Photocoagulation Treatment of Proliferative Diabetic Retinopathy: The Second Report of Diabetic Retinopathy Study Findings

Patz, Arnall; Fine, Stuart L.; Finkelstein, Daniel; Prout, Thaddeus E.; Aiello, Lloyd M.; Bradley, Robert F.; Briones, José C.; Myers, Frank L.; Bresnick, George H.; Venecia, Guillermo de; Stevens, Thomas S.; Wallow, Ingolf H. L.; Chandra, Suresh R.; Norton, Edward W.D.; Blankenship, George W.; Harris, John E.; Knobloch, William H.; Goetz, Frederick C.; Ramsay, Robert C.; McMeel, J. Wallace; Martin, Donald B.; Goldberg, Morton F.; Huamonte, Felipe U.; Peyman, Gholam A.; Straatsma, Bradley R.; Kopelow, Stanley; Heuven, W. A. J. Van; Kassoff, Aaron; Feman, Stephen S.; Watzke, Robert C.; Mensher, John H.; Tasman, William; Annesley, William H.; Leonard, Brian C.; Canny, Christopher; Joffe, Leonard; Pheasant, Thomas R.; Riekhof, F. Tempel; Dahl, M.J.; Bohart, William; Clarke, Dana H.; Berrocal, Jose; Ramos-Umpierre, Antonio; Velázquez, Guillermo Ángel; Margherio, Raymond R.; Nachazel, Delbert P.; McLean, Edward B.; Guzak, Steven V.; Knatterud, Genell L.; Klimt, Christian R.; Hillis, Argye E.; Makuc, Diane M.; Davis, Matthew D.; MacCormick, Alasdair; Magli, Yvonne L.; Segał, P; Lilienfeld, Abraham M.; Ballintine, Elmer J.; Cornfield, Jerome; Friedman, Ephraim; Miller, Max; Sears, Marvin L.; Wiesner, Elizabeth P.; Ederer, Fred; Ferris, Frederick L.; Becker, Bernard; Johnston, Glen P.; Meinert, Curtis L.; Bearman, Jacob E.; Rand, Lawrence I.

doi:10.1016/s0161-6420(78)35693-1

Cited by 542 publications

(16 citation statements)

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“…37 Therefore, photocoagulation had reduced the 2-year risk of blindness by about 60%. This finding was unexpected and highly statistically significant.…”

Section: Results (Before Protocol Change)mentioning

confidence: 99%

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Pan-retinal photocoagulation and other forms of laser treatment and drug therapies for non-proliferative diabetic retinopathy: systematic review and economic evaluation

Royle

Mistry

Auguste

et al. 2015

Health Technol Assess

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BackgroundDiabetic retinopathy is an important cause of visual loss. Laser photocoagulation preserves vision in diabetic retinopathy but is currently used at the stage of proliferative diabetic retinopathy (PDR).ObjectivesThe primary aim was to assess the clinical effectiveness and cost-effectiveness of pan-retinal photocoagulation (PRP) given at the non-proliferative stage of diabetic retinopathy (NPDR) compared with waiting until the high-risk PDR (HR-PDR) stage was reached. There have been recent advances in laser photocoagulation techniques, and in the use of laser treatments combined with anti-vascular endothelial growth factor (VEGF) drugs or injected steroids. Our secondary questions were: (1) If PRP were to be used in NPDR, which form of laser treatment should be used? and (2) Is adjuvant therapy with intravitreal drugs clinically effective and cost-effective in PRP?Eligibility criteriaRandomised controlled trials (RCTs) for efficacy but other designs also used.Data sourcesMEDLINE and EMBASE to February 2014, Web of Science.Review methodsSystematic review and economic modelling.ResultsThe Early Treatment Diabetic Retinopathy Study (ETDRS), published in 1991, was the only trial designed to determine the best time to initiate PRP. It randomised one eye of 3711 patients with mild-to-severe NPDR or early PDR to early photocoagulation, and the other to deferral of PRP until HR-PDR developed. The risk of severe visual loss after 5 years for eyes assigned to PRP for NPDR or early PDR compared with deferral of PRP was reduced by 23% (relative risk 0.77, 99% confidence interval 0.56 to 1.06). However, the ETDRS did not provide results separately for NPDR and early PDR. In economic modelling, the base case found that early PRP could be more effective and less costly than deferred PRP. Sensitivity analyses gave similar results, with early PRP continuing to dominate or having low incremental cost-effectiveness ratio. However, there are substantial uncertainties. For our secondary aims we found 12 trials of lasers in DR, with 982 patients in total, ranging from 40 to 150. Most were in PDR but five included some patients with severe NPDR. Three compared multi-spot pattern lasers against argon laser. RCTs comparing laser applied in a lighter manner (less-intensive burns) with conventional methods (more intense burns) reported little difference in efficacy but fewer adverse effects. One RCT suggested that selective laser treatment targeting only ischaemic areas was effective. Observational studies showed that the most important adverse effect of PRP was macular oedema (MO), which can cause visual impairment, usually temporary. Ten trials of laser and anti-VEGF or steroid drug combinations were consistent in reporting a reduction in risk of PRP-induced MO.LimitationThe current evidence is insufficient to recommend PRP for severe NPDR.ConclusionsThere is, as yet, no convincing evidence that modern laser systems are more effective than the argon laser used in ETDRS, but they appear to have fewer adverse effects. We recommend a trial of PRP for severe NPDR and early PDR compared with deferring PRP till the HR-PDR stage. The trial would use modern laser technologies, and investigate the value adjuvant prophylactic anti-VEGF or steroid drugs.Study registrationThis study is registered as PROSPERO CRD42013005408.FundingThe National Institute for Health Research Health Technology Assessment programme.

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“…37 Therefore, photocoagulation had reduced the 2-year risk of blindness by about 60%. This finding was unexpected and highly statistically significant.…”

Section: Results (Before Protocol Change)mentioning

confidence: 99%

“…They recommended careful follow-up for changes with DR and when non-proliferative changes are present, the follow-up visits should be at frequent intervals. 37 Finally, their conclusions stated:…”

Section: Implications Of Diabetic Retinopathy Study Findings For Treamentioning

confidence: 98%

Pan-retinal photocoagulation and other forms of laser treatment and drug therapies for non-proliferative diabetic retinopathy: systematic review and economic evaluation

Royle

Mistry

Auguste

et al. 2015

Health Technol Assess

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“…One of the major novelties of the Airlie House Classification was the usage of stereo-photograph montage [35], the ETDRS [36,37], the Diabetic Retinopathy Vitrectomy Study (DRVS) [38], and the Krypton-Argon Regression of Neovascularization Study (KARNS) [39]. These studies represented landmarks in the 20th-century ophthalmology, providing worldwide guidelines on the use of laser panretinal photocoagulation (PRP) and focal laser for the different stages of DR.…”

Section: Dr Classification and Laser Photocoagulationmentioning

confidence: 99%

19th EURETINA Congress Keynote Lecture: Diabetic Retinopathy Today

Bandello

Cicinelli

2020

Ophthalmologica

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In the last decades, significant changes have been taking place regarding the pathogenesis of diabetic retinopathy (DR) and the complex mechanisms that eventually lead to the various manifestations of the disease, including diabetic macular edema (DME). DR was first considered a pure microvascular disease, due to the evident capillary structural changes (microaneurysms), fluid extravasation, and lipid exudation. With the advent of fundus fluorescein angiography, the concept of ischemia and the correlation between peripheral nonperfusion and neovascularization has been introduced, which was eventually followed by the advent of new therapeutic strategies, such as peripheral photocoagulation. Nowadays, thanks to more advanced imaging techniques, namely optical coherence tomography (OCT), OCT angiography, and wide-field imaging (imaging up to 200° of the retina in a single shot), it became clear that other elements participate in the occurrence of DR and DME, including inflamma-tion and neurodegeneration. In the future, integration of standard investigations with new diagnostic devices would allow the prompt recognition of DR even before clinical signs of the disease are ophthalmoscopically evident, and the development of personalized treatment for both retinopathy and DME will be available.

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“…This intervention prevents further deterioration of vision if applied sufficiently early in the progression of the disease but does not usually restore lost vision. The Diabetes Retinopathy Study (DRS) and Early Treatment Diabetes Retinopathy Study (ETDRS) groups developed guidelines for the laser treatment of diabetic retinopathy [8–10]. In DRS, panretinal photocoagulation (PRP) was shown to reduce the risk of severe visual loss by 60% in 2 years, especially in patients with PDR and high-risk characteristics [8].…”

Section: Current Ophthalmic Therapeutic Optionsmentioning

confidence: 99%

“…The Diabetes Retinopathy Study (DRS) and Early Treatment Diabetes Retinopathy Study (ETDRS) groups developed guidelines for the laser treatment of diabetic retinopathy [8–10]. In DRS, panretinal photocoagulation (PRP) was shown to reduce the risk of severe visual loss by 60% in 2 years, especially in patients with PDR and high-risk characteristics [8]. Later, ETDRS suggested that patients with severe NPDR might also benefit from scatter photocoagulation as well [10].…”

Section: Current Ophthalmic Therapeutic Optionsmentioning

confidence: 99%

New Diagnostic and Therapeutic Approaches for Preventing the Progression of Diabetic Retinopathy

Park

Roh

2016

Journal of Diabetes Research

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Diabetic retinopathy (DR) is a severe sight-threatening complication of diabetes mellitus. Retinal laser photocoagulation, antivascular endothelial growth factors, steroid therapy, and pars plana vitrectomy are now used extensively to treat advanced stages of diabetic retinopathy. Currently, diagnostic devices like ultrawide field fundus fluorescein angiography and the improvement of optical coherence tomography have provided quicker and more precise diagnosis of early diabetic retinopathy. Thus, treatment protocols have been modified accordingly. Various types of lasers, including the subthreshold micropulse laser and RPE-targeting laser, and selective targeted photocoagulation may be future alternatives to conventional retinal photocoagulation, with fewer complications. The new developed intravitreal medications and implants have provided more therapeutic options, with promising results.

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Photocoagulation Treatment of Proliferative Diabetic Retinopathy: The Second Report of Diabetic Retinopathy Study Findings

Cited by 542 publications

References 2 publications

Pan-retinal photocoagulation and other forms of laser treatment and drug therapies for non-proliferative diabetic retinopathy: systematic review and economic evaluation

Pan-retinal photocoagulation and other forms of laser treatment and drug therapies for non-proliferative diabetic retinopathy: systematic review and economic evaluation

19th EURETINA Congress Keynote Lecture: Diabetic Retinopathy Today

New Diagnostic and Therapeutic Approaches for Preventing the Progression of Diabetic Retinopathy

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