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Diabetic Retinopathy

Prognosis

People who maintain healthy, active lifestyles and who optimize their blood sugar control have the best chance of slowing progression of diabetic retinopahy and preserving good vision. It is very important that people with diabetes mellitus undergo at least an annual eye exam, whether or not they have any vision symptoms. It is important to remember that diabetic retinopathy may progress and not cause any symptoms. It is also very important for people to understand that their blood glucose (sugar) control should be as good as possible with the goal of keeping the hemoglobin A1C level at a target level set by the physician guiding the treatment of the blood sugars.

Treatment

Injections

Medicines injected into the eye such as anti-VEGF drugs (eg. Lucentis, Eylea, and Avastin) and steroids (eg.  Triamcinolone, Ozudex, and Iluvien) are now commonly used to treat diabetic macular edema and some of the proliferative manifestations of the condition.  Both anti-VEGF and steroid medications have been proven in large-scale studies to be highly effective in reducing macular edema and improving vision.  The anti-VEGF agents are generally considered first line therapy for treating most cases.  Repeat injections may be necessary for long-term control of the problems.

The injections are performed in the office using topical drop anesthesia. They are very well tolerated and complications are rare. There is a very small risk of infection with any eye injection. Steroid injections also may be associated with elevating the pressure of the eye or causing progression of cataract. People should discuss risks and benefits of all treatments, including injection therapies with their eye specialist.

Laser

Laser photocoagulation is a well-established treatment for diabetic retinopathy. A laser delivers a split-second burst of intense light energy to treat leaky retinal blood vessels or promote shrinkage of abnormal blood vessels (neovascularization.) Laser photocoagulation has been proven in large clinical trials to significantly reduced the risk of both moderate and severe vision loss in people with diabetic retinopathy.

Laser photocoagulation is performed in the office setting with the patient seated in front of the laser unit. The eye is anesthetized with drops, and a contact lens in placed on the eye to focus the laser-aiming beam. People will experience bright flashes of lights and occasionally a pinching sensation, although many people will have no sensation of the laser at all. Some people may experience discomfort during laser photocoagulation, but generally it is a well tolerated office procedure.

There are two main types of laser treatments in diabetic retinopathy. One is called focal laser and this is the technique used to control diabetic macular edema. It is performed in one session, is generally painless, and can take up to 2 to 3 months to see the desired "drying" effect. The other type of laser treatment is called panretinal (or "scatter") photocoagulation. These are longer, more extensive treatments that are used to shrink abnormal vessels and reduce the number or severity of vitreous hemorrhages. Panretinal laser treatments may be divided into several sessions and can be associated with some ache in the eye during or after the treatment. The desired effects may take 4 to 6 weeks or more. Both focal and panretinal laser treatments may need to be repeated to control the diabetic retinopathy problems.

In general, laser treatments are intended to stabilize or prevent progression of various diabetic retinopathy complications and may or may not result in noticeable vision improvement. The best results with the best chances of preserving a good level of vision are achieved when diabetic retinopathy-related problems are caught early. Lastly, laser treatments may not work in everyone and other treatments (below) may be needed.

Vitrectomy

People with diabetic retinopathy may require vitrectomy surgery in an operating room setting. A vitrectomy is performed when there is bleeding or retinal traction that is causing loss of vision in people with advanced diabetic retinopathy. In this surgical procedure, small instruments are inserted into the eye under microscopic visualization, and both the vitreous hemorrhage and any scar tissue are removed. The vitreous gel typically is replaced with clear fluids at the end of the case. Laser photocoagulation may be performed at the time of surgery, and in some cases, a gas bubble or silicone oil may be placed to hold the retina in position if there are retinal holes or detachment. The prognosis for people who require vitrectomy surgery depends upon the status of the underlying diabetic retina.

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