What is the role of panretinal photocoagulation in the treatment of proliferative diabetic retinopathy?

Updated: Sep 02, 2021
  • Author: Abdhish R Bhavsar, MD; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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Answer

Panretinal photocoagulation (PRP) is the preferred form of treatment of proliferative diabetic retinopathy (PDR). [15, 16] It involves applying laser burns over the entire retina, sparing the central macular area, and may be performed using a variety of delivery systems, including the slit lamp, an indirect ophthalmoscope, and the EndoProbe.

Application starts in a circumference of 500 µm from the disc and 2 disc diameters from the fovea to wall off the central retina. Moderate intensity burns of 200-500 µm (gray-white burns) are placed 1 spot-size apart, except in areas of neovascularization where the entire frond is treated if DRS criteria are used, but most specialists today avoid directly treating neovascularization. This procedure is continued peripherally to achieve a total of 1200-1600 applications in 2 to 3 sessions.

The presence of high-risk PDR is an indication for immediate treatment.

In cases where macular edema and PDR coexist, laser treatments are performed: first, laser treatment is used for the macular edema; then for PDR, the PRP is spread over 3 to 4 sessions. If it is necessary to complete the 2 procedures at the same time, the PRP is applied initially to the nasal third of the retina.

The strategy for treating macular edema depends on the type and extent of vessel leakage. If the edema is due to focal leakage, microaneurysms are treated directly with laser photocoagulation. In cases where the foci of leakage are nonspecific, a grid pattern of laser burns is applied. Burns (100-200 μm) are placed 1 burn-size apart, covering the affected area.

The exact mechanism by which PRP works is not entirely understood. One theory is that destroying the hypoxic retina decreases the production of vasoproliferative factors, such as VEGF, thus reducing the rate of neovascularization. Another theory is that PRP allows increased diffusion of oxygen from the choroid, supplementing retinal circulation. The enhanced oxygen delivery also down-regulates vasoproliferative factor production and subsequent neovascularization.


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