Table 5.

Standard of Care for Management of Diabetic Retinopathy

• Fundus fluorescein angiography (FFA) is indicated at baseline in the management of STDR- to identify areas of leak in DME, ischemia (in the macula), areas of non-perfusion and subtle neovascularisation.

• Optical Coherence Tomography (OCT) has become indispensable in the management of DME. At baseline for qualitative and quantitative assessment (to identify center involving DME [CiDME]) and also during follow-up after treatment (intravitreal injections).

• Intravitreal injections of anti-vascular endothelial growth factor (VEGF) agents are indicated as the first line therapy for central-involving DME (CiDME).[43] All three drugs: aflibercept, bevacizumab, and ranibizumab are effective at improving vision over 1 and 2 years of treatment for DME. [44] Currently the role of focal laser/grid photocoagulation is for the management of non-center involving DME and also can be considered in partial/ non-responding DME to anti-VEGF injections.

• Although first-line therapy for most eyes with central-involved DME consists of anti-VEGF, intravitreal injection of steroids (Triamcinolone inj/dexamethasone implant) can also be effective for DME treatment especially in pseudophakic eyes or if there is any contraindication to use of anti-VEGF like any recent stroke/ myocardial infarction.[45]

• The standard doses for the conventional pharmacotherapies are: - Ranibizumab (Lucentis/Accentrix/Razumab) - 0.5 mg/0.05 ml; Aflibercept (Eylea) - 2 mg/0.05 ml; Bevacizumab (Avastin) - 1.25 mg/0.05 ml; Triamcinolone - 2 mg/0.05 ml; Ozurdex (dexamethasone implant) - 0.7 mg.

• The panretinal laser photocoagulation (PRP) therapy is the mainstay of treatment to reduce the risk of vision loss in patients with high-risk Proliferative Diabetic Retinopathy (PDR) and, indicated in some with severe Non-Proliferative Diabetic Retinopathy (NPDR) (in scenario like poor compliance with follow up, impending cataract surgery or pregnancy and status of fellow eye/precious eye, etc).

• Intravitreal injection of the Anti-VEGF can be combined with traditional PRP in cases with both macular edema and PDR.[46] Though there is evidence of effectiveness of anti-VEGF agents for PDR without DME, the task force does not recommend the use of anti-VEGF alone for PDR.

• The presence of DR is not a contraindication to aspirin therapy for cardioprotection, as aspirin does not increase the risk of pre-retinal or vitreous hemorrhage.

• Topical Non-steroidal anti-inflammatory eye drops like Nepafenac eye drops have no meaningful effect in the treatment of non-central DME (OCT measured retinal thickness).[47]

• For all people, regardless of the stage or severity of DR, medical management to optimize glycemic control, optimize blood pressure and serum lipid levels reduces the risk or slows the progression of diabetic retinopathy.[48]