We read with great interest the article by Lundeen et al. (1), which showed a 62% increase in the annual prevalence of diabetic macular edema (DME) or vision-threatening diabetic retinopathy (VTDR) among adults with diabetes under 65 years of age between 2009 and 2018. Beyond this quantitative overview across forms and treatment of diabetes-related eye diseases in real life, we would like to highlight two salient points.
First, despite an increase in the prevalence of severe forms (DME/VTDR) from 2011 to 2016, the almost flat shape of the curve since 2016 suggests that the number of new cases of DME/VTDR will decrease. This optimistic view of the future landscape of ocular complications of diabetes is supported by the observed decrease in the annual prevalence of non-VTDR forms in the study results (1). In addition, considering that half of patients with DME/VTDR are treated with anti-vascular endothelial growth factor, our recent results based on French health insurance data of treated DME prevalence, i.e., 1.5% in 2018 (2), are in accordance with the study results (1).
Second, as mentioned by the authors, the prevalence of DME/VTDR was higher in men than in women (1). As the study results offer an opportunity to evaluate sex-related differences stratified by age, we could observe that DME/VTDR prevalence in men aged 18–44 years old (2.84%) was comparable to that of women between 45 and 54 years old (2.96%), and results were similar for men aged 45–54 years (3.64%) versus women aged 55–64 years (3.62%) (Fig. 1 and Supplementary Table 11 in Lundeen et al. [1]). Thus, young and middle-aged men were ahead of women by more than 10 years in their ocular risk. However, this excess risk disappeared at age ≥55 years, as evidenced by the 26% increase in the risk of severe forms in men aged 18–44 years (23% between 45 and 54 years) compared with women, in contrast to 5% found in the group aged 55–64 years (Supplementary Table 11) (1). Therefore, while the DME/VTDR prevalence was higher in men than in women of the same age up to 55 years, this difference was equalized after this pivotal age, which is already underlined in cardiovascular risk (3). Even if sociodemographic factors, i.e., poor adherence of young men to follow-up (4), cannot be ruled out, hormone fluctuations (menopause and estrogen deficiency) could play a role in ocular protection of premenopausal women (5). To support this hypothesis, large-scale prospective studies on hormonal determinants are warranted to further clarify underlying mechanisms and provide insights into prevention strategies.
Finally, from a clinical point of view, physicians must be aware of this excess risk of severe forms in young men and take it into account for screening and follow-up. In this active professional group, the burden of visual loss will unfortunately accompany these young people throughout their lives, while the effectiveness of preventive measures no longer needs to be demonstrated.
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Duality of Interest. S.F.-B. has given conferences organized by AbbVie, Eli Lilly, Novartis, and Sanofi. P.M. is a consultant for Novartis. C.C.-G. is a consultant for AbbVie, Bayer, Novartis, Roche, Thea, and Horus Pharma. No other potential conflicts of interest relevant to this article were reported.