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Experts debate best first-line treatment for diabetic retinopathy
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HONG KONG — A panel of retina experts at the World Ophthalmology Congress here debated the merits of laser, anti-VEGF and triamcinolone treatment for diabetic retinopathy.
Donald D'Amico, MD; Charles Wilkinson, MD; Dennis SC Lam, MD, FRCS, FRCOphth; George A. Williams, MD; Peter E. Liggett, MD; Quan-Dong Nguyen, MD; and Thomas J. Wolfensberger, MD, participated in the panel, led by Dr. D'Amico. Dr. D'Amico began by asking the participants their opinion on laser as a first-line treatment for non-traction diabetic retinopathy.
"I still consider photocoagulation in the ETDRS technique the standard of care for most patients presenting with non-traction diabetic retinopathy," Dr. Williams began.
Dr. Lam quickly countered that there are many other choices available if fluorescein angiography and optical coherence tomography do not show structural abnormalities.
"With structural things, we go for surgery, but if not, then there is a choice and laser is only one of the choices," Dr. Lam said. "I would say less than 20% of the patients are receiving quick laser. The majority might get IVT or Avastin or combination treatment."
He said if he does choose to do laser, he will administer Avastin (bevacizumab, Genentech) 2 weeks prior to maximize the effect of the laser therapy.
Dr. Liggett said, "I agree with Dr. Lam. I'm a little leery of the laser except when it's very focal leakage. I think you can do a lot more damage."
The differentiation between focal and diffuse leakage was Dr. Wolfensberger's requirement for choosing between laser therapy and an alternative.
"I agree with George Williams on the laser for focal leakage. I think probably everyone on the panel would agree on that. I think the problem starts when you have diffuse leakage either straightaway for the first time or after laser treatment," he said. "I actually do a lot of sub-Tenon injections of triamcinolone, and I've been quite encouraged by later literature in the last year in Japan and Korea."
Depending on the anatomy of the sub-Tenon space, Dr. Wolfensberger said a physician can inject up to 40 mg of triamcinolone, but Dr. Lam said he found that amount ineffective.
"We are using 80 mg, which has a very prolonged effect, and the ocular side effects are minimal, especially on the ocular hypertension," Dr. Lam said.
Dr. D'Amico asked if the panelists agreed that "the blush is off the rose" of triamcinolone overall.
"Long-term follow-up is a difficult thing, and the longer I follow my triamcinolone patients, the more disappointed I am with the results," Dr. Williams answered.
"I think triamcinolone alone is not adequate, but it is a very strong agent. It's better than Avastin alone," Dr. Lam said, suggesting combination therapy.