17
Table 8. Management Recommendations for Patients With
Diabetes
Severity of
Retinopathy
Presence
of Macular
Edema
Follow-up
(Months)
Panretinal
Photocoagulation
(Scatter) Laser
Focal and/
or Grid
Laser
a
Intravitreal
Anti-VEGF
Therapy
Normal or
minimal
NPDR
No 12 No No No
Mild
NPDR
No 12 No No No
ME 4–6 No No No
CSME
b
1
a
No Sometimes Sometimes
Moderate
NPDR
No 6–12 No No No
ME 3–6 No No No
CSME
b
1
a
No Sometimes Sometimes
Severe
NPDR
No 4 Sometimes No No
ME 2–4 Sometimes No No
CSME
b
1
a
Sometimes Sometimes Sometimes
Non-high-
risk PDR
No 4 Sometimes No No
ME 4 Sometimes No No
CSME
b
1
a
Sometimes Sometimes Sometimes
High-risk
PDR
No 4 Recommended No Considered
ME 4 Recommended Sometimes Usually
CSME
b
1
a
Recommended Sometimes Usually
a
Adjunctive treatments that may be considered include intravitreal corticosteroids or anti-VEGF
agents (off-label use, except aflibercept and ranibizumab). Data from the Diabetic Retinopathy
Clinical Research Network in 2011 demonstrated that, at two years of follow-up, intravitreal
ranibizumab with prompt or deferred laser resulted in greater visual acuity gain and intravitreal
triamcinolone acetonide plus laser also resulted in greater visual gain in pseudophakic eyes compared
with laser alone. Individuals receiving the intravitreal injections of anti-VEGF agents may be re-
examined as early as one month following injection.
b
Exceptions include hypertension or fluid retention associated with heart failure, renal failure,
pregnancy, or any other causes that may aggravate macular edema. Deferral of photocoagulation
for a brief period of medical treatment may be considered in these cases. Also, deferral of CSME
treatment is an option when the center of the macula is not involved, visual acuity is excellent, close
follow-up is possible, and the patient understands the risks.
Anti-VEGF, anti-vascular endothelial growth factor; CSME, clinically significant
macular edema; ME, macular edema; NPDR, nonproliferative diabetic retinopathy;
PDR, proliferative diabetic retinopathy