Current Ophthalmology Reports

, Volume 7, Issue 1, pp 45–50 | Cite as

Decision Making in Proliferative Diabetic Retinopathy Treatment

  • Mary B. Kansora
  • Raquel GoldhardtEmail author
Retina (R Goldhardt, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Retina


Purpose of Review

The goal of this paper is to provide a comprehensive review of the recent advances in the management options for proliferative diabetic retinopathy.

Recent Findings

For many years, cases of proliferative diabetic retinopathy (PDR) have been managed by pan retinal photocoagulation (PRP). The advent of anti-vascular endothelial growth factor (anti-VEGF) agents has changed the future of PDR management and has provided an alternative to PRP.


Management of PDR requires the identification of high-risk characteristics for PDR and the decision regarding the most appropriate treatment modality. The risk to benefit ratio for each treatment modality must be considered in determining the appropriate choice between surgical intervention (PRP) versus medical intervention with anti-VEGF.


Proliferative diabetic retinopathy Vascular endothelial growth factor Anti-VEGF Pan retinal photocoagulation Intravitreal injection Ranibizumab Bevacizumab Aflibercept 



The editors thank Dr. Fernando Penha for lending his expertise and reviewing this manuscript.

Financial Support

This study is supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Clinical Sciences Research EPID-006-15S, NIH Center Core Grant P30EY014801, and Research to Prevent Blindness Unrestricted Grant.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Lee R, Wong T, Sabanayagam C. Epidemiology of diabetic retinopathy, diabetic macular edema and related vision loss. Eye Vis. 2015;2:17.CrossRefGoogle Scholar
  2. 2.
    Diabetic Retinopathy Study Research Group. Photocoagulation treatment of proliferative diabetic retinopathy. Clinical application of diabetic retinopathy study (DRS) findings, DRS report number 8. Ophthalmology. 1981;88(7):583–600.CrossRefGoogle Scholar
  3. 3.
    Antonetti DA, Klein R, Gardner TW. Diabetic retinopathy. N Engl J Med. 2012;366(13):1227–39.CrossRefPubMedGoogle Scholar
  4. 4.
    Ashton N. Studies of the retinal capillaries in relation to diabetic and other retinopathies. Br J Ophthalmol. 1963;47:521–38.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Cogan DG, Kuwabara T. Capillary shunts in the pathogenesis of diabetic retinopathy. Diabetes. 1963;12:293–300.CrossRefPubMedGoogle Scholar
  6. 6.
    Cogan DG, Toussaint D, Kuwabara T. Retinal vascular patterns. IV. Diabetic retinopathy. Arch. Ophthalmol. 1961;66:366–78.CrossRefPubMedGoogle Scholar
  7. 7.
    Kobayashi et al. Vitreous levels of vascular endothelial growth factor in eyes with anterior hyaloidal fibrovacular proliferation. Clin Ophthalmol. 2010;4:1043–6.Google Scholar
  8. 8.
    Gupta N, Mansoor S, Sharma A, Sapkal A, Sheth J, Falatoonzadeh P, et al. Diabetic retinopathy and VEGF. Open Ophthalmol J. 2013;7:4–10.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329(14):977–86.CrossRefGoogle Scholar
  10. 10.
    UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. Br Med J. 1998;317(7160):703–13.CrossRefGoogle Scholar
  11. 11.
    Diabetic Retinopathy Study Research Group. Preliminary report on effects of photocoagulation therapy. Am J Ophthalmol. 1976;81:383–96.CrossRefGoogle Scholar
  12. 12.
    Hamilton AM. Management of diabetic retinopathy. Trans Ophthalmol Soc UK. 1977;97:494–6.PubMedGoogle Scholar
  13. 13.
    Hercules BL, Gayed II, Lucas SB, Jeacock J. Peripheral retinal ablation in the treatment of proliferative diabetic retinopathy: a three-year interim report of a randomised, controlled study using the argon laser. Br J Ophthalmol. 1977;61:555–63.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Meyers SM. Macular edema after scatter laser photocoagulation for proliferative diabetic retinopathy. Am J Ophthalmol. 1980;90:210–6.CrossRefPubMedGoogle Scholar
  15. 15.
    Meyer-Schwickerath GRE, Schott K. Diabetic retinopathy and photocoagulation. Am J Ophthalmol. 1968;66:597–603.CrossRefPubMedGoogle Scholar
  16. 16.
    Okun E, Cibis PA. The role of photocoagulation in the therapy of proliferative diabetic retinopathy. Arch Ophthalmol. 1966;75:337–52.CrossRefPubMedGoogle Scholar
  17. 17.
    Patz A, Schatz H, Ryan SJ. Argon laser photocoagulation for treatment of advanced diabetic retinopathy. Trans Am Acad Ophthalmol Otolaryngol. 1972;76:984–9.PubMedGoogle Scholar
  18. 18.
    Plumb AP, Swan AV, Chignell AH, Shilling JS. A comparative trial of xenon arc and argon laser photocoagulation in the treatment of proliferative diabetic retinopathy. Br J Ophthalmol. 1982;66:213–8.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Early Treatment Diabetic Retinopathy Study Research Group. Early photocoagulation for diabetic retinopathy. ETDRS report number 9. Ophthalmology. 1991;98(5 suppl):766–85.Google Scholar
  20. 20.
    Mugit M, Marcellino G, Henson D, et al. Pascal panretinal laser and regression analysis in proliferative diabetic retinopathy: Manchester Pascal Study Report 4. Eye (Lond). 2011;25(11):1447–56.CrossRefGoogle Scholar
  21. 21.
    Mendrinos E, Mangioris G, Papadopoulou DN, et al. Retinal vessel analyzer measurements of the effect of panretinal photocoagulationon the retinal arteriolar diameter in diabetic retinopathy. Retina. 2010;30(4):555–61.CrossRefPubMedGoogle Scholar
  22. 22.
    Funatsu H, Hori S, Yamashita H, Kitano S. Effective mechanisms of laser photocoagulation for neovascularization in diabetic retinopathy. Nippon Ganka Gakkai Zasshi. 1996;100(5):339–49.PubMedGoogle Scholar
  23. 23.
    Marshall J, Clover G, Rothery S. Some new findings on retinal irradiation by krypton and argon lasers. Doc Ophthalmol Proc Ser. 1984;36:21–37.Google Scholar
  24. 24.
    Adamis AP, Miller JW, Bernal M-T. Increased vascular endothelial growth factor levels in the vitreous of eyes with proliferative diabetic retinopathy. Am J Ophthalmol. 1994;118:445–50.CrossRefPubMedGoogle Scholar
  25. 25.
    Early Treatment Diabetic Retinopathy Study Research Group. Photocoagulation for diabetic macular edema: EARLY Treatment Diabetic Retinopathy Study report number 1. Arch Ophthalmol. 1985;103(12):1796–806.CrossRefGoogle Scholar
  26. 26.
    Brucker AJ, Qin H, Antoszyk AN, Diabetic Retinopathy Clinical Research Network, et al. Observational study of the development of diabetic macular edema following panretinal (scatter) photocoagulation given in 1 or 4 sittings. Arch Ophthalmol. 2009;127(2):132–40.CrossRefPubMedGoogle Scholar
  27. 27.
    Googe J, Brucker AJ, Bressler NM, Diabetic Retinopathy Clinical Research Network, et al. Randomized trial evaluating short-term effects of intravitreal ranibizumab or triamcinolone acetonide on macular edema after focal/grid laser for diabetic macular edema in eyes also receiving panretinal photocoagulation. Retina. 2011;31(6):1009–27.CrossRefPubMedGoogle Scholar
  28. 28.
    Berger AR, Boniuk I. Bilateral subretinal neovascularization after focal argon laser photocoagulation for diabetic macular edema. Am J Ophthalmol. 1989;108:88–90.CrossRefPubMedGoogle Scholar
  29. 29.
    Lewis H, Schachat AP, Haimann MH. Choroidal neovascularization after laser photocoagulation for diabetic macular edema. Ophthalmology. 1990;97:503–11.CrossRefPubMedGoogle Scholar
  30. 30.
    Varley MP, Frank E, Purnell EW. Subretinal neovascularization after focal argon laser for diabetic macular edema. Ophthalmology. 1988;95:567–73.CrossRefPubMedGoogle Scholar
  31. 31.
    Guyer DR, D’Amico DJ, Smith CW. Subretinal fibrosis after laser photocoagulation for diabetic macular edema. Am J Ophthalmol. 1992;113:652–6.CrossRefPubMedGoogle Scholar
  32. 32.
    Han DP, Mieler WF, Burton TC. Submacular fibrosis after photocoagulation for diabetic macular edema. Am J Ophthalmol. 1992;113:513–21.CrossRefPubMedGoogle Scholar
  33. 33.
    Rutledge BK, Wallow IHL, Poulsen GL. Sub-pigment epithelial membranes after photocoagulation for diabetic macular edema. Arch Ophthalmol. 1993;111:608–13.CrossRefPubMedGoogle Scholar
  34. 34.
    Wallow IHL, Bindley CD. Focal photocoagulation of diabetic macular edema; a clinicopathologic case report. Retina. 1988;8:261–9.CrossRefPubMedGoogle Scholar
  35. 35.
    Elliott A, Flanagan D. Macular detachment following laser treatment for proliferative diabetic retinopathy. Graefes Arch Clin Exp Ophthalmol. 1990;228:438–41.CrossRefPubMedGoogle Scholar
  36. 36.
    Schatz H, Madeira D, McDonald HR, Johnson RN. Progressive enlargement of laser scars following grid laser photocoagulation for diffuse diabetic macular edema. Arch Ophthalmol. 1991;109:1549–51.CrossRefPubMedGoogle Scholar
  37. 37.
    Silva PS, Sun JK, Aiello LP. Role of steroids in the management of diabetic macular edema and proliferative diabetic retinopathy. Semin Ophthalmol. 2009;24:93–9.CrossRefPubMedGoogle Scholar
  38. 38.
    Zacks DN, Johnson MW. Combined intravitreal injection of triamcinolone acetonide and panretinal photocoagulation for concomitant diabetic macular edema and proliferative diabetic retinopathy. Retina. 2005;25:135–40.CrossRefPubMedGoogle Scholar
  39. 39.
    Machemer R, Sugita G, Tano Y. Treatment of intraocular proliferations with intravitreal steroids. Trans Am Ophthalmol Soc. 1979;77:171–80.PubMedPubMedCentralGoogle Scholar
  40. 40.
    Erdol H, Turk A, Akyol N, et al. The results of intravitreal bevacizumab injections for persistent neovascularizations in proliferative diabetic retinopathy after photocoagulation therapy. Retina. 2010;30:570–7.CrossRefPubMedGoogle Scholar
  41. 41.
    Yeh PT, Yang CM, Lin YC, et al. Bevacizumab pretreatment in vitrectomy with silicone oil for severe diabetic retinopathy. Retina. 2009;29:768–74.CrossRefPubMedGoogle Scholar
  42. 42.
    •• Writing Committee for the Diabetic Retinopathy Clinical Research Network. JAMA. 2015;314(20):2137–46 This study provides an in-depth comparison of the use of intravitreal ranibizumab vs PRP for the treatment of proliferative diabetic retinopathy.CrossRefGoogle Scholar
  43. 43.
    •• Gross JG, Glassman AR, Liu D, et al. Five-Year outcomes of panretinal photocoagulation vs intravitreal ranibizumab for proliferative diabetic retinopathy: a randomized clinical trial. JAMA Ophthalmol. 2018. This follow up study allowed the reader to observe how the primary outcome seen at 2 years was upheld, as well as allowed the observation of additional outcome measures regarding the use of intravitreal ranibizumab vs PRP for PDR.
  44. 44.
    Gross JG, Glassman AR, Klein MJ, Jampol LM, Ferris FL III, Bressler NM, et al. Interim safety data comparing ranibizumab with panretinal photocoagulation among participants with proliferative diabetic retinopathy. JAMA Ophthalmol. 2017;135(6):672–3.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Figueira J, Fletcher E, Massin P, Silva R, Bandello F, Midena E, et al. Ranibizumab plus panretinal photocoagulation versus panretinal photocoagulation alone for high-risk proliferative diabetic retinopathy (PROTEUS study). Ophthalmology. 2018;125(5):691–700.CrossRefPubMedGoogle Scholar
  46. 46.
    DongNguyen Q, Brown D, Marcus D, et al. Ranibizumab for diabetic macular edema: results from 2 phase III randomized trials: RISE and RIDE. Ophthalmology. 2012;119:789–801.CrossRefGoogle Scholar
  47. 47.
    Bressler S, Odia I, Glassman A, et al. Changes in diabetic retinopathy severity when treating diabetic macular edema with ranibizumab: protocol I 5-year report. Retina. 2018;38(10):1896–904.CrossRefPubMedGoogle Scholar
  48. 48.
    Arevalo JF, Maia M, Flynn HW Jr, et al. Tractional retinal detachment following intravitreal bevacizumab (Avastin) in patients with severe proliferative diabetic retinopathy. Br J Ophthalmol. 2008;92(2):213–6.CrossRefPubMedGoogle Scholar
  49. 49.
    • Hutton DW, Stein JD, Bressler NM, et al. Cost-effectiveness of intravitreous ranibizumab compared with panretinal photocoagulation for proliferative diabetic retinopathy. JAMA Ophthalmol. 2017;135(6):576–84 This study outlines the cost analysis of the 2-year Protocol S data in comparing the use of ranibizumab vs PRP for DME.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    • Lin J, Chang JS, Yannuzzi NA, Smiddy WE. Cost evaluation of early vitrectomy versus panretinal photocoagulation and intravitreal ranibizumab for proliferative diabetic retinopathy. Ophthalmology. 2018;125(9):1393–400 This study suggests that the cost utility of PPV vs PRP is similar and that PPV has a more favorable cost utility as compared to ranibizumab.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.VA North Texas Health Care SystemDallasUSA
  2. 2.Department of OphthalmologyThe University of Texas Southwestern Medical CenterDallasUSA
  3. 3.Surgical ServicesMiami Veterans Administration Medical CenterMiamiUSA
  4. 4.Bascom Palmer Eye Institute, Department of OphthalmologyUniversity of MiamiMiamiUSA

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