Making treatment decisions

To be effective, the strategies we use to detect and treat diabetic retinopathy must include the perspectives and needs of people with diabetes and align with what is practical and available in the local health system.

Mr Smith, is a 47 year old living with type 1 diabetes since the age of 17 years. He was referred from retinal screening at the age of 30 with exudates in the macula of his right eye. No immediate treatment was required but he was followed up regularly. The leak on the right macula increased 4 years after first presentation and was treated with focal (localised to the affected area) laser. Ten years later, his retinopathy had progressed with neovascularisation around both optic discs and a sudden haemorrhage in the retina.

Pan-retinal (all around the retina) photocoagulation laser treatment was started immediately, and despite the application of 3400 burns over 4 sessions in the left eye there was there was further areas of ischaemia and neovascularisation in the left retina. A similar amount of laser treatment was provided in the right eye. Both eyes also received two further laser sessions but both continued to show signs of activity with episodes of vitreous haemorrhage. Vitrectomy with endolaser (directly in the eye during surgery) was then performed in each eye. This resulted in stability to each eye with visual acuity of 6/9 in each eye.

Case study taken from “A practical manual of diabetic retinopathy management” edited by Peter Scanlon, Ahmed Sallam and Peter Van Wijngaarden

The treatment journey for many patients will be long. It may also be unsatisfactory, even in highly resourced health systems. Decisions on treatment need to take into account available resources and equipment, skills of the eye health team and the barriers faced by the patient in adhering to the treatment pathway.

In this video, Dr Anthony Hall, consultant ophthalmologist, shares his perspectives and experiences as a vitreo-retinal surgeon in high and low resources health systems. As you watch the video, consider the local treatment challenges faced by providers and people with diabetes in your local setting.