Diabetic Retinopathy Management Guidelines

Rahul Chakrabarti; C Alex Harper; Jill Elizabeth Keeffe


Expert Rev Ophthalmol. 2012;7(5):417-439. 

In This Article

Treatment of DR: Laser Photocoagulation & Vitrectomy

The indications and timing for photocoagulation and vitrectomy achieved consensus across all guidelines. Laser photocoagulation was consistently observed as the standard practice for treating DR. The NHMRC, AAO, WHO, SIGN, International Society for Pediatric and Adolescent Diabetes and RCO all specified the timing and type of photocoagulation in accordance with the strength of evidence from ETDRS[134] and DRS.[2] Laser photocoagulation was indicated in patients with Type 1 and Type 2 DM with new vessels elsewhere in the presence of vitreous hemorrhage, or with new vessels on the optic disc with or without vitreous hemorrhage. Patients with severe or very-severe NPDR were to be considered for pan-retinal photocoagulation. Furthermore, all guidelines recommended modified ETDRS grid laser photocoagulation in the setting of clinically significant macular edema when macular ischemia is absent. Guidelines also acknowledged the possible adverse effects of laser by suggesting that evaluation of risk and benefits was required when considering photocoagulation for less severe retinopathy. The RCO, Pacific Island, South African, Kenyan and Aravind guidelines did not specify the type of laser used for clinical severity of retinopathy. However, these guidelines were designed principally to guide screening and referral practice to an ophthalmologist for patients with any vision-threatening retinopathy.

Similarly, there was consensus regarding the timing of vitrectomy. The indications and rationale for vitrectomy were derived from the sentinel findings from the Diabetic Retinopathy Vitrectomy Study that demonstrated statistically significant recovery of visual acuity in patients with Type 1 DM.[135] Vitrectomy was indicated across all guidelines recommending vitrectomy in the setting of advanced DR including severe PDR with nonresolving vitreous hemorrhage or fibrosis, retinal detachment or areas of retinal traction that threatened the macula. While the rationale for vitrectomy has changed little since the Diabetic Retinopathy Vitrectomy Study, thresholds for performing surgery have lowered due to the advances in surgical methods and instrumentation.[136,137] The NHMRC was the only guideline to incorporate more recent evidence supporting the consideration of vitrectomy in the management of persistent diffuse macular edema.[138,139]