Journal Club Update
From the editors of New Retina MD
Harry W. Flynn Jr, MD, sat down with Retina Today Journal Club hosts Jonathan Prenner, MD, and Richard Kaiser, MD, to discuss laser use in patients with diabetic macular edema (DME).
Dr. Kaiser feigned surprise at Dr. Flynn’s use of laser for patients with DME.
“I thought everyone just injects,” Dr. Kaiser said. “Isn’t laser dead?”
Dr. Flynn said that one must weigh the advantages and disadvantages of laser before considering its place in a retina practice. The safety concerns for laser treatment are different from those for anti-VEGF therapy. Although laser therapy avoids the injection-associated risks of endophthalmitis and iatrogenic structural damage, it carries its own set of potential complications. The possibilities of inadvertent foveal treatment, overtreatment resulting in paracentral scotomas, and coalescence of laser scars should factor into the retina specialist’s evaluation of therapy options.
Still, Dr. Flynn said, the one-and-done nature of laser therapy for eligible patients lends itself to happy patients and efficient practices. Dr. Prenner underscored the benefits of this one-and-done philosophy. Speaking of patients with DME, Dr. Prenner pointed out that “these are patients who generally are not particularly compliant” with therapy. “And here, you have a guaranteed compliance.”
Watch it Now
Laser for DME
Drs. Flynn, Prenner, and Kaiser discuss situations in which laser therapy for DME patients is most effective.
Dr. Kaiser presented a hypothetical scenario for Dr. Flynn: A patient who has yet to see a retina specialist presents with peripheral edema and exudates. For this patient, Dr. Flynn suggested four to six monthly injections of an anti-VEGF agent to treat the central edema, followed by pattern laser to address the remaining noncentral edema as needed.
Regarding imaging in these patients, Dr. Flynn praised the use of optical coherence tomography (OCT), which allows clinicians to see specific areas in need of treatment without relying on angiography, which, Dr. Flynn contended, siphons valuable time from busy retina practices. Widefield angiography and OCT angiography have their places, he said, but OCT provides the best guidance for retina doctors seeking to target treatment.
Dr. Flynn stressed the importance of data from the Diabetic Retinopathy Clinical Research Network (DRCR.net) in determining treatment courses. Physicians considering localized peripheral pattern laser therapy in areas of ischemia for DME patients should await forthcoming DRCR.net data on the topic, he said.
Still, Dr. Flynn felt that DRCR.net data should not be taken as gospel. Data from the DRCR.net Protocol D study, Dr. Flynn said, showed that patients with vitreomacular interface issues and epiretinal membranes were good candidates for vitrectomy. But, as with many debates in retina, the crux in such data rests in the disconnect between anatomic recovery and visual improvement. Dr. Flynn said that, although such eyes experience anatomic improvement following vitrectomy, visual acuity improvements plateau. Therefore, he questioned the practical efficacy of vitrectomy for these patients. n
RECENT RETINA TODAY JOURNAL CLUB EPISODES
Episode 32: 3-D Imaging: The OR of Tomorrow, with Pravin Dugel, MD; Jonathan Prenner, MD; and Richard Kaiser, MD
Episode 33: Incorporating Laser Therapy for DME, with Harry W. Flynn Jr, MD; Jonathan Prenner, MD; and Richard Kaiser, MD
Episode 34: DAVE Trial: Targeted PRP With Anti-VEGF Therapy, with David Brown, MD; Jonathan Prenner, MD; and Richard Kaiser, MD