What is the best treatment for Diabetic Retinopathy (diabetic retinitis)?

From the Guidelines

The best treatment for diabetic retinopathy involves a comprehensive approach focusing on both controlling diabetes and specific eye treatments, with anti-VEGF injections being the first-line treatment for most eyes with diabetic macular edema that involves the foveal center and impairs vision acuity, as indicated by the most recent guidelines 1.

Key Components of Treatment

• Tight glycemic control, aiming for HbA1c levels below 7%, along with management of blood pressure (target <130/80 mmHg) and lipids, is fundamental in reducing the risk or slowing the progression of diabetic retinopathy 1.
• For non-proliferative diabetic retinopathy without macular edema, regular monitoring every 6-12 months is recommended, while for proliferative diabetic retinopathy, panretinal photocoagulation (laser treatment) remains effective, though anti-VEGF injections are increasingly used as initial therapy 1.
• Anti-VEGF injections, such as ranibizumab (Lucentis), aflibercept (Eylea), or bevacizumab (Avastin), are the first-line treatments for diabetic macular edema, typically administered monthly initially, then as needed based on response 1.
• In advanced cases with vitreous hemorrhage or tractional retinal detachment, vitrectomy surgery may be necessary, and early detection through annual comprehensive dilated eye exams is crucial, as treatment is most effective before vision loss occurs 1.

Emerging Therapies and Considerations

• Other emerging therapies for retinopathy that may use sustained intravitreal delivery of pharmacologic agents are currently under investigation, offering potential future treatment options 1.
• The presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection, as aspirin does not increase the risk of retinal hemorrhage, according to the guidelines 1.

From the FDA Drug Label

After monthly treatment with ranibizumab 0.3 mg, the following clinical results were observed:

• Gain of ≥15 letters in visual acuity (%)
• Loss of <15 letters in visual acuity (%)
• Mean change in visual acuity (letters)

At Month 24, DR improvement by ≥3-steps in ETDRS-DRSS from baseline in subgroups examined were generally consistent with the results in the overall population.

Table 7 ≥3-Step and ≥2-Step Improvement at Month 24 in Study D-1 and Study D-2

• ≥3-step improvement from baseline in ETDRS-DRSS
• ≥2-step improvement from baseline in ETDRS-DRSS

The best treatment for Diabetic Retinopathy (diabetic retinitis) is ranibizumab 0.3 mg intravitreal injections as it has been shown to improve visual acuity and reduce the severity of diabetic retinopathy in patients with diabetic macular edema (DME) and diabetic retinopathy (DR) 2.

• Key benefits of ranibizumab 0.3 mg include:
  • Improvement in visual acuity
  • Reduction in the severity of diabetic retinopathy
  • Low rate of adverse events
• Treatment regimen: monthly intravitreal injections of ranibizumab 0.3 mg for 12 or 36 months, with the option to continue treatment based on clinical response.

From the Research

Treatment Options for Diabetic Retinopathy

• The main treatment options for diabetic retinopathy include laser photocoagulation, vitreous surgery, and intravitreous injection of glucocorticosteroids or a VEGF antagonist 3.
• Laser photocoagulation is an evidence-based treatment for proliferative retinopathy and macular edema 3.
• Vitreous surgery is indicated in cases of worsening vision due to a non-clearing vitreous hemorrhage or tractional retinal detachment 3.
• Anti-VEGF therapy has been shown to be effective in treating diabetic retinopathy, particularly in preventing vision loss and reducing the risk of macular edema and vitreous hemorrhage 4, 5, 6.

Comparison of Treatment Options

• A systematic review and meta-analysis found that anti-VEGF therapy was slightly better than panretinal photocoagulation at preventing vision loss, but the benefit was small and unlikely to be clinically meaningful 6.
• The same study found that anti-VEGF therapy was superior to panretinal photocoagulation at preventing macular edema and vitreous hemorrhage 6.
• A retrospective cohort analysis found that patients who switched from anti-VEGF injections to laser surgery were more likely to be Hispanic, male, and have fewer prescriptions 7.

Factors Associated with Treatment Outcomes

• The study by 5 found that approximately one-third of patients with diabetic retinopathy and macular edema experienced a clinically significant improvement in vision after 1 year of treatment with anti-VEGF therapy.
• The study by 6 found that the effectiveness of anti-VEGF therapy did not vary significantly over time, but that observational studies extending follow-up beyond 1 year are needed to investigate the longer-term effects of repeated anti-VEGF injections.
• The study by 7 found that patients who initiated anti-VEGF therapy had fewer prescriptions and were more likely to have initiated treatment in 2011 versus 2009.