Laser photocoagulation for proliferative diabetic retinopathy - PubMed (original) (raw)

Review

Laser photocoagulation for proliferative diabetic retinopathy

Jennifer R Evans et al. Cochrane Database Syst Rev. 2014.

Abstract

Background: Diabetic retinopathy is a complication of diabetes in which high blood sugar levels damage the blood vessels in the retina. Sometimes new blood vessels grow in the retina, and these can have harmful effects; this is known as proliferative diabetic retinopathy. Laser photocoagulation is an intervention that is commonly used to treat diabetic retinopathy, in which light energy is applied to the retina with the aim of stopping the growth and development of new blood vessels, and thereby preserving vision.

Objectives: To assess the effects of laser photocoagulation for diabetic retinopathy compared to no treatment or deferred treatment.

Search methods: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2014, Issue 5), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to June 2014), EMBASE (January 1980 to June 2014), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 3 June 2014.

Selection criteria: We included randomised controlled trials (RCTs) where people (or eyes) with diabetic retinopathy were randomly allocated to laser photocoagulation or no treatment or deferred treatment. We excluded trials of lasers that are no longer in routine use. Our primary outcome was the proportion of people who lost 15 or more letters (3 lines) of best-corrected visual acuity (BCVA) as measured on a logMAR chart at 12 months. We also looked at longer-term follow-up of the primary outcome at two to five years. Secondary outcomes included mean best corrected distance visual acuity, severe visual loss, mean near visual acuity, progression of diabetic retinopathy, quality of life, pain, loss of driving licence, vitreous haemorrhage and retinal detachment.

Data collection and analysis: We used standard methods as expected by the Cochrane Collaboration. Two review authors selected studies and extracted data.

Main results: We identified a large number of trials of laser photocoagulation of diabetic retinopathy (n = 83) but only five of these studies were eligible for inclusion in the review, i.e. they compared laser photocoagulation with currently available lasers to no (or deferred) treatment. Three studies were conducted in the USA, one study in the UK and one study in Japan. A total of 4786 people (9503 eyes) were included in these studies. The majority of participants in four of these trials were people with proliferative diabetic retinopathy; one trial recruited mainly people with non-proliferative retinopathy. Four of the studies evaluated panretinal photocoagulation with argon laser and one study investigated selective photocoagulation of non-perfusion areas. Three studies compared laser treatment to no treatment and two studies compared laser treatment to deferred laser treatment. All studies were at risk of performance bias because the treatment and control were different and no study attempted to produce a sham treatment. Three studies were considered to be at risk of attrition bias.At 12 months there was little difference between eyes that received laser photocoagulation and those allocated to no treatment (or deferred treatment), in terms of loss of 15 or more letters of visual acuity (risk ratio (RR) 0.99, 95% confidence interval (CI) 0.89 to 1.11; 8926 eyes; 2 RCTs, low quality evidence). Longer term follow-up did not show a consistent pattern, but one study found a 20% reduction in risk of loss of 15 or more letters of visual acuity at five years with laser treatment. Treatment with laser reduced the risk of severe visual loss by over 50% at 12 months (RR 0.46, 95% CI 0.24 to 0.86; 9276 eyes; 4 RCTs, moderate quality evidence). There was a beneficial effect on progression of diabetic retinopathy with treated eyes experiencing a 50% reduction in risk of progression of diabetic retinopathy (RR 0.49, 95% CI 0.37 to 0.64; 8331 eyes; 4 RCTs, low quality evidence) and a similar reduction in risk of vitreous haemorrhage (RR 0.56, 95% CI 0.37 to 0.85; 224 eyes; 2 RCTs, low quality evidence).None of the studies reported near visual acuity or patient-relevant outcomes such as quality of life, pain, loss of driving licence or adverse effects such as retinal detachment.We did not plan any subgroup analyses, but there was a difference in baseline risk in participants with non-proliferative retinopathy compared to those with proliferative retinopathy. With the small number of included studies we could not do a formal subgroup analysis comparing effect in proliferative and non-proliferative retinopathy.

Authors' conclusions: This review provides evidence that laser photocoagulation is beneficial in treating proliferative diabetic retinopathy. We judged the evidence to be moderate or low, depending on the outcome. This is partly related to reporting of trials conducted many years ago, after which panretinal photocoagulation has become the mainstay of treatment of proliferative diabetic retinopathy.Future Cochrane Reviews on variations in the laser treatment protocol are planned. Future research on laser photocoagulation should investigate the combination of laser photocoagulation with newer treatments such as anti-vascular endothelial growth factors (anti-VEGFs).

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Conflict of interest statement

JE: none known MM: none known GV: none known

Figures

1

1

Results from searching for studies for inclusion in the review

2

2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

3

3

Forest plot of comparison: 1 Laser photocoagulation versus control, outcome: 1.1 Loss of 15 or more letters BCVA at 12 months

4

4

Forest plot of comparison: 1 Laser photocoagulation versus control, outcome: 1.4 Severe visual loss (BCVA < 6/60)

5

5

Forest plot of comparison: 1 Laser photocoagulation versus control, outcome: 1.5 Progression of diabetic retinopathy

1.1

1.1. Analysis

Comparison 1 Laser photocoagulation versus control, Outcome 1 Loss of 15 or more letters BCVA at 12 months.

1.2

1.2. Analysis

Comparison 1 Laser photocoagulation versus control, Outcome 2 Loss of 15 or more letters BCVA at 2 years.

1.3

1.3. Analysis

Comparison 1 Laser photocoagulation versus control, Outcome 3 Loss of 15 or more letters BCVA at 3 years.

1.4

1.4. Analysis

Comparison 1 Laser photocoagulation versus control, Outcome 4 Severe visual loss (BCVA < 6/60).

1.5

1.5. Analysis

Comparison 1 Laser photocoagulation versus control, Outcome 5 Progression of diabetic retinopathy.

1.6

1.6. Analysis

Comparison 1 Laser photocoagulation versus control, Outcome 6 Vitreous haemorrhage.

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PETER PAN Study 2013 {published data only}
    1. Muqit MM, Young LB, McKenzie R, John B, Marcellino GR, Henson DB, et al. Pilot randomised clinical trial of Pascal TargETEd Retinal versus variable fluence PANretinal 20 ms laser in diabetic retinopathy: PETER PAN study. British Journal of Ophthalmology 2013;97(2):220‐7. - PubMed
Plumb 1982 {published data only}
    1. Plumb AP, Swan AV, Chignell AH, Shilling JS. A comparative trial of xenon arc and argon laser photocoagulation in the treatment of proliferative diabetic retinopathy. British Journal of Ophthalmology 1982;66(4):213‐8. - PMC - PubMed
Salman 2011 {published data only}
    1. Salman AG. Pascal laser versus conventional laser for treatment of diabetic retinopathy. Saudi Journal of Ophthalmology 2011;25(2):175‐9. - PMC - PubMed
Schiodte 1983 {published data only}
    1. Schiodte SN. Changes in pressure pulse amplitudes of normotensive diabetic eyes after panretinal photocoagulation. A long term study with comparison of xenon arc and argon laser. Acta Ophthalmologica 1983;61(5):769‐77. - PubMed
Seiberth 1986 {published data only}
    1. Seiberth V, Alexandridis E, Feng W. Retinal function following panretinal laser coagulation in diabetic retinopathy‐‐dependence on the size and density of coagulation spots. Fortschritte der Ophthalmologie 1986;83(4):462‐6. - PubMed
Seiberth 1987 {published data only}
    1. Seiberth V, Alexandridis E, Feng W. Function of the diabetic retina after panretinal argon laser coagulation. Graefe's Archive for Clinical and Experimental Ophthalmology 1987;225(6):385‐90. - PubMed
Seiberth 1993 {published data only}
    1. Seiberth V, Schatanek S, Alexandridis E. Panretinal photocoagulation in diabetic retinopathy: argon versus dye laser coagulation. Graefe's Archive for Clinical and Experimental Ophthalmology 1993;231(6):318‐22. - PubMed
Seymenoglu 2013 {published data only}
    1. Seymenoglu G, Kayikcioglu O, Baser E, Sami Ilker S. Comparison of pain response of patients undergoing panretinal photocoagulation for proliferati diabetic retinopathy: 532 nm standard laser vs. multispot pattern scan laser. Turk Oftalmoloiji Dergisi 2013;43(4):221‐4.
Shimura 2003 {published data only}
    1. Shimura M, Yasuda K, Nakazawa T, Kano T, Ohta S, Tamai M. Quantifying alterations of macular thickness before and after panretinal photocoagulation in patients with severe diabetic retinopathy and good vision. Ophthalmology 2003;110(12):2386‐94. - PubMed
Shimura 2009 {published data only}
    1. Shimura M, Yasuda K, Nakazawa T, Abe T, Shiono T, Iida T, et al. Panretinal photocoagulation induces pro‐inflammatory cytokines and macular thickening in high‐risk proliferative diabetic retinopathy. Graefe's Archive for Clinical and Experimental Ophthalmology 2009;247(12):1617‐24. - PubMed
Stanga 2010 {published data only}
    1. Stanga PE, Muqit MM. Retinal laser photocoagulation, anaesthesia, and pain responses. Eye 2010;24(8):1415‐6. - PubMed
Tewari 2000 {published data only}
    1. Tewari HK, Ravindranath HM, Kumar A, Verma L. Diode laser scatter photocoagulation in diabetic retinopathy. Annals of Ophthalmology 2000;32(2):110‐2.
Theodossiadis 1990 {published data only}
    1. Theodossiadis GP, Boudouri A, Georgopoulos G, Koutsandrea C. Central visual field changes after panretinal photocoagulation in proliferative diabetic retinopathy. Ophthalmologica 1990;201(2):71‐8. - PubMed
Townsend 1980 {published data only}
    1. Townsend C, Bailey J, Kohner E. Xenon arc photocoagulation for the treatment of diabetic maculopathy. Interim report of a multicentre controlled clinical study. British Journal of Ophthalmology 1980;64(6):385‐91. - PMC - PubMed
    1. Townsend C, Bailey J, Kohner EM. Xenon arc photocoagulation in the treatment of diabetic maculopathy. Transactions of the Ophthalmological Societies of the United Kingdom 1979;99(1):13‐6. - PubMed
Uehara 1993 {published data only}
    1. Uehara M, Tamura N, Kinjo M, Shinzato K, Fukuda M. A prospective study on necessary and sufficient retinal photocoagulation for diabetic retinopathy. Journal of Japanese Ophthalmological Society 1993;97(1):83‐9. - PubMed
Vera‐Rodriguez 2008 {published data only}
    1. Vera‐Rodriguez SE, Velez‐Montoya R, Lopez‐Ramos ML, Alvarez‐Verduzco O, Martinez‐Castellanos MA, Gonzalez‐Mijares CC, et al. Pattern scan laser system vs. conventional photocoagulation system: electroretinogram changes after treatment. Investigative Ophthalmology and Visual Science 2008:ARVO E‐ abstract 2766.
Wade 1990 {published data only}
    1. Wade EC, Blankenship GW. The effect of short versus long exposure times of argon laser panretinal photocoagulation on proliferative diabetic retinopathy. Graefe's Archive for Clinical and Experimental Ophthalmology 1990;228(3):226‐31. - PubMed
Wiznia 1985 {published data only}
    1. Wiznia RA. Photocoagulation of non‐proliferative diabetic retinopathy. The Macula Society 1985:104.
Wroblewski 1991 {published data only}
    1. Wroblewski JJ, Anand R. Macular effects of central versus peripheral scatter laser treatment in proliferative‐diabetic retinopathy. Investigative Ophthalmology and Visual Science 1991;32:ARVO E‐abstract 1762.
Wroblewski 1992 {published data only}
    1. Wroblewski J, Anand R, Weakley D. Techniques of panretinal photocoagulation for proliferative diabetic retinopathy. A prospective clinical trial. Investigative Ophthalmology and Visual Science 1992;33:ARVO E‐abstract 3357.
Zaluski 1986 {published data only}
    1. Zaluski S, Marcil G, Lamer L, Lambert J. Study of the visual field using automated static perimetry following panretinal photocoagulation in the diabetic. Journal Français d'Ophtalmologie 1986;9(5):395‐401. - PubMed

References to studies awaiting assessment

Francois 1971 {published data only}
    1. Francois J, Cambie E. Retinal photocoagulation (xenon arc and lasers). Annals of Ophthalmology 1971;3(11):1201‐8. - PubMed
Gaudric 1987 {published data only}
    1. Gaudric A, Glacet A, Crama F, Coscas G. Intraocular photocoagulation using the argon laser. Bulletin des Societes d'Ophtalmologie de France 1987;87(10):1083‐4. - PubMed
Guo 2014 {published data only}
    1. Guo Y, Liu Y, Zhang SB. Proliferative diabetic retinopathy observed after laser photocoagulation. International Eye Science 2014;13(11):2333‐5.
Kaluzny 1985 {published data only}
    1. Kaluzny J, Kozlowski JM, Jalkh AE. Photocoagulation in diabetic retinopathy: indications and technics. Klinika Oczna 1985;87(4):154‐7. - PubMed
Krill 1971 {published data only}
    1. Krill AE, Archer DB, Newell FW, Chishti MI. Photocoagulation in diabetic retinopathy. American Journal of Ophthalmology 1971;72(2):299‐321. - PubMed
Leuenberger 1975 {published data only}
    1. Leuenberger AE. Light coagulation of diabetic retinopathy. Modern Problems in Ophthalmology 1975;15:307‐12. - PubMed
Li 1987 {published data only}
    1. Li XX. ERG in proliferative diabetic retinopathy after photocoagulation. Chinese Journal of Ophthalmology 1987;23(3):140‐2. - PubMed
Lund 1971 {published data only}
    1. Lund OE. Local treatment (light coagulation) in diabetic retinopathy [Lokalbehandlung (Lichtcoagulation) bei Retinopathia diabetica]. Internist 1971;12(11):475‐81. - PubMed
Mella 1976 {published data only}
    1. Mella I, Rios MG, Tapia JC, Garcia H, Guzman E. Results of photocoagulation in 111 eyes with diabetic retinopathy [Resultados de la fotocoagulacion en 111 ojos con retinopatia diabetica]. Revista Medica de Chile 1976;104(10):709‐12. - PubMed
Mirzabekova 2004 {published data only}
    1. Mirzabekova KA. Laser coagulation in the treatment of diabetic retinopathy. Vestnik Oftalmologii 2004;120(4):41‐4. - PubMed
Okun 1968 {published data only}
    1. Okun E. The effectiveness of photocoagulation in the therapy of proliferative diabetic retinopathy (PDR). (A controlled study in 50 patients). Transactions ‐ American Academy of Ophthalmology and Otolaryngology. American Academy of Ophthalmology and Otolaryngology 1968;72:246‐52. - PubMed
Pahor 1997 {published data only}
    1. Pahor D, Gracner B. Changes in central reference level of visual field following argon laser photocoagulation in diabetic retinopathy. Spektrum der Augenheilkunde 1997;11(1):19‐21.
Palacz 1988 {published data only}
    1. Palacz O, Sylwestrzak Z, Oszczyk U. Electrophysiologic studies before and after laser panphotocoagulation in diabetic retinopathy. I. Early results [Badania elektrofizjologiczne przed i po panfotokoagulacji laserowej w retinopatii cukrzycowej. I. Wyniki wczesne]. Klinika Oczna 1988;90(9):320‐2. - PubMed

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References to other published versions of this review

Evans 2014
    1. Evans JR, Fau C, Virgili G. Laser photocoagulation for diabetic retinopathy. Cochrane Database of Systematic Reviews 2014, Issue 8. [DOI: 10.1002/14651858.CD011234] - DOI - PMC - PubMed

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