eMedicine Specialties > Ophthalmology > Retina

Retinopathy, Diabetic, Proliferative: Follow-up

Author: Abdhish R Bhavsar, MD, Adjunct Assistant Professor, Department of Ophthalmology, University of Minnesota Medical School; Director of Clinical Research, Retina Center, PA; Past Chair, Consulting Staff, Department of Ophthalmology, Phillips Eye Institute
Coauthor(s): Neal H Atebara, MD, Clinical Assistant Professor, Department of Surgery, Division of Ophthalmology, University of Hawaii School of Medicine; John H Drouilhet, MD, FACS, Clinical Professor, Department of Surgery, Section of Ophthalmology, University of Hawaii, John A Burns School of Medicine
Contributor Information and Disclosures

Updated: Oct 6, 2009

Follow-up

Further Outpatient Care

  • The follow-up regimen of patients with early proliferative diabetic retinopathy (PDR) is dictated by its risk of developing high-risk characteristics. Of patients with early PDR, 75% develop high-risk characteristics within 5 years; therefore, they need to be monitored every 2-3 months for progression. Once high-risk characteristics are observed, promptly institute laser photocoagulation to decrease the chance of severe visual loss.
  • Promptly treat eyes with high-risk PDR with laser panretinal photocoagulation (PRP) to decrease the risk of severe visual loss. Monitor patients every 1-2 months until the retinopathy has stabilized.
  • Eyes with clinically significant macular edema (CSME), no matter what stage of retinopathy, should be treated promptly and monitored every 2-4 months thereafter to assess the efficacy of treatment and to watch for future incidences of edema.

Deterrence/Prevention

  • The Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UK-PDS) were large randomized clinical trials that demonstrated the importance of tight glucose control with respect to reducing the incidence and progression of diabetes complications including diabetic retinopathy for both type 1 and type 2 diabetes.16  

Complications

  • Complications of PRP include the following:
    • Visual field constriction
    • Night blindness
    • Foveal burns
    • Macular edema
    • Serous and/or choroidal detachment
    • Pain
    • Anterior segment complications, such as corneal and lenticular burns

Prognosis

  • The Diabetic Retinopathy Study (DRS) has found that adequate scatter PRP reduces the risk of severe visual loss (<5/200) by more than 50%.

Patient Education

  • One of the most important aspects in the management of diabetic retinopathy is patient education. Inform patients that they play an integral role in their own eye care. Emphasize the following facts:
    • Excellent glucose control is beneficial in any stage of diabetic retinopathy. It delays the onset and slows down the progression of the diabetic complications in the eye.
    • Other systemic problems, such as hypertension, renal disease, and hyperlipidemia, may contribute to the progression of the retinopathy and should be addressed promptly.
    • Smoking, although not directly proven to affect the course of the retinopathy, also may play a role in further compromising oxygen delivery to the retina. Therefore, all efforts should be made in the reduction, if not outright cessation, of smoking.
    • Visual symptoms (eg, changes in vision, redness, pain) could be manifestations of disease progression and should be reported immediately.
    • DM in general and diabetic retinopathy in particular are progressive conditions such that regular follow-up care with a physician is crucial to detect any changes that may benefit from treatment.
  • For excellent patient education resources, see eMedicine's Diabetes Center. Also, visit eMedicine's patient education article Diabetic Eye Disease.

Miscellaneous

Medicolegal Pitfalls

  • Failure to emphasize to the patient that all efforts in the treatment of diabetic retinopathy are mainly aimed at reducing the risk of visual loss and not at improving vision.

Special Concerns

  • All individuals with diabetes should be aware of the importance of regular dilated retinal examinations. Early diagnosis and treatment of diabetic retinopathy can help prevent blindness in more than 90% of cases. However, in spite of treatment, sometimes, individuals can still lose vision. The patient, ophthalmologist or retina specialist, and internist or endocrinologist must work together as a team to optimize the diabetes control and help to reduce the risk of blindness.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Sherman O Valero, MD, to the development and writing of this article.



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Multimedia: Retinopathy, Diabetic, Proliferative
References
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References

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  2. Aiello LM, Cavallerano JD, Aiello LP, Bursell SE. Diabetic retinopathy. In: Guyer DR, Yannuzzi LA, Chang S, et al, eds. Retina Vitreous Macula. Vol 2. 1999:316-44.

  3. Benson WE, Tasman W, Duane TD. Diabetes mellitus and the eye. In: Duane's Clinical Ophthalmology. Vol 3. 1994.

  4. Frank RN. Etiologic mechanisms in diabetic retinopathy. In: Ryan SJ, ed. Retina. 1994:1243-76.

  5. Praidou A, Klangas I, Papakonstantinou E, Androudi S, Georgiadis N, Karakiulakis G, et al. Vitreous and Serum Levels of Platelet-Derived Growth Factor and Their Correlation in Patients with Proliferative Diabetic Retinopathy. Curr Eye Res. Feb 2009;34(2):152-161. [Medline].

  6. Merlak M, Kovacevic D, Balog T, Marotti T, Misljenovic T, Mikulicic M, et al. Expression of vascular endothelial growth factor in proliferative diabetic retinopathy. Coll Antropol. Oct 2008;32 Suppl 2:39-43. [Medline].

  7. Davis MD. Proliferative diabetic retinopathy. In: Ryan SJ, ed. Retina. Vol 2. 1994:1319-60.

  8. Akduman L, Olk RJ. The early treatment for diabetic retinopathy study. In: Kertes C, ed. Clinical Trials in Ophthalmology: A Summary and Practice Guide. 1998:15-36.

  9. Bhavsar AR, Grillone LR, McNamara TR, Gow JA, Hochberg AM, Pearson RK. Predicting response of vitreous hemorrhage after intravitreous injection of highly purified ovine hyaluronidase (Vitrase) in patients with diabetes. Invest Ophthalmol Vis Sci. Oct 2008;49(10):4219-25. [Medline].

  10. Arevalo JF, Garcia-Amaris RA. Intravitreal bevacizumab for diabetic retinopathy. Curr Diabetes Rev. Feb 2009;5(1):39-46. [Medline].

  11. Rodriguez-Fontal M, Alfaro V, Kerrison JB, Jablon EP. Ranibizumab for diabetic retinopathy. Curr Diabetes Rev. Feb 2009;5(1):47-51. [Medline].

  12. Quillen DA, Gardner TW, Blankenship GW. The diabetic retinopathy study. In: Kertes C, ed. Clinical Trials in Ophthalmology: A Summary and Practice Guide. 1998:1-14.

  13. Bhavsar AR. Diabetic retinopathy: the latest in current management. Retina. Jul-Aug 2006;26(6 Suppl):S71-9. [Medline].

  14. Diabetic Retinopathy Clinical Research Network. A randomized trial comparing intravitreal triamcinolone acetonide and focal/grid photocoagulation for diabetic macular edema. Ophthalmology. September 2008;115 (9):1447-1449. [Medline].

  15. Meredith TA. The diabetic vitrectomy study. In: Kertes C, ed. Clinical Trials in Ophthalmology-A Summary and Practice Guide. 1998: 37-48.

  16. Genuth S. The UKPDS and its global impact. Diabet Med. Aug 2008;25 Suppl 2:57-62. [Medline].

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Further Reading

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Keywords

proliferative diabetic retinopathy, PDR, diabetic retinopathy treatment, macular edema, neovascularization, optic disc, optic disk, NVD, neovascularization elsewhere, NVE, background diabetic retinopathy, nonproliferative diabetic retinopathy, NPDR, diabetes mellitus, DM, diabetes mellitus retinopathy, DM retinopathy, blindness, vision loss, visual acuity loss, visual loss, tractional retinal detachment, vitreous hemorrhage

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Contributor Information and Disclosures

Author

Abdhish R Bhavsar, MD, Adjunct Assistant Professor, Department of Ophthalmology, University of Minnesota Medical School; Director of Clinical Research, Retina Center, PA; Past Chair, Consulting Staff, Department of Ophthalmology, Phillips Eye Institute
Abdhish R Bhavsar, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Medical Association, American Society of Retina Specialists, Association for Research in Vision and Ophthalmology, and Minnesota Medical Association
Disclosure: Allergan Grant/research funds None; genentech Grant/research funds None; regeneron Grant/research funds None; sirion Grant/research funds None

Coauthor(s)

Neal H Atebara, MD, Clinical Assistant Professor, Department of Surgery, Division of Ophthalmology, University of Hawaii School of Medicine
Neal H Atebara, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Retina Specialists, Hawaii Medical Association, and Retina Society
Disclosure: Nothing to disclose.

John H Drouilhet, MD, FACS, Clinical Professor, Department of Surgery, Section of Ophthalmology, University of Hawaii, John A Burns School of Medicine
John H Drouilhet, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

V Al Pakalnis, MD, PhD, Professor of Ophthalmology, University of South Carolina School of Medicine; Chief of Ophthalmology, Dorn Veterans Affairs Medical Center
V Al Pakalnis, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and South Carolina Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Steve Charles, MD, Director of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine; Adjunct Professor of Ophthalmology, Columbia College of Physicians & Surgeons; Clinical Professor Ophthalmology, Chinese University of Hong Kong
Steve Charles, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Retina Specialists, Club Jules Gonin, Macula Society, and Retina Society
Disclosure: Alcon Laboratories Consulting fee Consulting; OptiMedica Ownership interest Consulting

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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