KAVITA SUGUMARAN, 061303017, BATCH 19, B2

e-learning: LASER TREATMENT IN DIABETIC RETINOPATHY

Eye problems are common in diabetes and can, in some cases, seriously affect vision. Laser
photocoagulation is, at present, the only effective treatment for proliferative diabetic retinopathy
(PDR) and maculopathy, but it does not cure the disease. It can prevent, delay and sometimes reverse
vision loss. Without either laser treatment or surgery, vision loss caused by diabetic retinopathy and
its complications may progress until blindness occurs. The laser uses heat to seal or destroy large
areas of the outer retina by creating thousands of burns outside the macular area. Mass reduction of
oxygen-hungry photoreceptor cells appears to introduce choroidal oxygen to the ischemic inner retina,
with a resultant reduction in hypoxia-mediated secretion of vascular endothelial growth factor
(VEGF) and regression of neovascularization.(1) Photocoagulation is used to destroy areas of retinal
ischemia since it plays a major role in the development of neovascularization, to seal leaking
microaneurysms and to obliterate new vessels directly. Results of the Diabetic Retinopathy Study
(DRS) demonstrated that panretinal photocoagulation effectively reduces the risk of vision loss in
most (60%) patients with PDR.(2) Earlier and more adequate treatment is effective in over 90% of
cases. However, the retinal destruction inherent in conventional photocoagulation may cause both
short- and long-term visual field loss and compromise other visual functions.

The operation can be done as a day surgery procedure, which means that the patient can go
home on the same day of the operation. Initially, the pupil is dilated by using some special eye drops.
Following that, the eye is numbed with eye drops that contain local anaesthetic. Sometimes, an extra
injection into the side of the eye is needed to make the procedure totally painless and comfortable. A
contact lens is placed on the eye. The patient sits and faces the laser machine. The laser light passes
through the contact lens and the pupil in the eye and is directed in a very accurate way to the many
small vessels that have created the problem. During the procedure the patient may be asked to turn
their eyes to look in different directions so that the laser light can be applied to different areas of the
retina. Each bright flash lasts 0.05-0.02 seconds.(3)The commonest laser is Argon Green, wavelength
530nm, but other wavelengths can be used and most are equally effective.

The laser light works in two ways. First, it scars the vessels that have a tendency to bleed and
so prevents any further bleeding. Second, it destroys substances in the retina that stimulate the
massive disorganised proliferation of small vessels in the surface of the retina. (4) There are two types
of laser surgery for non proliferative diabetic retinopathy (NPDR): Focal (or specific) surgery and
Grid surgery. Focal photocoagulation, which targets specific blood vessels, is effective in reducing
the risk of vision loss in people with macular edema. It lowers the risk of moderate vision loss by 20%
in people who have mild to moderate nonproliferative diabetic retinopathy. With focal laser surgery,
the specific leaking spots in the retina are found by a fluorescein angiogram, which is then used as a
guide for the laser in an attempt to stop the leakage. In some patients, all of the leaking spots may be
properly treated. In some patients, all of the leaking spots may be properly treated, but they may
continue to leak, or new ones may develop. In such cases, further leakage causes more swelling and
worsening of vision. Additional laser surgery frequently needs to be done in order to stop new
leakage, but again, the vision is not likely to improve. In other situations, further laser surgery is not
helpful and should not be done.

In some cases of NPDR, blood vessels appear to be leaking everywhere in the macula and not
just in a few specific areas. In such cases, a scatter of laser in a grid pattern is placed across the entire
swollen macular area. Grid laser surgery has a fair chance of drying the macula and holding vision
stable.(5) Grid surgery, however, infrequently improves vision.

After the laser surgery, the patient will often see the many small spots caused by laser burns.
With time, the spots tend to shrink and fade, and the patient will be less bothered by them, though
they will always be there. Even when laser surgery has successfully sealed the leaking vessels, new
areas of leakage frequently appear later, causing more swelling and more loss of vision. The patient
who is treated with laser should continue to check the vision in each eye daily and tell the doctor
immediately if there are new changes, such as a return of distortion or blurriness. Vision does not
usually improve with laser surgery, but if NPDR is discovered early enough, laser surgery may stop
further loss.

All diabetic patient should be examined regularly to be sure that neovascularization is not
developing. When neovascularization does develop in PDR patient and the amount is not severe,
laser surgery is not necessary as long as the patient is examined regularly. If the amount of
neovascularization is great, laser surgery can often prevent loss of vision. The type of laser surgery
that is done when there is a lot of neovascularization is called panretinal laser photocoagulation.
Scatter (pan-retinal) photocoagulation, which treats a wide area of the retina, reduces the risk for
severe vision loss by 50% to 60% over 6 years in people with a high risk of vision loss. It reduces the
risk of serious bleeding and progression of severe proliferative retinopathy and the need for surgery
(vitrectomy) by 50% in people with type 2 diabetes and people age 40 and older with type 1 diabetes
who already have severe nonproliferative or mild proliferative retinopathy. Studies suggest that up to
90% of cases of legal blindness caused by proliferative retinopathy could be prevented by prompt
scatter photocoagulation.(6) This type of laser surgery is usually done in two or more separate sessions.
The idea is to use the laser to destroy all of the dead areas of retina where the blood vessels have been
closed. When these areas are treated with the laser, the retina stops manufacturing new blood vessels,
and those that are already present tend to decrease or disappear.

There are side effects of panretinal laser photocoagulation and, for this reason, this surgery is
not done when only a small amount of neovascularization is present. It is important to remember,
however, that when the amount is great enough to warrant laser surgery, the longer the eye remains
untreated the more likely vision will be lost and blindness will occur. The earlier severe
neovascularization is discovered and the eye is treated with laser the more likely blindness can be
prevented. If you have developed neovascularization, your doctor will advise you about when
panretinal laser photocoagulation should be done.

Panretinal laser photocoagulation does not improve vision, however, it is the best possible
means of holding vision stable to prevent further loss. After laser surgery, patients may still have
reduced vision or may continue to lose more vision. But if panretinal laser photocoaculation is
indicated, the chances are that it will prevent severe loss of vision. Panretinal laser photocoagulation
is placed on the periphery side of the retina, not on the center, and peripheral side vision will
definitely be diminished to some extent. These side areas are sacrificed in order to save as much of
the central vision as possible and to save the eye itself. Night vision will also be diminished. After
laser, blurred vision is very common. Usually, this blur goes away, but in a small number of patients,
some blur will continue forever. Rare complications of laser photocoagulation may cause severe
vision loss. These are include vitreous hemorrhage, traction retinal detachment and accidental laser
burn of the fovea resulting in severe central vision loss.

Diabetes experts agree that early detection and treatment of retinopathy can prevent many, or
even most, cases of severe vision loss and blindness in people with diabetes.It is also important to
keep your blood sugar levels low after laser treatment. Even if your eyes are better, diabetic
retinopathy will keep getting worse over time if your blood sugar levels rise again.