What are the treatment options for vision loss due to conditions like glaucoma, diabetic retinopathy, or age-related macular degeneration?

Treatment of Vision Loss

For vision loss from glaucoma, diabetic retinopathy, or age-related macular degeneration, immediate ophthalmology referral is essential, with specific treatments including topical pressure-lowering medications or laser for glaucoma, anti-VEGF injections or panretinal photocoagulation for diabetic retinopathy, and anti-VEGF injections for wet AMD or antioxidant vitamins for dry AMD. 1

Diabetic Retinopathy Management

Urgent same-day ophthalmology referral is required for any diabetic patient with visual symptoms, or for patients with diabetes >5 years (type 1) or any duration (type 2) without recent eye examination. 2

Immediate Treatment Priorities

• Optimize glycemic control immediately to prevent and delay retinopathy progression (Grade A evidence). 1, 2
• Optimize blood pressure control to reduce retinopathy progression (Grade A evidence). 1, 2
• Consider fenofibrate for patients with mild nonproliferative diabetic retinopathy to slow progression (Grade B evidence). 1, 2

Specific Interventions by Severity

For proliferative diabetic retinopathy or severe nonproliferative disease:

• Panretinal laser photocoagulation reduces severe vision loss from 15.9% to 6.4% and remains the traditional standard treatment (Grade A evidence). 1, 2
• Anti-VEGF therapy (ranibizumab) is non-inferior to laser photocoagulation and is equally indicated (Grade A evidence). 1, 2

For diabetic macular edema:

• Intravitreal anti-VEGF injections are indicated for central-involved macular edema threatening reading vision (Grade A evidence). 1

Critical Pitfall

Do not delay referral until proliferative disease develops—patients with severe nonproliferative retinopathy benefit from early laser treatment with 50% reduction in severe visual loss and vitrectomy risk. 1

Glaucoma Management

Medicated eye drops that reduce intraocular pressure are the first-line treatment to delay progression of vision loss in glaucoma patients. 3

• Topical beta-blockers (timolol) reduce both elevated and normal intraocular pressure by decreasing aqueous humor formation, with effects detectable within 30 minutes and lasting up to 24 hours. 4
• Laser trabeculoplasty lowers intraocular pressure and preserves vision in primary open-angle glaucoma, though long-term benefit data are still needed. 3

Important Contraindications

Timolol should not be used in patients with bronchial asthma, severe COPD, sinus bradycardia, second or third degree AV block, or cardiac failure. 4

Age-Related Macular Degeneration

Wet (Neovascular) AMD

Intravitreal anti-VEGF inhibitor injections are the primary treatment that can preserve vision in wet AMD (Grade A evidence). 1, 3

• Photodynamic therapy with verteporfin plus low-level laser is an alternative treatment option. 1
• Laser photocoagulation is no longer commonly used due to blind spots in the treatment area. 1

Dry AMD

Antioxidant vitamins and minerals are the treatment to reduce progression of dry AMD. 1, 3

Cataracts

Surgical removal of the natural lens followed by intraocular lens implantation is effective for improving visual acuity in cataract patients. 1

• Cataract surgery combined with uncorrected refractive error accounts for 55% of blindness and 77% of vision impairment in adults ≥50 years. 5
• Preoperative testing before cataract surgery does not improve outcomes and is not recommended. 3

Refractive Error

Corrective lenses effectively improve visual acuity in patients with refractive error, which is the most common cause of impaired visual acuity worldwide. 1, 5

Special Population: Pregnancy and Diabetes

Pregnant women with pre-existing type 1 or type 2 diabetes require eye examination before pregnancy or in the first trimester, then every trimester and for 1 year postpartum, as pregnancy accelerates retinopathy progression (Grade B evidence). 1, 2

• Laser photocoagulation can minimize vision loss risk during pregnancy. 1
• Women with gestational diabetes do not require screening as they are not at increased risk. 1, 2

Vision Rehabilitation

Patients experiencing vision loss should be referred for vision rehabilitation with an ophthalmologist or optometrist trained in low-vision care. 1

• Magnification devices, improved lighting, increased contrast, and assistive technologies can help maximize remaining vision. 1
• Counseling and peer support groups address the psychological impact of irreversible vision loss. 1