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Treatment

Early diabetic retinopathy

To attempt to slow, halt or sometimes even reverse the progression of diabetic retinopathy, every effort should be made to correct the modifiable risk factors as discussed previously. Most people with retinopathy will need regular follow-up exams to monitor the level of disease.


Fenofibrate 

Typically, during the earlier (non-proliferative) stages of diabetic retinopathy, a person’s vision will be monitored carefully. In the past, treatment may not have been recommended unless vision had been affected. The drug fenofibrate which is normally used for treating people with high or unbalanced blood lipid levels, has recently 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 levels3. If you are not already taking this drug,and have any degree of diabetic retinopathy, you should discuss with youreye specialist whether this treatment may be suitable for you.


Treatment for more advanced vision-threatening diabetic retinopathy

Several treatment options are available 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.


Injections 

The choice of the most appropriate drug should be discussed with the eye specialist. 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 eye specialist’s rooms, although some patients may be treated by the eye specialist 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 eye specialist 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 eye specialist and patient.

  • For those being treated with a steroid, the eye specialist will recommend the frequency of injections.

  • The treatment schedule should always be followed, and cease only when advised by the eye specialist.

  • Appointments with the eye specialist 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 eye specialist 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 advised to the eye specialist immediately.

  • If there are any other concerns you have regarding coping with treatment, discuss them with the eye specialist.

  • If injections are given in the doctor’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 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.
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