diabetic retinopathy and maculopathy management

 Severe non proliferative DR

·   compliant patient without diabetic maculopathy: regular follow up

Recommendation: conditional

Evidence level: high [19-21]

·   non-compliant patient without diabetic maculopathy: laser PRP

Recommendation: Strong

Evidence level: high [19-21]

 PDR and high risk PDR without diabetic maculopathy and no abundant fibrosis

·   Non-compliant patient: laser PRP

Recommendation: strong

Evidence level: high [22-27]

· Compliant patient: Laser PRP or antiVEGF injection within 4 weeks;

Recommendation: strong

Evidence level: high [28-121]

PDR and high risk PDR with diabetic maculopathy

· Compliant patient: antiVEGF before PRP

Recommendation: moderate

Evidence level: moderate

Non compliant patient: laser PRP with focal/grid laser for the macula

Recommendation: moderate

Evidence level: high [22-121]

NCI-DME:

· Vision 6/12 or better in compliant patients: observe with control of risk factors.

 Recommendation: conditional

Evidence level: high [22-121]

· Vision 6/12 or better in non-compliant patients: laser treatment based on angiography and OCT

Recommendation:  strong

Evidence level: high [22-121]

·   Vision less than 6/12: no treatment and investigate to exclude ischemic maculopathy, if present, IVI of anti VEGF or steroids

Recommendation: consensous

Evidence level: low         [22-121]

CI-DME

·  Vision better than 6/12 compliant patient: observe with control of risk factors

Recommendation: Conditional

Evidence level: low [28-121]

· Vision better than 6/12 non compliant patient: laser treatment

Recommendation: strong

Evidence level: high [28-121]

·  Vision less than 6/12 in compliant patient: AntiVEGF

Recommendation: strong

Evidence: high [28-121]

·   Vision less than 6/12 in non compliant patient: laser

Recommendation: strong

Evidence: low [28-121]

·   Vision less than 6/12 with signs of vitreo-retinal traction: Vitrectomy +/-AntiVEGF

Recommendation: strong

Evidence: very low [22-118]

Refractory DME: received a minimum of three monthly injections of AntiVEGF with poor anatomical and functional response in compliant patient: intra vitreal steroids/vitrectomy only in places with subspecialty retinal service.

Recommendation: strong

Evidence level: low [22-118]

 

Remarks on treatment

1.  Laser PRP :

•   Laser for mild PDR (neovessels less than 1/3 DD) should be between 1200-1800 shot 500um size, moderate PDR (NVD: greater than third of disc diameter, and forward NVD extending beyond the disc margin or NVE: complexes in all quadrants, forward NVE in any quadrant) 2000-2500 shot, severe PDR (Large, NVE complexes in any quadrant, NVE with tractional retinal detachment, large, forward NVD covering whole optic disc surface, NVD with tractional retinal detachment.These cases are high risk of continued traction and haemorrhagic complications following PRP) full PRP 3000 sots

Evidence level: high [22-118]

•  If possible, PRP should be delivered on the same day of the diagnosis of high‑risk PDR and if not, within 2 weeks from the time of diagnosis.

Evidence level moderate [22-118]

•  PRP should be postponed until clinically significant macular edema (CSME) is treated.

Evidence level moderate [22-118]

•  Coexisting high-risk PDR and CSME should be treated with combined PRP plus intravitreal antivascular endothelial growth factor (VEGF) injection or macular laser photocoagulation (MPC).

Evidence level: very low [22-118]

• In cases with fresh vitreous hemorrhage, PRP is usually applied after intravitreal injection of anti‑VEGF when the ocular media is clear.

Evidence level: very low [22-118]

•  In patients with florid type DR, PRP may be applied with shorter intervals (3‑5 days between PRP sessions instead of 1‑4 weeks).

Evidence level: very low [22-118]

Recommendations for follow up laser therapy:

•  First follow up should be at three to four months – ideally at two months

Evidence level: high [22-118]

•  PDR: Retreatment is required if vessels have not regressed, or further new vessels develop [22-121]

2.   AntiVEGF monotherapy for PDR

•  Frequent, regular, follow up i.e., every two to three months for at least a year is an essential prerequisite for the treatment of PDR with AntiVEGF agents.

•  Repeat injections, if required. [119-120]

3. Vitrectomy

Recommendations for treatment

•  Early vitrectomy (within three months) is indicated for people with Type 1 DM who develop severe vitreous haemorrhage in whom severe PDR is suspected

Evidence level: high [123-127]

•  Consider early vitrectomy in eyes where PDR does not respond to extensive and aggressive laser PRP

Evidence level: moderate [123-127]

•  Consider vitreoretinal surgery to relieve vitreoretinal traction if the macular is detached or threatening to detach, to salvage some vision

Evidence level: very low [123-127]

•  Consider combined cataract surgery / vitrectomy in eyes with DR and/or DME with lens opacities, to enable subsequent management of PDR and/or DME.

Evidence: moderate [123-127]

Recommendations for practice

•  Counselling patients before treatment, regarding improving the control of their diabetes and comorbidities is essential.

The procedure should be explained, including the likely outcome as well as the need for and timing and frequency of follow up, the likelihood of repeat treatment and the need for lifelong care. [123-127]

Intravitreal injection before vitrectomy

•      Patients with PDR and active neovascularization who have been planned for vitrectomy may receive intravitreal anti‑VEGF injection within one week before surgery to minimize intraoperative and early

postoperative bleeding.

Evidence level: high [123-127]

• Patients with advanced DR and active fibrovascular tissue who are vitrectomy candidates may receive intravitreal anti‑VEGF injection within one week before the surgery to minimize the risk of bleeding during and after the surgical procedure.

Evidence level: high[123-127]

•  Extensive fibrovascular tissue increases the risk of traction retinal detachment following intravitreal injection of anti‑VEGF drugs; the time interval between the injection and vitrectomy should be not more than 2‑3 days in such cases.

Evidence level: moderate [123-127]

➡️Updates:

To keep these recommendations up to date and ensure its validity it will be periodically updated. This will be done whenever new strong evidence is available and necessitates updating.