What are the treatment options for retina disorders?

Treatment Options for Retinal Disorders

The primary treatment options for retinal disorders include panretinal laser photocoagulation for proliferative diabetic retinopathy, intravitreal anti-VEGF injections for diabetic macular edema and proliferative retinopathy, and optimization of systemic factors such as glycemic control, blood pressure, and lipids to prevent progression of retinopathy. 1, 2

Diabetic Retinopathy Management

Prevention and Risk Factor Management

• Optimize glycemic control to reduce the risk or slow progression of diabetic retinopathy, aiming for near-normoglycemia 3
• Maintain blood pressure control with targets <130/80 mmHg to decrease retinopathy progression 3, 1
• Optimize serum lipid control to reduce the risk or slow progression of diabetic retinopathy 3, 1
• Consider adding fenofibrate, which may slow retinopathy progression particularly in patients with very mild nonproliferative diabetic retinopathy 3, 1

Screening and Early Detection

• Patients with type 1 diabetes should have an initial dilated eye examination within 5 years after diabetes onset 3
• Patients with type 2 diabetes should have an initial dilated eye examination at the time of diagnosis 3
• If no retinopathy is present and glycemia is well-controlled, exams every 1-2 years may be considered 3
• If any level of retinopathy is present, dilated retinal examinations should be performed at least annually 3
• Telemedicine programs using validated retinal photography with remote reading can be an appropriate screening strategy for diabetic retinopathy 3

Treatment 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, 4
• Ranibizumab has been shown to improve vision in patients with diabetic macular edema 4
• Most patients require near-monthly administration of intravitreal anti-VEGF agents during the first 12 months, with fewer injections in subsequent years 1

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 3, 1

For Proliferative Diabetic Retinopathy (PDR)

• Panretinal laser photocoagulation therapy is indicated to reduce the risk of vision loss in patients with high-risk proliferative diabetic retinopathy 3
• Panretinal photocoagulation has been shown to reduce the risk of severe vision loss from PDR from 15.9% to 6.4% 3
• Intravitreous injections of anti-VEGF (ranibizumab) are not inferior to traditional panretinal laser photocoagulation and are also indicated to reduce vision loss risk in PDR 3, 2

Age-Related Macular Degeneration (AMD)

• AMD is the leading cause of registered blindness in people over age 50 in western countries 5
• Treatment options include anti-VEGF therapy (intravitreal injections) for wet AMD 5
• Verteporfin therapy (photodynamic therapy) is effective for selected patients with AMD at high risk of central vision loss 5

Retinal Vascular Occlusive Disorders

• Retinal vascular occlusions require prompt diagnosis and management to prevent vision loss 6
• Treatment approaches differ between arterial and venous occlusions 6
• Anti-VEGF therapy may be beneficial in macular edema secondary to retinal vein occlusions 1

Special Considerations

Pregnancy and Diabetic Retinopathy

• Women with pre-existing diabetes who are planning pregnancy should be counseled on the risk of development/progression of diabetic retinopathy 3
• Eye examinations should occur before pregnancy or in first trimester, with monitoring every trimester and for 1-year postpartum 3
• Pregnancy may aggravate retinopathy and threaten vision, especially with poor glycemic control at conception 3

Common Pitfalls to Avoid

• Delaying referral to an ophthalmologist when macular edema or severe/proliferative retinopathy is present 3, 1
• Rapid implementation of intensive glycemic management in patients with existing retinopathy, which can cause early worsening 1
• Discontinuing aspirin therapy due to concerns about retinal hemorrhage - retinopathy is not a contraindication to aspirin therapy for cardioprotection 3, 1
• Inadequate follow-up of patients with existing retinopathy 3, 1
• Neglecting blood pressure and lipid control while focusing only on glycemic control 3, 1

Global Burden of Retinal Disorders

• Retinal disorders cause substantial visual burden globally 7
• Diabetic retinopathy accounts for the largest proportion of patients with visual impairment (60% of bilateral visual impairment) and blindness (64% of bilateral blindness) 7
• Other significant contributors to vision loss include AMD, myopic maculopathy, retinal vein occlusion, and rhegmatogenous retinal detachment 7
• Women, older patients, and those from less developed regions are more likely to suffer from vision loss due to retinal disorders 7