Diabetic Retinopathy: Surgical Therapy

1st order

  • Panretinal laser therapy (coagulation of the entire retina (retina) except the macula/site of sharpest vision); indications:
    • Proliferative diabetic retinopathy (PDR):
      • Panretinal laser therapy should be performed
    • Nonproliferative diabetic retinopathy (NPDR):
      • Panretinal laser therapy should not be offered in cases of mild or moderate NPDR
      • In severe NPDR, panretinal laser coagulation may be considered in certain high-risk patients
  • Vitrectomy (vitreous removal; to be offered):
    • In the case of nonabsorbing vitreous hemorrhage or
    • In the presence of impending or existing tractional (“traction-related”) central retinal detachment (ablatio retinae).

    Possible complications: Retinal detachment after surgery (may also be due to advanced diabetes mellitus); post-operative bleeding into the vitreous space (can lead to significant visual impairment; cataract (cataract; lens opacity) in the period of 5 years in 8 of 10 patients.

  • Focal laser therapy (may be offered); indications:
    • Presence of clinically significant diabetic macular edema (accumulation of extracellular fluid (edema) in the area of the yellow spot (macula lutea) of the human eye) threatening visual acuity (vision) without foveal involvement (fovea: depression located in center of yellow spot)

Further notes

  • Note: According to a randomized trial, macular edema does not need to be treated by laser coagulation or injection of anti-VEGF drugs as long as there has been no worsening of visual acuity. The multicenter study enrolled 702 patients with diabetic macular edema (accumulation of extracellular fluid (edema) in the area of the yellow spot (macula lutea)) and a visual acuity of 20/25 or better. Patients were randomly assigned to three treatment strategies: first group received an intraocular injection with aflibercept every 4 weeks, the second group received laser coagulation, and the third group served as a control group. After 2 years of study the following result was found: the primary endpoint a worsening of visual acuity, occurred equally often in all three groups.Conclusion: Immediate anti-VEGF treatment may have protected the patients from complications (e.g. eye loss due to endophthalmitis). Furthermore, it should be mentioned that there was a more frequent increase in intraocular pressure during aflibercept treatment compared with the control group (8 versus 3%).
  • In cases of mild damage to the retina (retinal) at an early stage, laser treatment should not be performed.
  • A randomized clinical trial could show that compared with panretinal laser coagulation (see above), the benefit of intravitreal (“into the vitreous”) injection of the VEGF inhibitor ranibizumab in proliferative diabetic retinopathy could be at least comparable or even higher.