PRP Preferred for Some Patients?

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In the ideal world of controlled scientific studies, the strategy of treating proliferative diabetic reti­nopathy (PDR) with intravitreal injec­tions has proved effective and possibly superior to panretinal photocoagulation (PRP). Now researchers report that in the “real” world, where patients are often lost to follow-up, PRP may be the better option.¹

“Part of the impetus for this study was that we know PRP has long-lasting effects on stabilizing PDR, but we have little data on whether anti-VEGF thera­py has any long-lasting effects once it is stopped,” said Jason Hsu, MD, at Wills Eye Hospital in Baltimore.

Now, data exist. “Our study sug­gests that if there is a period of loss to follow-up, patients with PDR who receive PRP may have better outcomes compared to those who received only anti-VEGF therapy,” said coauthor An­thony Obeid, MD, MPH, also at Wills Eye Hospital.  

RD RISK. This eye with PDR developed an RD after being lost to follow-up.

Retrospective cohort. The findings are based on medical records of 59 pa­tients with PDR (76 eyes) who returned at various time points for follow-up treatment. All of the 59 patients had been lost to follow-up for 6 or more months immediately after receiving ei­ther intravitreal injections (20 patients; 30 eyes) or PRP (39 patients; 46 eyes).

Findings include the following:

• Visual acuity (VA) scores worsened in anti-VEGF eyes, from 20/54 at the visit before patients were lost to follow-up to 20/187 at the return visit and 20/ 166 at the final visit.
• In PRP eyes, VA significantly wors­ened from 20/53 at the visit before pa­tients were lost to follow-up to 20/83 at the return visit. However, VA improved by the final visit to 20/58.
• There was a significantly greater in­cidence of neovascularization of the iris in the anti-VEGF group compared to the PRP arm at the final visit (4 vs. 0).
• A significantly greater number of eyes in the anti-VEGF group had tractional retinal detachment (RD) after patients returned to care. At the return visit, 5 in the anti-VEGF group experienced tractional RD, versus none in the PRP group. At the final visit, 10 anti-VEGF patients had tractional RD, versus 1 PRP patient. However, the incidence of tractional RD was lower in eyes that received a greater number of anti-VEGF injections prior to being lost to follow-up. “This may suggest that receiving a certain minimum number of injections may have lasting effects on PDR regression,” Dr. Obeid said.

Stick with PRP. The findings are par­ticularly relevant as practice patterns are shifting toward anti-VEGF mono­therapy for eyes with PDR, the authors said. They assume even greater relevance given the “strikingly high” rates of pa­tients lost to follow-up,² said Dr. Hsu.

“Some clinicians believe that PRP may not be necessary or can be delayed while the patient is actively receiving anti-VEGF treatments,” Dr. Hsu added. “However, our study suggests that phy­sicians may want to proceed with PRP at an earlier time point given the po­tential for poorer outcomes with erratic follow-up.” (For more on this topic, see “Five-Year Outcomes of Randomized Trial Comparing Laser with Ranibizumab for PDR” in this month’s Journal Highlights.)

—Miriam Karmel

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1 Obeid A et al. Ophthalmology. Published online Aug. 2, 2018.

2 Obeid A et al. Ophthalmology. 2018;129(9):1386-1392.

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Relevant financial disclosures—Drs. Hsu and Obeid: None.

For full disclosures and the disclosure key, see below.

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