Why do patients still require surgery for the late complications of Proliferative Diabetic Retinopathy?

Abstract

Aim To briefly review and discuss the literature on why patients still require surgery for the late complications of proliferative diabetic retinopathy (PDR). Methods: Literature review. Results The reasons for incomplete coverage of screening and screening failures can be divided into non-modifiable and potentially modifiable risk factors. The non-modifiable group includes duration of diabetes, age, genetic predisposition, ethnic differences, and the various reasons for vitrectomy when optimum laser treatment has been applied at the appropriate stage of the disease process. The potentially modifiable group includes glycaemic control, blood pressure control, lipid control, and cessation of smoking in type 1 diabetes. Other potentially modifiable factors include adequacy of screening, including reaching the regular non-attender, and attempting to modify the psychological factors that lead to late presentations including depression and eating disorders. Other potentially modifiable risk factors are optimising laser treatments and the potential use of anti-VEGF therapy to prevent vitrectomy in iris neovascularisation and neovascular glaucoma. Conclusion Surgery for the late complications of PDR continues to be required even in some patients who have received optimal medical care and optimal laser treatment. There are certain modifiable risk factors that could be altered and further research is needed in specific fields, particularly with regard to the adequacy of laser treatments, the use of anti-VEGF agents in iris neovascularisation, and in the role of psychological support in reducing the type of late complications leading to surgery for PDR.

Surgical management of diabetic retinopathy

“…[5] Other factors influencing the decision to perform PPV include degree of improvement or progression of anterior segment neovascularization, previous panretinal photocoagulation, the visual acuity, and the preference or needs of the patient. [1920] Simple vitreous hemorrhage clears spontaneously through the zonules via aqueous outflow. The presence of red blood cells in the anterior chamber indicates the patency of this outflow channel.…”

Intravitreal aflibercept compared with panretinal photocoagulation for proliferative diabetic retinopathy: the CLARITY non-inferiority RCT

“…2 However, despite better control of these well-established risk factors, good uptake of established national diabetic retinopathy screening programmes in many countries and improved patient awareness, diabetic retinopathy remains a significant morbidity, indicating the need for alternative management options for this condition. [3][4][5] The two vision-threatening complications of diabetic retinopathy are diabetic macular oedema (DMO) and proliferative diabetic retinopathy (PDR). DMO is caused by accumulation of excess extracellular fluid in the macula.…”

Excerpt from the Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of diabetic retinopathy

“…If the IOP does not remain controlled after this treatment approach, a glaucoma specialist should be consulted to provide a definitive treatment to control IOP. 307 This may include trabeculectomy with or without mitomycin C, 308,309 a tube shunt procedure, or cyclophotocoagulation.…”