Laser still gold standard for diabetic retinopathy, although advances are in pipeline

Fort Lauderdale, FL-Although rapid advances are being made in pharmacotherapy, laser photocoagulation remains a gold standard for diabetic macular edema and proliferative disease, said Mark S. Blumenkranz, MD, professor and chairman, Department of Ophthalmology, Stanford University, Stanford, CA. One caveat, however, is that the evolving standard of care will be based on solid clinical study data principally from the classic studies of diabetic retinopathy to provide better patient outcomes and more cost-effective treatments.

A number of substantial changes in lasers are making treatment more beneficial, with different laser wavelengths, shorter pulses, and multi-patterns. As with drugs, the doses of the laser applications can be modulated to make laser treatment “less like a sledgehammer,” he said.

The importance of laser pulse duration has been rediscovered in terms of patient comfort and, potentially, in terms of lesion size, morphology, and function, he added. With short pulses (10 to 30 msec), the acute lesion are smaller, do not enlarge over 1 to 2 years, and may not be associated with loss of function as with longer (100 to 200 msec) pulse applications.

Pattern scanning and newer lasers have a role in making treatment more cost effective and more comfortable for patients when treatment is administered in a single session.

“The single sessions were found to be fundamentally effective with their ability to effect regression,” Dr. Blumenkranz said. “There also was no long-term exacerbation of macular edema.”

Combinations of laser and drug therapies are on the horizon and their application may be complementary and case-dependent, according to Dr. Blumenkranz. Intravitreal triamcinolone and photocoagulation were compared in one study, and at 2 years laser treatment was associated with slightly better visual acuity than 1 or 4 mg of the drug.

Future therapy will likely be a combination of antivascular endothelial growth factors drugs or triamcinolone with photocoagulation “to make them work together in the most meaningful way,” Dr. Blumenkranz concluded.