What are the main treatment methods for diabetic retinopathy?

Main Treatment Methods for Diabetic Retinopathy

The main treatment methods for diabetic retinopathy are anti-VEGF intravitreal injections (first-line for diabetic macular edema), panretinal laser photocoagulation (for proliferative disease), vitrectomy (for advanced complications), and optimization of systemic risk factors including glycemic control, blood pressure management, and lipid control with fenofibrate. 1

Treatment Based on Disease Stage

Non-Proliferative Diabetic Retinopathy (NPDR)

Mild to Moderate NPDR:

• Optimize systemic control as the primary intervention - this includes intensive glycemic control targeting near-normoglycemia, blood pressure control to <130/80 mmHg, and lipid management 1
• Consider adding fenofibrate for lipid control, which specifically slows retinopathy progression particularly in patients with very mild NPDR at baseline 2, 1
• ACE inhibitors or ARBs are both effective for blood pressure management in these patients 2, 1
• No laser photocoagulation is indicated at this stage 3

Severe NPDR:

• Panretinal laser photocoagulation may be considered in selected patients, especially those with poor adherence to follow-up, imminent cataract surgery, or pregnancy 3
• Laser reduces the risk of severe visual loss by approximately 50% when applied at severe NPDR stages 3
• However, laser is not routinely recommended for mild or moderate NPDR 3

Proliferative Diabetic Retinopathy (PDR)

Panretinal photocoagulation (PRP) remains the mainstay treatment for PDR with high-risk characteristics 1, 4

• The landmark Diabetic Retinopathy Study demonstrated that PRP reduced the risk of severe vision loss from 15.9% in untreated eyes to 6.4% in treated eyes, with greatest benefit in those with more advanced baseline disease (disc neovascularization or vitreous hemorrhage) 2, 1

Anti-VEGF therapy has emerged as an alternative to PRP:

• Intravitreal anti-VEGF injections are non-inferior to PRP for PDR and may provide superior visual outcomes 2
• However, anti-VEGF requires reliable patient follow-up for repeated injections 5
• Ranibizumab is FDA-approved for treatment of diabetic retinopathy 2

Diabetic Macular Edema (DME)

Anti-VEGF intravitreal injections are first-line treatment for center-involved DME with vision loss 1

• Three anti-VEGF agents are commonly used: bevacizumab, ranibizumab, and aflibercept 2
• Aflibercept (EYLEA HD) is FDA-approved for DME, with dosing every 12-16 weeks after initial monthly doses 6
• Most patients require near-monthly administration during the first 12 months, with fewer injections needed in subsequent years to maintain remission 2, 1
• Anti-VEGF therapy provides more effective treatment than laser monotherapy or combination therapy for central-involved DME 2

Laser photocoagulation:

• Remains the preferred treatment for non-center-involved DME 1
• Focal/grid laser is no longer first-line for center-involved DME, as anti-VEGF agents have superior outcomes 2, 7

Advanced Complications

Vitrectomy is indicated for:

• Non-clearing vitreous hemorrhage 4
• Tractional retinal detachment 4
• Pars plana vitrectomy with removal of the posterior hyaloid relieves tangential traction at the macula 5

Systemic Risk Factor Optimization

This is critical across all stages and works synergistically with ocular treatments:

Glycemic Control:

• Intensive glucose control targeting near-normoglycemia is the most important intervention to prevent and delay progression of diabetic retinopathy 1, 3
• Strict glucose control substantially reduces the risk and progression 3

Blood Pressure Management:

• Target <130/80 mmHg to decrease retinopathy progression 1
• Lowering blood pressure decreases progression, though tight targets (systolic <120 mmHg) do not provide additional benefit 2
• Both ACE inhibitors and ARBs are effective 2, 1

Lipid Control:

• Optimize serum lipid control to reduce risk or slow progression 1
• Fenofibrate specifically slows retinopathy progression, particularly with very mild NPDR at baseline 2, 1

Common Pitfalls to Avoid

• Do not delay referral to an ophthalmologist when macular edema or severe/proliferative retinopathy is present - immediate referral is required 1, 3
• Avoid rapid implementation of intensive glycemic management in patients with existing retinopathy, as this can cause early worsening 1
• Do not discontinue aspirin therapy due to concerns about retinal hemorrhage - aspirin does not increase the risk of retinal hemorrhage and is not contraindicated for cardioprotection 2, 1, 3
• Do not neglect blood pressure and lipid control while focusing only on glycemic control - all three systemic factors must be addressed 1
• Ensure adequate follow-up of patients with existing retinopathy, as inadequate monitoring leads to missed progression 1

Special Considerations

Pregnancy:

• Pregnancy in patients with type 1 diabetes may aggravate retinopathy and threaten vision, especially with poor glycemic control at conception 2
• Laser photocoagulation can minimize the risk of vision loss during pregnancy 2
• Women with pre-existing diabetes who become pregnant should be examined early and closely during pregnancy 1