Should severe proliferative diabetic retinopathy (PDR) with diabetic macular edema (DME) and vitreous hemorrhage be treated with only anti-vascular endothelial growth factor (anti-VEGF) therapy?

From the Guidelines

No, severe proliferative diabetic retinopathy (PDR) with diabetic macular edema (DME) and vitreous hemorrhage should not be treated with anti-VEGF therapy alone. The recommended approach is a combination of treatments. Initially, anti-VEGF injections such as ranibizumab (Lucentis), aflibercept (Eylea), or bevacizumab (Avastin) should be administered, typically at doses of 0.3-0.5 mg per injection, as shown in studies such as DRCR.net Protocol T 1. However, panretinal photocoagulation (PRP) laser therapy is also essential to address the neovascularization causing the vitreous hemorrhage. In cases with significant vitreous hemorrhage that doesn't clear within 1-3 months or with tractional retinal detachment, vitrectomy surgery is indicated. This multimodal approach is necessary because anti-VEGF therapy alone may temporarily reduce neovascularization and macular edema, but doesn't provide the long-term regression of abnormal blood vessels that PRP offers, as noted in the diabetic retinopathy preferred practice pattern 1. Additionally, the mechanical complications of vitreous hemorrhage often require surgical intervention for complete resolution and to prevent further vision loss.

Some key points to consider in the management of PDR with DME and vitreous hemorrhage include:

• The importance of patient compliance with follow-up, as highlighted in the diabetic retinopathy preferred practice pattern 1
• The potential benefits of combining anti-VEGF therapy with PRP, as demonstrated in DRCR.net Protocol S 1
• The need for individualized treatment plans, taking into account factors such as the severity of the disease, the presence of macular edema, and the patient's overall health status, as discussed in the diabetic retinopathy preferred practice pattern 1
• The role of vitrectomy surgery in cases with significant vitreous hemorrhage or tractional retinal detachment, as noted in the example answer

Overall, a comprehensive approach that incorporates anti-VEGF therapy, PRP, and vitrectomy surgery as needed is likely to provide the best outcomes for patients with severe PDR, DME, and vitreous hemorrhage, as supported by the evidence from studies such as DRCR.net Protocol T 1 and the diabetic retinopathy preferred practice pattern 1.

From the Research

Treatment of Severe Proliferative Diabetic Retinopathy (PDR) with Diabetic Macular Edema (DME) and Vitreous Hemorrhage

• The use of anti-vascular endothelial growth factor (anti-VEGF) therapy for the treatment of severe PDR with DME and vitreous hemorrhage has been studied in several clinical trials 2, 3, 4, 5, 6.
• According to the studies, anti-VEGF therapy can be effective in improving visual acuity and reducing retinal thickness in patients with DME 2, 4.
• However, the use of anti-VEGF therapy alone for the treatment of PDR with vitreous hemorrhage may not be sufficient, and combination therapy with panretinal photocoagulation (PRP) or pars plana vitrectomy (PPV) may be necessary 3, 5, 6.
• The studies suggest that combination therapy with anti-VEGF and PRP may be more effective in reducing the risk of vitreous hemorrhage and improving visual acuity compared to anti-VEGF therapy alone 3, 6.
• Additionally, the use of anti-VEGF therapy as an adjunct to PPV may be beneficial in reducing the recurrence of vitreous hemorrhage 4, 5.

Key Findings

• Anti-VEGF therapy can improve visual acuity and reduce retinal thickness in patients with DME 2, 4.
• Combination therapy with anti-VEGF and PRP may be more effective in reducing the risk of vitreous hemorrhage and improving visual acuity compared to anti-VEGF therapy alone 3, 6.
• Anti-VEGF therapy as an adjunct to PPV may be beneficial in reducing the recurrence of vitreous hemorrhage 4, 5.
• The choice of treatment should be individualized based on the patient's specific condition and preferences 6.