What is the treatment for diabetic retinopathy?

Treatment of Diabetic Retinopathy

The treatment of diabetic retinopathy requires a combination of systemic glycemic control, blood pressure management, and specific ocular interventions including anti-VEGF injections, laser photocoagulation, and intravitreal corticosteroids based on disease severity and presence of macular edema. 1

Disease Classification and Screening

• Diabetic retinopathy is classified as non-proliferative diabetic retinopathy (NPDR) or proliferative diabetic retinopathy (PDR), with diabetic macular edema (DME) potentially occurring at any stage 1
• Patients with type 1 diabetes should have an initial comprehensive eye examination within 5 years after diagnosis 1
• Patients with type 2 diabetes should have an initial comprehensive eye examination at the time of diagnosis 1
• If no retinopathy is present and glycemia is well-controlled, examinations every 1-2 years may be considered; otherwise, annual examinations are recommended 1
• Pregnant women with pre-existing diabetes should be examined in the first trimester and monitored every trimester due to potential rapid progression 1

Systemic Management

• Optimize glycemic control (HbA1c) to reduce the risk or slow the progression of diabetic retinopathy 1
• Optimize blood pressure control to reduce the risk or slow the progression of retinopathy 1
• Manage serum lipids to help slow retinopathy progression 1, 2
• Note that aspirin therapy for cardioprotection is not contraindicated in patients with diabetic retinopathy, as it does not increase the risk of retinal hemorrhage 1

Treatment for Non-Proliferative Diabetic Retinopathy (NPDR)

• Mild to moderate NPDR without macular edema typically requires monitoring without specific ocular intervention 1
• Severe NPDR may warrant consideration for panretinal photocoagulation (PRP) in some cases to prevent progression to PDR 1
• Promptly refer patients with severe NPDR to an ophthalmologist experienced in managing diabetic retinopathy 1
• Anti-VEGF therapy may be considered for patients with severe NPDR to prevent progression to PDR 3, 4

Treatment for Proliferative Diabetic Retinopathy (PDR)

• Promptly refer patients with any level of PDR to an ophthalmologist experienced in managing diabetic retinopathy 1
• Panretinal laser photocoagulation (PRP) remains the mainstay treatment for PDR to reduce the risk of severe vision loss 1
• Intravitreal anti-VEGF injections (such as ranibizumab or aflibercept) are effective alternatives to PRP for PDR and may lead to noninferior or superior visual acuity outcomes 1, 3
• Anti-VEGF treatment for PDR has been associated with less peripheral visual field loss, fewer vitrectomy surgeries, and lower risk of developing diabetic macular edema compared to PRP 3, 5
• Patients should avoid activities that cause Valsalva maneuvers or substantially increase blood pressure if they have PDR 6

Treatment for Diabetic Macular Edema (DME)

• For center-involved diabetic macular edema with vision loss, intravitreal anti-VEGF agents are the first-line treatment 1
• FDA-approved anti-VEGF agents include ranibizumab and aflibercept, which have demonstrated efficacy in improving visual acuity in patients with DME 5, 4
• Laser photocoagulation (focal/grid) remains the preferred treatment for non-center-involved diabetic macular edema 1
• Intravitreal corticosteroids may be considered as an alternative treatment option for DME in certain cases 1, 7
• Combination therapy using anti-VEGF injections followed by focal/grid laser may provide sustained response in some cases of DME 7

Follow-up and Monitoring

• Patients with any level of diabetic retinopathy should have at least annual dilated eye examinations 1
• If retinopathy is progressing or sight-threatening, examinations will be required more frequently 1
• For patients receiving anti-VEGF therapy, follow-up should occur according to the treatment protocol, typically every 4-8 weeks initially 3, 5
• Continued monitoring of systemic factors (glycemic control, blood pressure, lipids) is essential alongside ocular treatment 1, 2

Special Considerations

• The presence of diabetic kidney disease often correlates with worsening retinopathy and may require coordinated care between ophthalmologists and nephrologists 1, 8
• Patients with PDR should avoid activities that dramatically increase intraocular pressure or cause Valsalva maneuvers 6
• Early intervention is critical, as the benefits of good glycemic control continue to accrue over many years despite subsequent comparable glycemic control (metabolic memory) 9
• Emerging evidence suggests retinal neurodegeneration is an early event in diabetic retinopathy pathogenesis, which may lead to future neuroprotective treatment strategies 2, 10