Controversies and perspectives in diabetic retinopathy

Professor Francesco Bandello and Professor Anat Loewenstein who chaired the Diabetic Retinopathy Symposium. The “Diabetic Retinopathy: Controversies & Perspectives” symposium was chaired by , University Vita-Salute, San Raffaele Scientific Institute, Milan, Italy, and Professor Anat Loewenstein, Tel Aviv Medical Center, Israel. The symposium featured seven speakers who shared their expertise, research results and points of view on the management of diabetic retinopathy (DRP). Professor José Cunha-Vaz, University of Coimbra, Portugal, addressed the difficulty of predicting progression to diabetic macular oedema (DME). He suggested considering the newly discovered phenotypes of DRP based largely on microaneurysm turnover: Phenotype A (50%) has a minimal risk of progression, whereas Phenotypes B and C, each representing about 25%, each have a high risk. Considering the difficulty of efficiently imaging retinas suffering from DRP, what is the best way to do it? Prof Bandello considered this topic in his presentation, “Ultra-Wide Field Angiography: Any New Information for our Diabetic Patients?” He is a strong proponent of the Optos ultra-wide field system. “This allows 82% of the retina to be imaged, up to 200°, which is significantly greater than the 7-standard field (7SF) technique,” he said, referring to the current gold standard. This allows 3.2x more total retinal surface, 3.9x more nonperfusion, 1.9x more neovascularisation and 3.8x more PRP-treated area to be seen, as compared to the 7SF technique, according to a study that compared the two modalities. Professor José Garcia-Arumí, Instituto De Microcirurgia Ocular, Barcelona, Spain, then covered the very difficult topic of vitrectomy for patients with DME. He addressed the question of whether vitrectomy would be useful in a greater proportion of patients now that 25- and 27-gauge systems have become widespread. Prof Garcia-Arumí concluded that although tractional macular oedema is still a good indication for surgery, large randomised controlled trials are needed to compare vitrectomy to the latest gold standard, anti-VEGF drugs. However, such studies are difficult, as surgery is only considered in refractor or end-stage cases. Next up was a debate: “Laser Therapy for Clinically Significant Macular Edema: Yes or No?” Defending the “No” side was Dr Maurizio Battaglia-Parodi, Vita-Salute San Raffaele University, Milan, Italy. He highlighted the potentially severe side-effects of laser treatment, and contrasted them with the comparatively safe anti-VEGF injections. Prof Loewenstein defended laser therapy for DME. “I really do believe that there are cases in which a single laser session can be of great benefit,” she said, but only as an adjunctive tool. Rounding off the dynamic program were Professor Michaella Goldstein, also of Tel Aviv Medical Center, Israel, and Dr Sobha Sivaprasad, Moorfields Eye Hospital, London, England. Prof Goldstein explained her views on laser treatment for proliferative DRP (PDR). Her most poignant point was the fact that adherence to follow-up with an anti-VEGF treatment regimen is critical to its success. However, success after PRP is much less dependent on long-term follow-up. Dr Sivaprasad discussed the possible role of photoreceptors in the development of DRP, pointing to the relative ischaemia induced by rods due to their very high metabolic demands in the dark-adapted state.