diabetic%20retinopathy
DIABETIC RETINOPATHY
Diabetic retinopathy is an abnormality of the microvasculature of the retina that occurs to almost all patients with chronic diabetes mellitus.
It is one of the leading cause of blindness worldwide and principal cause of impaired vision in patients aged 25-75 years of age.
The abnormality causes microaneurysms, retinal hemorrhages, lipid exudates, macular edema & neovascular vessel growth that may lead to blindness.

Surgical Intervention

Laser Photocoagulation

  • Standard technique for treating DR that aims to reduce the risk of visual loss
  • Retrobulbar or peribulbar injections can be used with laser photocoagulation techniques

Focal or Grid Laser Photocoagulation

  • Applies small sized burns to leaking microaneurysms in the macula in order to reduce the plasma leakage responsible for intraretinal swelling
  • Decreases the risk of moderate vision loss in patients with CSME, decreases the changes of visual loss and increases those of partial to complete resolution of DME compared to no intervention at 1-3 years
  • Painless and only takes <10 minutes to perform under topical anesthesia
  • Indicated for patients with DR with CSME; preferably done prior to panretinal photocoagulation in patients with DME, with severe NPDR and non-high-risk PDR
    • May be performed as initial therapy for poorly compliant patients with DME or as adjunctive therapy for patients unresponsive to or with incomplete response to anti-VEGF treatment
  • Preferred treatment option patients with noncenter-involved DME
  • May be considered in patients with center-involved DME with persistent retinal thickening after 24 weeks of anti-VEGF treatment
  • Complications can include:
    • Laser scars that tend to increase with time
    • Paracentral scotomas
    • Accidental foveal photocoagulation
    • Choroidal neovascularization
    • Subfoveal fibrosis

Panretinal/Scatter Laser Photocoagulation

  • Applies hundreds of laser wavelength burns to the peripheral retina to reduce the ischemic retina that brings about angiogenesis
  • Primary treatment for PDR and is recommended in type 2 DM patients with severe NPDR or non-high-risk PDR before high-risk PDR develops
    • Decreases the risk of severe vision loss in severe NPDR and PDR
  • May be performed in patients with CSME
    • Anti-VEGF therapy and/or focal anticoagulation before or concomitant with panretinal photocoagulation must be performed when evidence suggests exacerbation of macular edema and increase rate of moderate visual loss with panretinal photocoagulation alone
  • Indications:
    • High-risk PDR
    • Rubeosis with or without neovascular glaucoma
    • Moderate to severe neovascularization not involving the optic disc
    • Widespread retinal ischemia and capillary non-perfusion
    • PDR during pregnancy
    • Preproliferative retinopathy in the second eye with severe PDR in the other eye
    • May be considered in patients with severe NPDR and non-high-risk PDR at high risk of progression to high-risk PDR or with poor follow-up compliance
  • Additional panretinal photocoagulation or anti-VEGF therapy may be performed in the following conditions:
    • Neovascularization fails to regress
    • Increasing neovascularization of the iris or retina
    • New vitreous hemorrhage
    • New areas of vascularization
  • Complications:
    • Pain during treatment
    • Transient increases in IOP
    • Corneal abrasions
    • Mydriasis due to damage of nerves in the uveal tract
    • Macular edema
    • Visual acuity and/or field loss
    • Loss of dark adaptation
    • Decreased or compromised accommodation
    • Choroidal detachment or hemorrhage
    • Exudative retinal detachment
    • Subretinal neovascularization
    • Vascular occlusions
    • Lens opacities
    • Vitreous hemorrhage from regression of neovascular tissue

Vitrectomy

  • Surgical removal of the vitreous gel, blood and fibrovascular tissue
  • Has been shown to restore useful vision in eyes with non-resolving vitreous hemorrhage and traction retinal detachment of the macula
  • Treatment option for advanced DR
    • Shown to increase vision-related quality of life in patients with PDR
    • Treatment option for persistent DR despite optimal medical therapy with anti-VEGF or panretinal photocoagulation or in patient with DR that is not manageable with pharmacological therapy alone
  • Indications:
    • Severe 1-≥3 months duration non-clearing vitreous hemorrhage
    • Severe PDR or chronic or diffuse DME not responding to aggressive and extensive panretinal photocoagulation
    • PDR and vitreous opacities that interfere with vision or treatment 
    • Traction retinal detachment recently involving the macula
    • Combined traction and rhegmatogenous detachment
    • Progressive fibrovascular proliferation
    • Dense pre-macular subhyaloid hemorrhage
    • Rubeosis iridis and vitreous hemorrhage with opacity preventing adequate laser
  • May be considered in patients with center-involved DME with vitreoretinal traction and with persistent retinal thickening after 24 weeks of anti-VEGF treatment
  • May be considered in treatment-naive PDR patients with vitreous opacities and active neovascular or fibrovascular proliferation
  • Pars plana vitrectomy may improve visual acuity in selected patients with diffuse CSME that is unresponsive to previous macular laser photocoagulation and/or anti-VEGF therapy
  • Complications:
    • Recurrent vitreous hemorrhage
    • Endophthalmitis
    • Glaucoma
    • Retinal tear/detachment
    • Rubeosis iridis
    • Premature development of cataract
Editor's Recommendations
Special Reports