What is the treatment for diabetic retinopathy?

Treatment for Diabetic Retinopathy

The treatment for diabetic retinopathy includes optimizing glycemic control, blood pressure management, panretinal laser photocoagulation for proliferative disease, and anti-VEGF therapy for diabetic macular edema, with prompt referral to an ophthalmologist for any level of macular edema or severe/proliferative retinopathy. 1

Prevention and Risk Factor Management

• Optimize glycemic control to reduce the risk or slow the progression of diabetic retinopathy, aiming for near-normoglycemia 1
• Maintain blood pressure control with targets <130/80 mmHg to decrease retinopathy progression (note that systolic targets <120 mmHg do not provide additional benefits) 1, 2
• ACE inhibitors and ARBs are both effective treatments for blood pressure control in patients with diabetic retinopathy 1, 2
• Optimize serum lipid control to reduce the risk or slow progression of diabetic retinopathy 1, 2
• Consider adding fenofibrate, which may slow retinopathy progression particularly in patients with very mild nonproliferative diabetic retinopathy 1, 2
• Avoid rapid reductions in HbA1c when intensifying glucose-lowering therapies, as this can cause initial worsening of retinopathy 2, 3

Screening and Referral

• Patients with type 1 diabetes should have an initial dilated eye examination within 5 years after diabetes onset 1
• Patients with type 2 diabetes should have an initial dilated eye examination at the time of diagnosis 1
• If no retinopathy is present and glycemia is well-controlled, exams every 1-2 years may be considered 1
• If any level of retinopathy is present, dilated retinal examinations should be performed at least annually 1
• Promptly refer patients with any level of macular edema, severe nonproliferative diabetic retinopathy, or any proliferative diabetic retinopathy to an ophthalmologist experienced in managing diabetic retinopathy 1

Treatment Options Based on Disease Stage

For Diabetic Macular Edema (DME)

• Anti-VEGF therapy (intravitreal injections) is the first-line treatment for center-involved diabetic macular edema with vision loss 1
• Ranibizumab is FDA-approved for the treatment of diabetic retinopathy and has been shown to improve vision in patients with diabetic macular edema 1, 4
• Most patients require near-monthly administration of intravitreal anti-VEGF agents during the first 12 months, with fewer injections in subsequent years 1
• Laser photocoagulation remains the preferred treatment for non-center-involved diabetic macular edema 1
• Intravitreal corticosteroids can also be used to treat vision-threatening diabetic macular edema 1, 5

For Nonproliferative Diabetic Retinopathy (NPDR)

• Mild to moderate NPDR: Continue optimizing systemic factors (glycemic control, blood pressure, lipids) 1
• Severe NPDR: Consider panretinal laser photocoagulation, especially in patients with type 2 diabetes or poor follow-up 1

For Proliferative Diabetic Retinopathy (PDR)

• Panretinal laser photocoagulation (PRP) remains the mainstay treatment for proliferative diabetic retinopathy 1
• PRP has been shown to reduce the risk of severe vision loss from PDR from 15.9% to 6.4%, with greatest benefit in those with more advanced disease 1
• Anti-VEGF therapy may be considered as an alternative or adjunct to PRP in selected cases 1, 5
• Vitrectomy may be necessary for complications such as vitreous hemorrhage and tractional retinal detachment 5, 6

Special Considerations

• Pregnancy is associated with rapid progression of diabetic retinopathy; women with pre-existing diabetes who become pregnant should be examined early and closely during pregnancy 1
• Women with gestational diabetes do not require eye examinations during pregnancy 1
• Retinopathy is not a contraindication to aspirin therapy for cardioprotection, as aspirin does not increase the risk of retinal hemorrhage 1

Treatment Algorithm

1. Initial Management:

   • Optimize glycemic control (target HbA1c ≤7%) 1, 2
   • Control blood pressure (<130/80 mmHg) preferably with ACE inhibitors or ARBs 1, 2
   • Manage dyslipidemia 1, 2

2. For Diabetic Macular Edema:

   • Center-involved with vision loss: Anti-VEGF intravitreal injections 1, 4
   • Non-center-involved: Focal/grid laser photocoagulation 1

3. For Severe NPDR or PDR:

   • Panretinal laser photocoagulation 1
   • Consider anti-VEGF therapy as adjunctive treatment 1, 5

4. For Advanced Complications:

   • Vitrectomy for vitreous hemorrhage or tractional retinal detachment 5, 6

Common Pitfalls to Avoid

• Delaying referral to an ophthalmologist when macular edema or severe/proliferative retinopathy is present 1
• Rapid implementation of intensive glycemic management in patients with existing retinopathy, which can cause early worsening 1, 3
• Discontinuing aspirin therapy due to concerns about retinal hemorrhage 1
• Inadequate follow-up of patients with existing retinopathy 1
• Neglecting blood pressure and lipid control while focusing only on glycemic control 1, 2