February 16, 2023
Authored by: Burton Wisotsky, MD
A 27-year-old woman was referred for floaters in her left eye. She is a juvenile insulin-dependent diabetic since age 6. Blood sugars over the years have been poorly controlled. She saw her OD for her first-ever eye exam last week after noting red strings in the vision of the left eye. She was noted to have diabetic eye disease and was referred to us for evaluation and management.
On examination, VA was OU: 20/20. IOPs and the SLE were normal. The lens was clear OU. The vitreous cavity of the right eye was clear – in the left eye there was mild vitreous hemorrhage. Examination of the retina revealed advanced diabetic changes in both eyes. There was NVD, NVE, and extensive intraretinal hemorrhages. Fluorescein angiography demonstrated extensive capillary destruction with numerous areas of neovascularization. See the images below:
Before discussing treatment, it is important to point out several things about juvenile diabetics. First, blood sugars are typically poorly controlled. Second, even with good vision, diabetic changes can be advanced. The reason is that in contrast to adult-onset diabetics who typically first have maculopathy before peripheral disease, juvenile diabetics typically have peripheral ischemia and neovascularization before macular involvement. Thus, vision can be excellent with advanced disease. For this reason, juvenile diabetics need yearly retinal examinations even with perfect vision. Fluorescein angiography can often detect ischemic changes even in relatively unremarkable retinas, so this is an important test to perform when necessary. 95% of juvenile diabetics require treatment within 25 years of onset of diabetes, so it’s not a matter of whether he or she will need treatment – it’s a matter of when.
Up until several years ago, the mainstay of treatment was panretinal laser. The Diabetic Retinopathy Study from the 1980’s concluded that laser for PDR can markedly reduce the rate of severe vision loss. More recently, studies have shown that frequent antiVEGF injections can similarly arrest PDR without the potentially destructive effect of laser. I have a strong opinion about these conclusions. While antiVEGF certainly is effective, the problem is that it is not a cure – the injections have to be carried out indefinitely because the abnormal diabetic blood vessels do not go away – they regress. They will reactivate without treatment – therefore treatment needs to be indefinite. The problem is that most patients ultimately are noncompliant – so most patients eventually will miss a few visits and come back with advancing disease and vitreous hemorrhage. Therefore, I always perform laser with antiVEGF injections – the combination is much more effective than either one alone in arresting and maintaining good permanent resolution.
The patient initially had two monthly avastin injections in each eye accompanied by heavy PRP each time. After two months the retinopathy regressed. Vision stayed at 20/20 OU and the retinas were much improved. See photos below:
Unfortunately, the patient did not return for several months for follow up, and the retinopathy markedly worsened. Macular edema developed, the posterior NVE became more active, and vision dropped to 20/50 OU (see images).
We treated with additional laser and avastin with rapid improvement in retinal status. Vision returned to 20/20 OU (see images). With injections every couple of months the vision has remained stable. We hope to maintain good vision and wean her off injections in the future.