- what is proliferative retinopathy?
- some details
- description of events
- anti-VEGF injections
- injections best Clarity study 2017
- severe proliferative retinopathy
- diabetes is not forgiving
Enlarge side view: in proliferative retinopathy 'new blood vessels' grow on the surface of the retina and can bleed.
In this condition very small blood vessels grow from the surface of the retina.
The retina is the film at the back of your eye , and the tiny blood vessels are capillaries. The retina is damaged by the high bolld sugar/glucose levels. These growing blood vessels are very delicate and bleed easily. Without laser treatment, the bleeding causes scar tissue that starts to shrink and pull the retina off, and the eye becomes blind. Laser treatment prevents blindness, but often some vision is lost (and anti-VEGF injections also help).
If you have had diabetes for years your retinae
may develop this condition. As the retina is damaged
by diabetes, the diseased retina releases special
growth chemicals. These chemicals make tiny blood
vessels grow: these are called 'new blood vessels'.
See Animation, case with obvious new vessels, photo , photo OCT changes AJO 18
Enlarge New blood vessels growing on the retinal surface and slightly in front of the surface.
The new vessel growth in diabetes only occurs in the retina, nowhere else in the body. When a retina becomes damaged by a high blood glucose/sugar, over many years, it seems to release special growth hormones.
VEGF is one of the main growth hormones; VEGF stands for Vascular Endothelial Cell Growth Factor. It seems to be made and released by 'sick' retinal capillaries, and in turn makes other capillaries grow.
This seems to be an exaggeration of one of the body's normal responses.... the retina becomes starved of nutrients, and then the retina makes chemicals that make new blood vessels grow to deliver more nutrients. Other growth factors and processes involved.
the mechanism of proliferative retinopathy (start at top) with laser treatment
Enlarge Laser burns for proliferative retinopathy. 500-1000 burns in a typical session
Laser is the only treatment if anti-VEGF injections are not available.
The tiny laser burns allow more oxygen and nutrients to reach the retina, and this improves the retinal circulation. The retina then stops making the growth substances, and the 'new vessels' close up as a result. NEJM 11
Deterioration may be rapid if the control of your diabetes suddenly improves: see rapid progression.
Laser was the main way of treating this condition. With laser the new vessels will usually stop growing, although sometimes several laser sessions are needed.
The new vessels do usually close up, but may start growing again 4-8 months later, and requiring more laser. 2-3000 or so light laser shots are applied at each session to each eye(see Laser Treatment), but in the average insulin-dependant person about 5 sessions may be needed. See photos.
The anti-VEGF injections should be started as soon as possible. They will reduce the proliferation without causing retinal scarring or epiretinal membrane formation.
Patients with more aggressive disease may also need laser.
There were reports that traction increases with anti-VEGF injections. Traction may increse with anti-VEGF injections , but in such patients a combination of vitrectomy surgery and anti-VEGF injections might be best. Anti-VEGF injections can be safely given if there is a little traction, Bressler, Seminar, 2017 DRCRnet 16 .
Each one anti-VEGF injection will have temporary effect, and monthly treatment may be needed, especially for a while. Retina 14 Oph 15. Jama 15. At least 5/each eye injections are generally needed he first year, but fewer are needed after that. At present, NICE guidelines only recommend anti-VEGF injections if there is more than 400µ macular oedema, although some hospitals are able to offer Avastin treatment which is very effective.
Enlarge Extensive laser is needed for some people with proliferative retinopathy
If you have the severest type of proliferative retinopathy,
a lot of anti-VEGF injections and/or laser will be needed over the years. As a result,
r side vision and night vision may be badly affected.
In 2016 with anti-VEGF injections we are likely to get much better results than we did previously, and none smokers detected early (unless control is very poor indeed) should be expected to keep good vision. Many patients with type 1 diabetes may benefit from an insulin pump, and these may be necessary to achieve the best results.
More bleeding causes vitreous haemorrhages. These is make it difficult seeing..like looking through cobwebs.
A wide field fluorescein angiogram will detect the areas of non-perfusion, but if this is unavailalbe these can be estimated clinically. An angiogram is therefore seldom required prior to laser for proliferative retinopathy see. In any respect, the laser treatment does not have to be precisely applied in any particular section of retina. See also and here if maculopathy is present as well as proliferation...new drugs are being used.
Good control of your diabetes is important if you want to keep your sight. Unfortunately retinopathy can still affect people who have tried really hard to control their diabetes (legacy effect). Doctors treating people with retinopathy know that their patients have tried really hard, but the condition can be really vicious. There are some genetic factors that make it more likely for some people to get proliferative changes than those that don't, but as we cannot get new genes we have to make the most of what we have.
We now believe that if you can reach these targets below, and do not smoke, the conditions has every chance of stabilising and you will need much less laser than you would have otherwise. Conversely we know that if someone's diabetes diabetes is very badly controlled, the eye disease can be very severe indeed. Renal failure is a risk factor Retina16.
Controlling the diabetes is critically important in the long term. see
Without anti-VEGF or laser 10% of patients lose vision each year (ETDRS).
Laser may not keep all sight, but unless's your diabetes has been very badly controlled or the laser was started very late, it will keep most of your sight (see). The benefits of laser last all your life.
before laser enlarge
before laser enlarge
after laser enlarge
after laser enlarge
This patient presented late, and his new vessels remain despite laser, indirect laser, and IVT. Vision on presentation was 6/60 & 6/9, and has deteriorated to 6/60 & 6/36 despite treatment. He is awaiting his first dose of Avastin. enlarge
the laser burns enlarge
the laser burns enlarge
Anti-VEGF: Avastin, Lucentis, Eyelea injections into the eye can be very helpful, but effects may be temporary. Anti-VEGF drugs block the effect of VEGF, and stop the new vessels growth for a while. Repeated injections may be needed, and laser is strongly recommended in addition (initial anti-VEGF treatment helps Retina15).
Even without laser, new vessels disappear in a few days, but unless there is adequate laser they always seem to reappear. Even with laser, they may reappear. Nevertheless, Avastin should prove extremely helpful. Few Primary Care Trusts will fund treatment in the UK. We had a few patients funded and could see the effects, but now funding has been withdrawn.
this paper complete laser was given, but the new
vessels continued to grow. The Avastin was then
given after the laser was completed. Given in this
way the Avastin was effective if given every 3 months.
Anti-VEGFs are not considered safe alone...laser must be given also, but nearly all retinopathy experts would like to have access to Anti-VEGFs for certain stages of proliferative retinopathy, particularly reducing the new vessel growth whilst waiting for the laser and good diabetic control to take effect (see 2010).
Iluvien, a steroid implant , will also prevent or help to resolve proliferation.
After 3 years of no laser or new vessel growth, and if there are no/very few retinal haemorrhages, patients can be discharged from the clinic. Photographic monitoring is best restarted, in a screening program. Such patients also need to be checked for glaucoma (at their optometrists, yearly checks), and many will develop cataracts.
When lots of laser has been needed and the retinopathy stabilises, so there are no haemorrhages/exudates/oedema, the condition is stable, termed 'burnt out'.
On the other hand, when lots of anti-VEGF treatment has been given and the haemorrhages etc disappear, the condition may reactivate unless the diabetic control has improved a lot. Such patients need to be monitored regularly, and in the UK this will usually be in the diabetic retinopathy screening program with regular photographs.
Lots of laser, few haemorrhages or exudates. OCT shows slight retinal atrophy but no oedema. The retinopathy is nearly stable, and unless the diabetic control is poor, is unlikely to change. Cataracts may develop, and rarely glaucoma: optometry checks /diabetic screening service review) are needed yearly. There is one haemorrhage at the left fovea. Vision 6/12 both eyes.