disorders of glucose metabolism. The prevalence in our population is about 1%. There are many eye complications caused by diabetes, and diabetic retinopathy is one of the most serious complications.
1, the basis of individualized treatment – the relationship between individuality and commonality.
Anything that exists in reality is the organic unity of commonality and individuality. On the one hand, commonality cannot be separated from individuality, commonality exists in individuality, general can only exist through individual, and any individual is general. On the other hand, individuality must be connected with commonality, and there is no such thing as individuality without commonality.
In terms of its pathogenesis, diabetic retinopathy is related to genetic, environmental, psychological and physiological factors. Glucose metabolism disorder is the root cause of DRP, in addition, platelet adhesion and agglutination abnormalities, increased blood viscosity, the role of growth hormone, ischemia and hypoxia caused by the increase in neovascular growth factor and immunogenetic factors also play a role in the development of DRP.
In its pathological basis, damage to the microvascular system is its commonality. For different patients, the development of lesions is related to the degree of metabolic disorders, age of onset, duration of disease, genetic factors and diabetic control.
In terms of symptoms, the commonality of patients with diabetic retinopathy is manifested in symptoms of diabetes such as polyphagia, polyphagia, polyuria, fatigue, and wasting. In the early stages of retinopathy, there are usually no self-conscious symptoms in the eyes. With the development of lesions, it can cause different degrees of visual impairment. Different personalities, i.e. specificity, are exhibited. Such as decreased visual acuity, visual distortion, floating black shadows, flash sensation, visual field defects and other symptoms
In terms of signs, the common basis is abnormal retinal microcirculation. The manifestation of the signs reflects the specificity of the individual. In the different stages of the lesion also has its relative common features. It is based on these characteristics that DRP is typed and staged. However, each patient has its own signs and symptoms.
It can be seen that the treatment of different patients should be based on their specific individual performance to develop individualized treatment plan. Only by combining the commonality and individuality, fully considering the patient’s specificity, and choosing suitable individualized treatment measures, can we get the ideal and best treatment effect.
2. Research on individualized treatment methods – adhering to the epistemological point of view.
Dialectical materialist epistemology believes that the process of cognition in which the subject reflects the object is a process full of contradictions, a process of constant generation and resolution of contradictions, a process based on practice, from perceptual cognition to rational cognition and from rational cognition to practice, a process of practice, cognition, re-practice and re-cognition, a cycle of repetition and continuous development.
The research on diabetic retinopathy has continued to explore effective treatment measures.
Drug treatment.
The incidence of DRP was found to be extremely low in patients with rheumatoid arthritis and diabetes mellitus treated with salicylates in the early 1960s. Aspirin has an inhibitory effect on platelet agglutination and has a preventive effect on the formation of microcirculatory thrombosis in clinical practice. Based on these clinical and theoretical insights, aspirin is applied to diabetic patients for the prevention of DRP and in patients with early DPR.
However, the effect is still not certain. Low-fat diets and cholesterol-lowering medications given to patients with high blood lipids have also been reported to reduce exudation and improve visual acuity. Drugs that activate blood circulation and promote blood stasis are also effective in improving retinal ischemia and hypoxia.
Photocoagulation therapy.
Some of the hypoxic retina is destroyed by photocoagulation, the oxygen consumption of the retina is reduced, and the hypoxic state of the remaining retinal tissue is relieved. No more neovascular growth factor is produced. This allows the existing neovascularization to regress and no more neovascularization is produced in order to maintain partial retinal visual function. For non-proliferative DRP, photocoagulation burns the outer retina, which has the highest oxygen demand, into a scar, allowing the inner layer to receive a higher supply of oxygen and eliminating the vascular proliferation factor produced due to hypoxia. These mechanisms are the reasons why photocoagulation has achieved the best efficacy and wide application in the treatment of DRP.
Cryocoagulation.
The mechanism of cryocoagulation is the same as that of photocoagulation. It can be used to stop the progression of the lesion in areas of the peripheral retina that cannot be reached by photocoagulation, at depths that cannot be reached by photocoagulation, and in patients with refractive interstitial opacities that cannot be treated with photocoagulation. However, because extensive condensation can cause vitreous contraction leading to vitreous hemorrhage or retinal detachment, it should be used with caution in patients with severe vitreoretinal traction.
Surgical treatment.
It is mainly used to treat complications caused by proliferative diabetic retinopathy (PDR). For example, vitrectomy is feasible for severe vitreous hemorrhage with long-term non-resolution. For retinal detachment, corresponding repair surgery is feasible. Partial pituitary resection is useful in some patients to reduce the vascular lesions of retinopathy. However, it should be used with caution. For a few patients with better prognosis of general condition and visual acuity, and who are not suitable for photocoagulation, it can be considered as an option.
3, specific measures of individualized treatment – the application of the systemic theory.
The principle of wholeness.
Man is an organic whole, and the whole, i.e., the patient’s whole body, should be fully considered in the process of treatment of the local. From the system theory, it is known that the part and the whole are mutually constrained and interact with each other. In practical application, we should see the importance of local treatment as well as the interaction between the whole and the whole.
Individualized treatment also reflects the principle of wholeness from another level. The systemic state of different patients is often an important indicator for the appropriate treatment. The individualized treatment plan of the patient should be developed from the dialectical relationship between the whole and the local.
Blood glucose control is the key to treatment. The results of the American DCCT study showed that intensive glycemic control prevented the development and delayed the progression of diabetic retinopathy [4]. Drug or insulin therapy is given according to the patient’s type of diabetes, age, duration of disease, and need for ocular treatment. If for patients who need surgical treatment, insulin can be used for blood glucose control during the perioperative period.
Blood pressure control. Diabetic patients with hypertension are more likely to develop severe DRP than those without hypertension, so for patients with other risk factors, it is important to pay attention to blood pressure monitoring and treatment of hypertension while controlling hyperglycemia.
Renal disease. The fundus manifestations of diabetic patients with combined renal hypertension include hypertensive retinopathy and nephrogenic retinopathy. Patients with renal retinopathy combined with DRP have an increased incidence of neovascular glaucoma, which is difficult to treat once it occurs. Treatment of DRP is best performed with laser photocoagulation in the preproliferative or early proliferative phase, and should be performed in the early stages of renal failure, before the appearance of hypertension and renal retinopathy. Hemodialysis treatment can reduce diffuse retinal edema and macular edema. However, a temporary increase in IOP can occur during dialysis and should be monitored [5].
Pregnancy. Blood glucose can increase during pregnancy, resulting in pregnant women with diabetes, whose DRP is exacerbated. Monitoring should be intensified in these patients. Laser treatment can be done early for patients with existing preproliferative or proliferative DRP.
Dynamic principle
The materialistic dialectic believes that nothing in the world is static. Systems theory also emphasizes that any system is in motion and change. As a system of people is also inevitably in change. For patients, their conditions are in constant change as their age, environment, psychology, etc. change. Different treatment measures should be taken in different periods.
Non-proliferative stage DRP.
Local laser photocoagulation is feasible for those with macular edema and circumferential exudative lesions.
Pre-proliferative DRP.
Due to large capillary nonperfusion and extensive retinal edema, total retinal photocoagulation (PRP) should be performed [5].
Proliferative DRP.
Once neovascularization is present, all patients should undergo total retinal photocoagulation. all patients should be followed up regularly after PRP with fluorescence angiography, visual field, and ocular electrophysiology. If fluoroscopy reveals neovascularization and capillary nonperfusion, then enhanced PRP should be considered, and direct photocoagulation should be performed if needed. For patients with neovascularization of the optic papilla (NVD), it is more important to follow up diligently. If 50% of the NVD is still not atrophied at the postoperative review, or 25% of the NVD is still visible after 3 months, additional photocoagulation should be performed in the original laser spot gap, or the peripheral photocoagulation area should be extended.
For NVD that has not atrophied by 6 months, direct photocoagulation of the feeder vessels can be performed; for macular edema still present 2-3 months after PRP, local photocoagulation or lattice photocoagulation of the posterior pole can be performed. For patients with recalcitrant disease and iris neovascularization, condensation is feasible, condensing the peripheral retina on the outer surface of the sclera in each quadrant to induce regression of the NVD or retinal neovascularization (NVE).
Patients with severe complications should be treated accordingly. For example, vitrectomy is a safe and effective treatment with few postoperative complications and good surgical results in patients with long-term non-absorption of vitreous blood medication due to diabetic proliferative retinopathy [6]. In cases of combined retinal detachment, combined infusion of gas and/or fluid
The normal retinal anatomical relationships are restored and the integrity of the eye is maintained for laser photocoagulation or condensation. In patients with cataract combined with proliferative diabetic retinopathy, simultaneous cataract extraction and posterior chamber IOL implantation during vitreous surgery resulted in improved visual acuity in most patients without significant complications.
Optimization principle.
Individualized treatment fully reflects the goal DD optimization to be achieved by the systematic approach. For different patients, after weighing the overall gains and losses, seeking the benefits and avoiding the harms, and optimizing the choice, the final individualized treatment plan is the most optimal plan for the patient.
*Summary.
The individualized treatment for patients with diabetic retinopathy fully reflects the philosophical objective, dialectical and historical ideas. It is feasible, necessary, and beneficial in practical medical applications. For specific cases, different treatments and therapeutic pathways should be carefully selected or applied in combination, and adjusted in a timely manner in the dynamic observation of the disease, with specific analysis of each case. With a comprehensive and dialectical viewpoint, a dynamic view of the specific patient, a flexible application of extensive medical knowledge, and an individualized treatment plan, diabetic retinal patients will certainly receive an ideal treatment and prognosis.