Treatment
Every effort should be made to correct the modifiable risk factors of diabetic retinopathy in an attempt to slow, halt or even reverse its progression.
Regardless of the treatment being undertaken, any changes in vision should be reported to the ophthalmologist immediately.
Early stages
Typically, during the earlier (non-proliferative) stages of diabetic retinopathy, a person’s vision will be monitored carefully by their eye specialist.
In the past, treatment may not have been recommended unless vision had been affected. However recently, the drug fenofibrate, which is normally used for treating people with high or unbalanced blood lipid levels, has been shown to reduce the risk of diabetic retinopathy progressing by about 30%. It appears to provide benefit even for people who have normal lipid levels. If you are not already taking this drug, and have any degree of diabetic retinopathy, you should discuss this treatment with your ophthalmologist.
Most people with retinopathy will need regular follow-up exams by an eye health professional to monitor the level of disease.
Advanced stages
Several treatment options are available for more advanced vision-threatening diabetic retinopathy, depending on the stage and location of the disease.
Diabetic macular edema (DME)
The treatment for DME has changed significantly in recent years. Previously, focal or grid laser was the preferred treatment approach. Nowadays, for most people with DME, the usual treatment is a series of injections into the eye using an anti-VEGF drug or in some cases (particularly in people who have had cataract surgery) a steroid. In most people, this effectively reduces the swelling, and for many, some improvement in vision will occur. Some people may also require additional focal or grid laser.
Injection treatment
The choice of the most appropriate drug should be discussed with the ophthalmologist. The following applies regardless of which drug is used:
- An anaesthetic is given before the injection. Very little, if any pain should be experienced during the procedure
- It is a quick procedure and usually occurs in the ophthalmologist’s rooms, although some patients may be treated by the ophthalmologist in a day-stay unit
- For those being treated with an anti-VEGF drug, injections are typically given every month for a few months, but may then be given less frequently once the swelling is controlled. For some people, the ophthalmologist may decide to cease the injections after a period, however others may need to continue to receive injections on an ongoing basis
- Even if vision has stabilised or improved, treatment may still need to be continued. This is dependent on each person’s individual medical circumstance and discussion between the ophthalmologist and patient
- For those being treated with a steroid, the ophthalmologist will recommend the frequency of injections
- The treatment schedule should always be followed, and cease only when advised by the ophthalmologist
- Appointments with the ophthalmologist should not be missed, even if there does not appear to be any problem with vision
- Any sudden changes in vision should be reported to the ophthalmologist immediately, regardless of whether or not injections are being received. Do not wait for the next appointment
- Any difficulties experienced after an injection, including significant pain or changes in vision, should be reported to the ophthalmologist immediately
- Discuss any concerns regarding treatment with the ophthalmologist
Read about the costs of injection treatment and rebates available.
If injections are given in the ophthalmologist’s rooms, it is important to register for the Medicare Safety Net as additional reimbursement of costs may apply once a threshold is reached each year. Contact the Foundation for more information on this if necessary.
Proliferative diabetic retinopathy
Potentially blinding proliferative diabetic retinopathy requires laser treatment to a large area of the retina. This is called PRP (pan-retinal photocoagulation) or scatter laser. A large number of laser spots are made in the peripheral retina. This helps to reduce the amount of oxygen needed by the retina and hence reduces the stimulus for the abnormal, fragile, new blood vessels to form. With sufficient treatment, the vessels shrink completely and often permanently. Because of the large number of laser spots needed, more than one treatment session is nearly always required. Although anaesthetic drops and possibly an anaesthetic injection are normally used, some discomfort may be experienced during PRP laser treatment.
As vision is normally quite blurry for several hours afterwards, another person may be needed to take you home.
Some patients with proliferative disease may also receive injections of an anti-VEGF agent (see previous section).
Vitreous bleeding (haemorrhage)
In proliferative diabetic retinopathy (PDR), the abnormal new blood vessels eventually break and bleed into the clear gel (vitreous) that occupies the central cavity of the eye, resulting in partial or complete blockage of vision.
The blood will often slowly clear over months but further bleeds usually occur as the PDR gets progressively worse. If left untreated, the scar tissue that forms may result in complete and permanent loss of all vision. Early, extensive laser treatment (PRP) must be undertaken.
In some severe cases of PDR, laser treatment is unable to penetrate the blood in the vitreous cavity. An advanced, delicate surgical operation called a vitrectomy may be necessary. During the operation, the vitreous gel and blood is removed, and any pulling on the retina is relieved. Some laser treatment is also usually given at the end of the procedure.
The procedure is done in an eye operating theatre under anaesthesia, usually on a day case basis.