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Low Vision Assessment and Rehabilitation

Initial Management of Diabetic Retinopathy

At Dr. Cole's first laser treatment five days later, his visual acuity had fallen to 1/200 (20/4000) right eye and 20/300 left eye because of worsening macular edema, and increasing vascular damage in the central retina.

Control of Macular Edema

The first priority was to control his diffuse macular edema. The widespread damage to the retinal blood vessels in both maculae suggested that extensive macular treatments would be necessary to control this aspect of his diabetic eye disease process. Fluorescein angiography showed that the microvasculature of the right eye was less severely affected and so the treatment for macular edema of this eye was undertaken first.

Relatively high laser powers were used because of poor laser uptake, a manifestation of the severe retinal edema. Laser powers were selected that produced subtle greying at the site of the laser application. Initial treatments avoided the area close to the center of his vision because of the poor contrast related to the tissue swelling, and the consequent difficulty of determining where the center of the vision lay. An anti-VEGF agent can be successfully used in conjunction with laser treatment or as a stand-alone treatment for "wet" (neovascular) macular degeneration (Rosenfeld PJ, et al., 2006; Massin P, et al., 2010). Several treatment options are available for "wet" macular degeneration.

Note in the table that the laser powers were reduced in subsequent treatments as the diffuse edema lessened and laser uptake increased. The paracentral area was also treated.

Control of Proliferative Diabetic Retinopathy

After extensive and repeated grid laser treatments to both maculae, pan-retinal laser photocoagulation was performed to the peripheral retinas of both eyes to control his proliferative diabetic retinopathy. Several treatments were required initially. The number and intensity of the treatments were determined by the response to treatment. Additional treatments were performed following initial control, if there were reformation of the development of intraocular neovascular fronds (new blood vessels) or scar tissue proliferations.