The Evolving Treatment of Diabetic Retinopathy

Sam E Mansour,1,2 David J Browning,3 Keye Wong,4 Harry W Flynn Jr,5 Abdhish R Bhavsar6 1George Washington University, Washington, DC, USA; 2Virginia Retina Center, Warrenton, VA, 20186, USA; 3Charlotte Eye Ear Nose & Throat Associates, Charlotte, NC 28210, USA; 4Retina Associates of Sarasota...

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Autores principales:	Mansour SE, Browning DJ, Wong K, Flynn Jr HW, Bhavsar AR
Formato:	article
Lenguaje:	EN
Publicado:	Dove Medical Press 2020
Materias:	• diabetes retina diabetic retinopathy diabetic macular edema neovascularization laser photocoagulation intravitreal injection vascular endothelial growth factor vitrectomy pars plana vitreous surgery antiangiogenic therapy. Ophthalmology RE1-994
Acceso en línea:	https://doaj.org/article/8b55ede0de14442283734395bfa6e191
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id	oai:doaj.org-article:8b55ede0de14442283734395bfa6e191
record_format	dspace
institution	DOAJ
collection	DOAJ
language	EN
topic	• diabetes retina diabetic retinopathy diabetic macular edema neovascularization laser photocoagulation intravitreal injection vascular endothelial growth factor vitrectomy pars plana vitreous surgery antiangiogenic therapy. Ophthalmology RE1-994
spellingShingle	• diabetes retina diabetic retinopathy diabetic macular edema neovascularization laser photocoagulation intravitreal injection vascular endothelial growth factor vitrectomy pars plana vitreous surgery antiangiogenic therapy. Ophthalmology RE1-994 Mansour SE Browning DJ Wong K Flynn Jr HW Bhavsar AR The Evolving Treatment of Diabetic Retinopathy
description	Sam E Mansour,1,2 David J Browning,3 Keye Wong,4 Harry W Flynn Jr,5 Abdhish R Bhavsar6 1George Washington University, Washington, DC, USA; 2Virginia Retina Center, Warrenton, VA, 20186, USA; 3Charlotte Eye Ear Nose & Throat Associates, Charlotte, NC 28210, USA; 4Retina Associates of Sarasota, Sarasota, FL 34233, USA; 5Bascom Palmer Eye Institute, University of Miami Health System, Miami, FL, USA; 6Retina Center of Minnesota, Minneapolis, MN 55404, USACorrespondence: Sam E MansourVirginia Retina Center, 45 North Hill Drive, Suite 202, Warrenton, VA 20186, USATel +1 703 443-0015Fax +1 703 738-7157Email smansour@virginiaretina.comPurpose: To review the current therapeutic options for the management of diabetic retinopathy (DR) and diabetic macular edema (DME) and examine the evidence for integration of laser and pharmacotherapy.Methods: A review of the PubMed database was performed using the search terms diabetic retinopathy, diabetic macular edema, neovascularization, laser photocoagulation, intravitreal injection, vascular endothelial growth factor (VEGF), vitrectomy, pars plana vitreous surgery, antiangiogenic therapy. With additional cross-referencing, this yielded 835 publications of which 301 were selected based on content and relevance.Results: Many recent studies have evaluated the pharmacological, laser and surgical therapeutic strategies for the treatment and prevention of DR and DME. Several newer diagnostic systems such as optical coherence tomography (OCT), microperimetry, and multifocal electroretinography (mfERG) are also assisting in further refinements in the staging and classification of DR and DME. Pharmacological therapies for both DR and DME include both systemic and ocular agents. Systemic agents that promote intensive glycemic control, control of dyslipidemia and antagonists of the renin-angiotensin system demonstrate beneficial effects for both DR and DME. Ocular therapies include anti-VEGF agents, corticosteroids and nonsteroidal anti-inflammatory drugs. Laser therapy, both as panretinal and focal or grid applications continue to be employed in management of DR and DME. Refinements in laser devices have yielded more tissue-sparing (subthreshold) modes in which many of the benefits of conventional continuous wave (CW) lasers can be obtained without the adverse side effects. Recent attempts to lessen the burden of anti-VEGF injections by integrating laser therapy have met with mixed results. Increasingly, vitreoretinal surgical techniques are employed for less advanced stages of DR and DME. The development and use of smaller gauge instrumentation and advanced anesthesia agents have been associated with a trend toward earlier surgical intervention for diabetic retinopathy. Several novel drug delivery strategies are currently being examined with the goal of decreasing the therapeutic burden of monthly intravitreal injections. These fall into one of the five categories: non-biodegradable polymeric drug delivery systems, biodegradable polymeric drug delivery systems, nanoparticle-based drug delivery systems, ocular injection devices and with sustained release refillable devices. At present, there remains no one single strategy for the management of the particular stages of DR and DME as there are many options that have not been rigorously tested through large, randomized, controlled clinical trials.Conclusion: Pharmacotherapy, both ocular and systemic, will be the primary mode of intervention in the management of DR and DME in many cases when cost and treatment burden are less constrained. Conventional laser therapy has become a secondary intervention in these instances, but remains a first-line option when cost and treatment burden are more constrained. Results with subthreshold laser appear promising but will require more rigorous study to establish its role as adjunctive therapy. Evidence to support an optimal integration of the various treatment options is lacking. Central to the widespread adoption of any therapeutic regimen for DR and DME is substantiation of safety, efficacy, and cost-effectiveness by a body of sound clinical trials.Keywords: diabetes, retina, diabetic retinopathy, diabetic macular edema, neovascularization, laser photocoagulation, intravitreal injection, vascular endothelial growth factor, vitrectomy pars plana vitreous surgery, antiangiogenic therapy
format	article
author	Mansour SE Browning DJ Wong K Flynn Jr HW Bhavsar AR
author_facet	Mansour SE Browning DJ Wong K Flynn Jr HW Bhavsar AR
author_sort	Mansour SE
title	The Evolving Treatment of Diabetic Retinopathy
title_short	The Evolving Treatment of Diabetic Retinopathy
title_full	The Evolving Treatment of Diabetic Retinopathy
title_fullStr	The Evolving Treatment of Diabetic Retinopathy
title_full_unstemmed	The Evolving Treatment of Diabetic Retinopathy
title_sort	evolving treatment of diabetic retinopathy
publisher	Dove Medical Press
publishDate	2020
url	https://doaj.org/article/8b55ede0de14442283734395bfa6e191
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spelling	oai:doaj.org-article:8b55ede0de14442283734395bfa6e1912021-12-02T08:05:22ZThe Evolving Treatment of Diabetic Retinopathy1177-5483https://doaj.org/article/8b55ede0de14442283734395bfa6e1912020-03-01T00:00:00Zhttps://www.dovepress.com/the-evolving-treatment-of-diabetic-retinopathy-peer-reviewed-article-OPTHhttps://doaj.org/toc/1177-5483Sam E Mansour,1,2 David J Browning,3 Keye Wong,4 Harry W Flynn Jr,5 Abdhish R Bhavsar6 1George Washington University, Washington, DC, USA; 2Virginia Retina Center, Warrenton, VA, 20186, USA; 3Charlotte Eye Ear Nose & Throat Associates, Charlotte, NC 28210, USA; 4Retina Associates of Sarasota, Sarasota, FL 34233, USA; 5Bascom Palmer Eye Institute, University of Miami Health System, Miami, FL, USA; 6Retina Center of Minnesota, Minneapolis, MN 55404, USACorrespondence: Sam E MansourVirginia Retina Center, 45 North Hill Drive, Suite 202, Warrenton, VA 20186, USATel +1 703 443-0015Fax +1 703 738-7157Email smansour@virginiaretina.comPurpose: To review the current therapeutic options for the management of diabetic retinopathy (DR) and diabetic macular edema (DME) and examine the evidence for integration of laser and pharmacotherapy.Methods: A review of the PubMed database was performed using the search terms diabetic retinopathy, diabetic macular edema, neovascularization, laser photocoagulation, intravitreal injection, vascular endothelial growth factor (VEGF), vitrectomy, pars plana vitreous surgery, antiangiogenic therapy. With additional cross-referencing, this yielded 835 publications of which 301 were selected based on content and relevance.Results: Many recent studies have evaluated the pharmacological, laser and surgical therapeutic strategies for the treatment and prevention of DR and DME. Several newer diagnostic systems such as optical coherence tomography (OCT), microperimetry, and multifocal electroretinography (mfERG) are also assisting in further refinements in the staging and classification of DR and DME. Pharmacological therapies for both DR and DME include both systemic and ocular agents. Systemic agents that promote intensive glycemic control, control of dyslipidemia and antagonists of the renin-angiotensin system demonstrate beneficial effects for both DR and DME. Ocular therapies include anti-VEGF agents, corticosteroids and nonsteroidal anti-inflammatory drugs. Laser therapy, both as panretinal and focal or grid applications continue to be employed in management of DR and DME. Refinements in laser devices have yielded more tissue-sparing (subthreshold) modes in which many of the benefits of conventional continuous wave (CW) lasers can be obtained without the adverse side effects. Recent attempts to lessen the burden of anti-VEGF injections by integrating laser therapy have met with mixed results. Increasingly, vitreoretinal surgical techniques are employed for less advanced stages of DR and DME. The development and use of smaller gauge instrumentation and advanced anesthesia agents have been associated with a trend toward earlier surgical intervention for diabetic retinopathy. Several novel drug delivery strategies are currently being examined with the goal of decreasing the therapeutic burden of monthly intravitreal injections. These fall into one of the five categories: non-biodegradable polymeric drug delivery systems, biodegradable polymeric drug delivery systems, nanoparticle-based drug delivery systems, ocular injection devices and with sustained release refillable devices. At present, there remains no one single strategy for the management of the particular stages of DR and DME as there are many options that have not been rigorously tested through large, randomized, controlled clinical trials.Conclusion: Pharmacotherapy, both ocular and systemic, will be the primary mode of intervention in the management of DR and DME in many cases when cost and treatment burden are less constrained. Conventional laser therapy has become a secondary intervention in these instances, but remains a first-line option when cost and treatment burden are more constrained. Results with subthreshold laser appear promising but will require more rigorous study to establish its role as adjunctive therapy. Evidence to support an optimal integration of the various treatment options is lacking. Central to the widespread adoption of any therapeutic regimen for DR and DME is substantiation of safety, efficacy, and cost-effectiveness by a body of sound clinical trials.Keywords: diabetes, retina, diabetic retinopathy, diabetic macular edema, neovascularization, laser photocoagulation, intravitreal injection, vascular endothelial growth factor, vitrectomy pars plana vitreous surgery, antiangiogenic therapyMansour SEBrowning DJWong KFlynn Jr HWBhavsar ARDove Medical Pressarticle• diabetesretinadiabetic retinopathydiabetic macular edemaneovascularizationlaser photocoagulationintravitreal injectionvascular endothelial growth factorvitrectomy pars plana vitreous surgeryantiangiogenic therapy.OphthalmologyRE1-994ENClinical Ophthalmology, Vol Volume 14, Pp 653-678 (2020)

The Evolving Treatment of Diabetic Retinopathy

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