management of proliferative diabetic retinopathy

Last reviewed 01/2018

Principal goal is prevention with

  • systemic and local measures (1)
    • good glycaemic control
    • control of hypertension

Treatment is directed at regressing neovascularisation using Argon laser pan-retinal photocoagulation

  • the new vessels themselves are not targeted but photocoagulation is spread over a wide area in order to destroy ischaemic retina and remove the vasoproliferative stimulus
  • there is variable visual loss and night blindness.

Vitrectomy is indicated if a vitreous haemorrhage has not resolved spontaneously within 6 months or retinal detachment is suspected.

  • vitrectomy (2)
    • a surgical technique
      • approached from the pars plana,
      • vitreous excised
      • suctioning the gel done
      • replaced with aqueous fluid.
      • fibrous tissue removed
      • areas of retinal detachment flattened

Patients with neovascular glaucoma or high-risk proliferative diabetic retinopathy should receive prompt scatter photocoagulation (3)

Gene therapy for ocular neovascularization is still under study (4)

Future treatment prospects under trial include (5)

  • protein kinase C inhibitors,
  • intravitreal steroid,
  • anti-vascular endothelial growth factor agents,
  • angiotensin converting enzyme inhibitors,
  • growth hormone

Pan-retinal photocoagulation may prevent thrombotic glaucoma but once developed, this may be difficult to treat.

Untreated eyes with severe disease have about 40% risk of severe visual loss within two years.

Reference:

  1. American Academy of Ophthalmology, basic and clinical science course,2005-2006, retina and vitreous, section12, 99-119
  2. Ferris FL et al. Treatment of Diabetic Retinopathy.N Engl J Med 1999;341:667.
  3. Campochiaro PA.Gene therapy for ocular neovascularization. Curr Gene Ther. 2007 Feb;7(1):25-33.
  4. American Academy of Ophthalmology Retina Panel (2003). Diabetic Retinopathy,Preferred Practice Pattern® Guideline
  5. Yam JC et al. Update on the treatment of diabetic retinopathy.Hong Kong Med J. 2007 Feb;13(1):46-60.