Diabetic retinopathy - Treating diabetic retinopathy

Early-stage retinopathy may not need treatment, but more advanced retinopathy may require laser treatment or injections of medicine into the eye.

Immediate treatment may not be necessary if you have:

• stage one (background) retinopathy
• stage two (pre-proliferative) retinopathy
• maculopathy with no symptoms 

However, you should still attend your annual screening check to monitor the progress of your retinopathy. You may also be given advice on how to control your diabetes.

If maculopathy is detected, you may need more frequent specialised testing (called optical coherence tomography). Additional tests may include a fluorescein angiography, which uses a camera and dye to examine blood flow in the back of the eye.

When treatment is necessary

• Laser treatment should be offered for proliferative (stage three or four) diabetic retinopathy and some cases of maculopathy.
• Intravitreal injections may be recommended if you have maculopathy.
• Vitreoretinal surgery may be needed if laser treatment is not possible because retinopathy is too advanced.

These three treatments are covered below.

Laser treatment

The aim of laser treatment is to stabilise the changes caused in your eyes by your diabetes. The treatment does not generally improve your sight, although it might in some cases.

The type of laser treatment used to treat diabetic retinopathy is called photocoagulation.

A course of photocoagulation usually involves one or more visits to a laser treatment clinic. An ophthalmologist will carry out the procedure, which is usually available on an outpatient basis. This means you will not have to stay in hospital overnight.

Before the procedure, you will be given a local anaesthetic to numb the surface of your eye, as well as eye drops to widen your pupils. A special contact lens will be placed on your eye to hold your eyelids open and allow the laser beam to be focused onto your retina.

Photocoagulation is not usually a painful procedure, but you may feel a sharp pricking sensation when certain areas of your retina are being treated.

If you have proliferative retinopathy (new blood vessels on the retina), or if the doctor thinks you will very soon have proliferative retinopathy, a large number of laser burns will be applied to the outer part of your retina (the part of the retina that allows you to see to the side and in the dark). This treatment is called peripheral scatter laser photocoagulation. 

If you have macular changes, gentle laser burns will be applied close to the central part of the retina – the part you use for seeing clearly. You need much less laser treatment than for proliferative retinopathy.

Possible side effects after the laser treatment

After laser treatment, your vision may be blurred. However, it should return to normal after a few hours.

Your eyes may also be more sensitive to light, and some people wear sunglasses until their eyes have adjusted.

You will not be able to drive after having laser surgery, so ask a friend or relative to drive you home, or take public transport.

If you have had previous eye treatment, your eyes may ache afterwards. Over-the-counter painkillers, such as paracetamol, should help.

Photocoagulation can sometimes affect your night vision and peripheral vision (side vision), and some patients may have to stop driving as a result. 

Approximately one in four people who have had laser treatment to both eyes for proliferative diabetic retinopathy have to stop driving.

Occasionally, some people have a bleed into the jelly that fills the eye (the vitreous). If you notice a shower of floaters (specks that float across your vision) or your sight gets worse, you should get medical advice.

Complications are very rare for macular treatment. Some people can still "see" a laser grid pattern after treatment. This usually continues for up to two months, and very occasionally for up to six months after treatment.

In a national survey, around 1 in 10 people who had had laser treatment for their macula reported seeing a small, but permanent, blind spot close to the centre of their sight.

Contact your GP or ophthalmologist if you experience any new problems with your eyes after treatment.

Intravitreal injections

Intravitreal anti-VEGF injections are often used to treat age-related macular degeneration. However, research has shown that they can also improve the vision of people with diabetic maculopathy.

VEGF stands for "vascular endothelial growth factor". It is one of the chemicals responsible for the growth of new blood vessels that form in the eye. Anti-VEGF medicines work by blocking this chemical and stopping it from producing the blood vessels. A medicine called ranibizumab (brand name Lucentis) will be injected directly into the eyeball.

Before the procedure, your eye and the skin around it will be cleaned, and the area around your eye will be covered with a drape to keep it free of infection. A small clip will be used to keep your eye open during the procedure.

You will be given local anaesthetic eye drops to numb your eye, so you do not feel any pain during the injection. 

Three injections are initially given, one month apart, and an ophthalmologist will assess how you respond to these. Most patients need around 7-10 injections in the first year of treatment, but this decreases sharply in the second and third years.

If you don't respond to anti-VEGF injections or you have had maculopathy for a long time, you may be tried on an intravitreal injection of a steroid drug called Iluvien (fluocinolone acetonide).

Possible side effects of intravitreal injections

The main risks of anti-VEGF drugs are infection of the eye or bleeding inside the eye. There is also a very small increased of risk of stroke or heart attack. Read a full list of the possible side effects of ranibizumab.

The main risk with Iluvien is increased pressure inside the eye, which can be treated.

Vitrectomy

A vitrectomy (also called vitreoretinal surgery) is surgery used to remove some or all of the vitreous humour. This is the transparent, jelly-like substance that fills the space behind the lens of the eye. This type of surgery may be needed if:

• a large amount of blood has collected in the centre of your eye, obscuring your vision
• there is extensive scar tissue that is likely to cause, or has already caused, retinal detachment

During the procedure, the surgeon will make a small incision in your eye before removing the vitreous humour in front of the retina.

The surgeon will remove any scar tissue that is causing damage to the retina or pulling it out of shape, and will use laser inside the eye to prevent further deterioration.

Vitreous surgery is usually carried out under local anaesthetic and sedation. This means you will not experience any pain or have any awareness of the surgery being performed.

Possible risks of a vitreous surgery are:

• developing a cataract
• further bleeding into the vitreous gel
• retinal detachment
• fluid build-up in the cornea (outer layer at the front of the eye)
• infection inside the eye

There's a small chance that you will need further retinal surgery afterwards. Your surgeon will explain the risks to you.

After the procedure

You should be able to go home on the same day or the day after your surgery.

For the first few days, you may need to wear an eye patch at certain times of the day. This is because activities such as reading and watching television can quickly tire your eye, but wearing an eye patch will allow you to gradually make more use of it.

If gas was used to hold your retina in place, you should not travel by plane until all the gas has been absorbed by your body. Your surgeon can talk to you about this.

After vitreous surgery, you are likely to have blurred vision for several weeks. This should improve gradually, although it may take several months for your vision to return to normal.

Managing your diabetes

Managing your diabetes is the most important part of your treatment. It's important to keep your blood sugar levels under control to stop your eyes deteriorating again. 

Read about how you can prevent diabetic retinopathy.