Diabetic Retinopathy Management

Abstract

Strict control of blood glucose and blood pressure is critical for reduction of the incidence and progression of diabetic retinopathy (DR). Follow-up of patients with diabetes mellitus is protocol based and not based solely on the presence of symptoms. Staging of the level of DR (mild, moderate, or severe nonproliferative DR vs. proliferative DR, PDR) drives the follow-up interval. The most common cause of visual loss in diabetic patients is diabetic macular edema (DME). The results of multicenter, randomized studies suggest that the best visual results for DME currently are achieved with intravitreal ranibizumab injections ± focal laser photocoagulation. Results using bevacizumab seem quite comparable to those with ranibizumab. In addition to treating DME, this approach also seems to reduce the likelihood of progression of DR. Selected patients also may benefit from intravitreal steroid treatment + focal laser therapy, but there is a relatively higher rate of glaucoma and cataract formation. Panretinal photocoagulation is currently the most effective treatment for high-risk PDR. Panretinal photocoagulation also should be considered for patients with severe nonproliferative DR and early PDR, particularly if follow-up cannot be assured and/or if the patient has type 2 diabetes mellitus. Pars plana vitrectomy is used to manage severe complications of DR such as nonclearing vitreous hemorrhage, severe fibrovascular proliferation, and retinal detachment. Adjunctive anti-vascular endothelial growth factor agents might enhance those results in selected subsets of patients.