How Effective Are Treatments
for Diabetic Retinopathy?
ANALYSIS of data from four decades of clinical research
demonstrates that currently recommended treatments are
considerably more effective in preventing blindness from
proliferative diabetic retinopathy (PDR) than has been pre-
viously appreciated. In fact, careful follow-up, timely photo-
coagulation, and vitrectomy when necessary strikingly re-
duce the risk of blindness for patients with PDR. This re-
markable finding lends even greater urgency to current ef-
forts to ensure that virtually all persons with diabetes receive
at least yearly dilated eye examinations and are offered ap-
propriate treatment when indicated.
Based on the results of clinical trials supported by the
National Eye Institute and extensive clinical experience, spe-
cific recommendations have been developed concerning for
whom and when treatment is appropriate.1-5 Prior to the
availability ofthese treatments, the development of PDR was
reason for extreme concern by both patients and their phy-
sicians about the risk of impending blindness. A 1963 study
by Beetham6 showed that about half of his patients who
developed PDR became legally blind (visual acuity [VA] ^20/
200 in the better eye) and that this occurred on average 3.2
years after the development of PDR. Other reports con¬
firmed that within 5 years of the onset of PDR, about 50% of
patients were blind.7·8 The first major clinical trial of photo-
coagulation for diabetic retinopathy, the Diabetic Retinopa¬
thy Study (DRS), which had many more patients with long-
term follow-up than earlier case series, reported similar high
rates for blindness in the untreated control eyes with PDR.
After only 3 years of follow-up, more than one third of these
untreated eyes had reached the legal blindness level and
nearly 30% had severe visual loss (VA <5/200). Scatter pho¬
tocoagulation reduced the risk of blindness by 60% in DRS-
treated eyes and became the standard of care for all eyes with
high-risk PDR.9 Subsequent clinical trials, the Diabetic Re¬
tinopathy Vitrectomy Study (DRVS) and the Early Treat¬
ment Diabetic Retinopathy Study (ETDRS), further dem¬
onstrated the marked effectiveness of prompt and thorough
treatment for PDR.
Current recommendations for the treatment of diabetic
retinopathy include careful follow-up, scatter photocoagula-
tion for eyes that approach or reach high-risk PDR, focal
From the Clinical Trials Branch, National Eye Institute, Bethesda, Md.
Reprint requests to the Clinical Trials Branch, National Eye Institute, Bldg 31, Room
6A24, 9000 Rockville Pike, Bethesda, MD 20892 (Dr Ferris).
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photocoagulation for most eyes with clinically significant mac¬
ular edema, and vitrectomy when necessary for severe PDR
or vitreous hemorrhage. Scatter photocoagulation (also called
panretinal photocoagulation) is a treatment in which hun¬
dreds of moderate-sized photocoagulation burns are placed in
the peripheral retina. This indirect treatment often results in
the resolution or stabilization of PDR. In focal photocoagu¬
lation, much smaller laser burns are aimed at leaking mi-
croaneurysms in the macular area. Several treatments are
often necessary but usually the retinal thickening from the
edema can be reversed. Vitrectomy is performed in eyes with
PDR to surgically remove persistent vitreous hemorrhage or
to release vitreoretinal traction.
Although there were many different treatment strategies
used in the ETDRS, all treatment strategies in that study
incorporated careful follow-up, scatter photocoagulation, and
vitrectomy when necessary. Each of the ETDRS treatment
strategies for PDR resulted in a low rate of severe visual loss.
Because the rates of severe visual loss in each of the ETDRS
treatment groups are similar, the overall rate of severe visual
loss in the ETDRS can be considered roughly comparable to
that expected using currently recommended treatment. How
effectively do these strategies, which we should be applying
in everyday practice, reduce the risk of blindness?
The Figure shows rates of severe visual loss (VA <5/200),
assessed at each study visit after PDR was diagnosed, for
untreated eyes in the DRS compared with treated eyes (or
patients) in the ETDRS. Although the risk of severe visual
loss for untreated DRS eyes at 3 years approached 30%, only
4% of treated eyes with PDR in the ETDRS had reached
severe visual loss by 5 years and only 1% of patients had this
degree of visual loss in both eyes. Long-term studies indicate
that 10- and 15-year rates may not be much higher than this
5-year rate.10 Results using VA 20/200 or worse as the end
point are similar. Data from the DRS and other sources
suggest that untreated, about 50% of patients with PDR
become legally blind within 5 years, compared with only 5%
of ETDRS patients with PDR.
These results graphically demonstrate the marked reduc¬
tion in blindness that can result from full implementation of
current treatment recommendations for diabetic retinopa-
thy. A 60% reduction in blindness, as first shown in the DRS,
would be reason enough to ensure that everyone with PDR
gets adequate treatment. The economic value of photocoag¬
ulation, not to mention the vision saved, has been previously
documented using DRS results.11,12 These new data, demon-
 requiring it. The National Eye Institute is sponsoring a Na¬
50- tional Eye Health Education Program, which is designed to
DRS Untreated Eyes inform people with diabetes about the need for dilated eye
• ETDRSbyEye examinations to detect diabetic retinopathy. The American
A ETDRS by Patient
40- Academy of Ophthalmology's Diabetes 2000 program is work¬
ing to inform all physicians about screening for retinopathy
and assure adequate treatment for those patients needing it.
These programs are complementary in intent, and they need
our full support to help eliminate needless blindness from
diabetic retinopathy. For decades, people with diabetes be¬
came blind from diabetic retinopathy; with sight-saving treat¬
ments now available, it is a tragedy that people may still
suffer preventable blindness.
Frederick L. Ferris III, MD
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proliferative diabetic retinopathy: clinical applications of Diabetic Retinopathy
Study (DRS) findings: DRS report number 8. Ophthalmology. 1981;88:583-600.
2. The Diabetic Retinopathy Vitrectomy Study Research Group. Early vitrectomy
for severe proliferative diabetic retinopathy in eyes with useful vision: DRVS report
Baseline 2 3 number 3. Ophthalmology. 1988;95:1307-1334.
Year of Study 3. The Diabetic Retinopathy Vitrectomy Study Research Group. Early vitrectomy
for severe vitreous hemorrhage in diabetic retinopathy: DRVS report number 5.
Arch Ophthalmol. 1990;108:958-964.
4. Early Treatment Diabetic Retinopathy Study (ETDRS) Research Group. Early
Proportion of untreated eyes with proliferative diabetic retinopathy (PDR) from photocoagulation for diabetic retinopathy: ETDRS report number 9. Ophthalmolo-
the Diabetic Retinopathy Study (DRS) developing severe visual loss (visual
gy. 1991;98(suppl):767-785.
acuity [VA] <5/200) compared with rates in treated eyes and patients with PDR 5. Diabetic Retinopathy: American Academy of Ophthalmology Preferred Practice
from the Early Treatment Diabetic Retinopathy Study (ETDRS). (All eyes have Patterns. San Francisco, Calif: American Academy of Ophthalmology Quality of Care
PDR and VA ==5/200 at baseline in this analysis, but PDR may have been Committee Retinal Panel, American Academy of Ophthalmology; 1989.
somewhat worse on average at baseline in the DRS than the ETDRS. Number 6. Beetham WP. Visual prognosis of proliferating diabetic retinopathy. Br J
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7. Caird FI, Burditt AF, Draper GJ. Diabetic retinopathy: a further study of prog-
2127, 1960, 1795, and 1586.) nosis for vision. Diabetes. 1968;17:121-123.
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juvenile diabetes. Diabetes. 1967;10:728-733.
strating that use of the currently recommended treatment 9. The Diabetic Retinopathy Study (DRS) Research Group. Preliminary report on
strategies strikingly reduces the risk of blindness for patients effects of photocoagulation therapy: DRS report number 1. Am J Ophthalmol. 1976;
81:383-384.
with PDR, makes full implementation of recommended treat¬ 10. Blankenship GW. Fifteen-year argon laser and xenon photocoagulation results
ments for diabetic retinopathy all the more imperative. of Bascom Palmer Eye Institute's patients participating in the Diabetic Retinopa-
thy Study. Ophthalmology. 1991;98:125-128.
A number of programs have been developed to help ensure 11. Javitt JC, Canner JK, Sommer A. Cost-effectiveness of current approaches to the
that all persons with diabetes are examined for diabetic re¬ control of retinopathy in type I diabetics. Ophthalmology. 1989;96:255-264.
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tinopathy, and that adequate treatment is available for those medical research: the Diabetic Retinopathy Study. Soc Sci Med. 1992;9:973-981.

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