OSN Retina 150 Survey

Do you perform peripheral (wide-field or montage) fluorescein angiography guided panretinal laser photocoagulation for ischemic retinopathies (eg, proliferative diabetic retinopathy or ischemic central retinal vein occlusion) or do you apply scatter laser in another way?

Perspective

Timothy W. Olsen

For newly ischemic or proliferative patients, I like to see a wide-field or montage fluorescein angiogram if possible, yet it is not critical. For high-risk proliferative diabetic retinopathy, I next look to see if the macula is affected by clinically significant macular edema. If these are both present, I begin by injecting anti-VEGF agents. Once the macular edema is under control, I will add panretinal laser ablation to the entire periphery. I prefer to use the indirect ophthalmoscope for laser application and treat more anterior to the equator and concentrate in areas of ischemia. When there has been associated macular edema, then I will place the peripheral laser in multiple sessions (two to four). I’ve been seeing much less anterior segment neovascularization in CRVO since using anti-VEGF.

Timothy W. Olsen, MD

Disclosure: Olsen’s financial disclosures include RO-1AG025392, NIH/NEI:R44 EY016229, RPB unrestricted grant, Emtech Biotechnology grant, Georgia Research Alliance, Dobbs Foundation and Johnson & Johnson.

Perspective

Jennifer Lim

Regardless of FA findings, I ablate the entire peripheral retina completely on most patients. The VEGF output can be decreased with PRP performed as per the ETDRS or CVOS protocols. Eyes with PDR on FA show significant leakage and focal areas of ischemia. I typically ask the photographer to perform “sweeping” views of the periphery to capture the degree of peripheral ischemia or neovascularization. However, I do not apply laser only in the area of ischemia. I believe that there are areas of borderline ischemia in these eyes and that these areas are producing VEGF before frank ischemia is seen on the FA. This VEGF results in the neovascularization and in macular edema.

Jennifer I. Lim, MD

Disclosure: Lim receives honoraria from and is on the advisory boards of Genentech and Regeneron.

Perspective

K. Bailey Freund

In the offices where I have ultra wide-field imaging available, my preference is to use that as a guide to best apply scatter laser treatment. There are no real good randomized trials showing that this sort of targeted approach is more or less effective for treating proliferative diabetic retinopathy or ischemic central retinal vein occlusion. But, there is good scientific rationale for focusing the laser in those areas that are poorly profused as a way to maximize the benefit of treatment while minimizing side effects, such as decreased night vision and perhaps some loss of peripheral vision when extensive scatter laser treatment is done. In my experience, I have been able to perform effective scatter laser treatments using this approach while minimizing some of the side effects and some of the discomfort for patients.

K. Bailey Freund, MD

Disclosure: Freund is a consultant for Genentech and Regeneron and receives research support from Genentech.