ASRS outlines management guidelines for diabetic retinopathy without DME
The American Society of Retina Specialists provided guidance on the management of nonproliferative and proliferative diabetic retinopathy without diabetic macular edema in an article in Journal of VitreoRetinal Diseases.
“As retina specialists, we play an integral role in the diabetes management team,” Yoshihiro Yonekawa, MD, of Mid Atlantic Retina, and colleagues wrote. “Landmark studies have established practice patterns, and recent advances hold promise in further improving patient outcomes. Many treatment options are available now, and we recommend a thoughtful approach for the individual patient.”
Yonekawa and colleagues proposed clinicians monitor patients’ glycemic factors and blood pressure over time, as both play a role in diabetic retinopathy (DR) development and progression. They also recommended monitoring serum lipids; while serum lipids have not been reliably linked to DR, fenofibrate may have decreased the progression of retinopathy in the ACCORD and FIELD studies.
Panretinal photocoagulation (PRP) is the standard of care for proliferative diabetic retinopathy (PDR), established by the Early Treat Diabetic Retinopathy Study and the Diabetic Retinopathy Study (DRS). However, due to technological advancements, Yonekawa and colleagues suggested using pattern delivery systems with a higher number of spots over single-spot delivery, although they noted there was no difference in outcomes between single and multiple sessions.
Despite PRP being the standard of care, the authors wrote that anti-VEGF agents are a noninferior option for PDR treatment and could be used alone or together with PRP. They suggested using anti-VEGF agents in visually significant DME and using PRP when close follow-up and frequent injections are not possible.
The authors upheld the following guidelines, established in the DRS, for use of PRP in severe nonproliferative diabetic retinopathy (NPDR):
- treatment of one eye in bilateral severe NPDR;
- treatment of eyes with significant retinal ischemia;
- treatment of the second eye when the first eye progressed from deferred treatment;
- and treatment in cases of pregnancy or development of renal failure.
Yonekawa and colleagues wrote that there is increasing evidence that anti-VEGF treatment improves the Diabetic Retinopathy Severity Scale in NPDR. However, whether it is a long-term solution is undetermined.
Overall, management for NPDR and PDR without DME should be based on clinical practice guidelines, with final decisions made on an individual basis.
“Every patient is unique, and our hope is that individual patients will receive the best treatment for their particular ophthalmic, systemic and social needs,” the authors wrote.
Perspective
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This paper is a summary of multiple other studies. No new information is presented, but it does summarize diabetic retinopathy treatment protocols.
There was decreased progression to high-risk PDR when mild, moderate, severe and very severe NPDR was treated with prophylactic PRP. There is visual improvement with use of anti-VEGF agents in patients with moderately severe and severe NPDR with DME. Comparative studies of intravitreal ranibizumab, aflibercept and bevacizumab suggest no difference at 2 years between the medications in NPDR with DME.
Light PRP of patients with early PDR results in less vision loss and visual field constriction but had double the progression to high-risk PDR when compared with full PRP. This implies that the PRP treatment type should be adjusted based on the severity of the disease. All studies noted improvement in vision with use of anti-VEGF in patients with PDR with macular edema. Patients with DME and PDR may do best when treated with both anti-VEGF and PRP. Therefore, combination therapy may be the best approach for most patients.
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