www.diabeticretinopathy.org.uk

Pre-proliferative /severe none-proliferative retinopathy

David Kinshuck

 

What is pre-proliferative (severe none-proliferative retinopathy)?

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In this condition the retina has been damaged by the higher than normal sugar levels over several years. The condition is called 'pre-proliferative' as it usually progresses to develop proliferative retinopathy, when 'new vessels' develop.

It is now generally termed severe none-proliferative' severe none-proliferative'  or 'none-proliferative'.

In severe forms of pre-proliferative retinopathy there are lot of haemorrhages, as the retina is very ischaemic.

Previously this needed laser treatment to prevent new vessel growth, but the Panorama Trial indicates anti-VEGF injections are liekly to be best.

Proliferative retinopathy in one eye is especially likely if the other eye has already developed new vessels. It is rarely asymmetric hereAnti-VEGF injection may also help..some clinics now have stopped laser and just use anti-VEGF injections.

In milder forms regular observation is needed to check new vessels do not grow, every 4-6 months. See animation , photo tour  , photos  , Case 15: right Colour photo, red free , Case 39

Small haemorrhages (flecks of blood) and tiny abnormal blood vessels are present. If there are lots of haemorrhages, more than illustrated here, new vessels may grow over the next 12 months, and laser will be needed.
There will be damage to the tiny retinal vessels, such as 'IRMAs' (intra-retinal-microvascular abnormalities). There may be cotton wool spots (areas of retinal damage).

 

'Unexpected' deterioration

It is important to control the retinopathy over the long term. However, if the control has been mediocre, and then starts to improve, then the retinopathy may occasionally get worse, and may need a lot of laser.

However, in parts of the world here anti-VEGF injection injections are available, results are better waiting without laser, and offering injections if macular oedema or proliferation develops.

But after 2-3 years of good control your retinopathy will be better than it would have been otherwise: In the long term good control is crucial,  as below. Progression may be rapid, see.

 

Mild pre-proliferative does not need laser/anti-VEGF

Mild pre-proliferative retinopathy does not need laser/anti-VEGF. It is often termed background retinopathy, If your diabetic control (sugar, smoking, BP, cholesterol, weight) is good as below, then any progression will be slow. Progression to a more serious type of retinopathy (macular oedema or proliferation) will be much quicker if your control is poor, and such a patient should be examined every 4 months or so.
Also, when a patient with type 2 diabetes changes from tablets to insulin, a rapid improvement in diabetic control may occur, and so such patients may develop a rapid deterioration of their retinopathy. This applies to anyone with poorl contrl who then starts to achieve good cobntrol, perhaps an immediate deterioration but very helpful  in he long run (after 3 years) .

Anti-VEGF injections   helps all types of retinopathy, as discussed on relevant pages see 19

 

Laser pre-proliferative retinopathy

Pre-proliferative / severe none-proliferative retinopathy usually needs anti-VEGF injections or  laser to stop proliferation developing (that is prevent the 'new-blood vessels' growing.

If anti-VEGF injections are not available,   PRP laser is indicated. Light subhreshld laser for mild cases is helpful, more severe cases need heavier laser.

There is evidence this reduces the number of vitreous haemorrhages etc later see. Sometimes 2-3 more sessions of laser are needed.

On the other hand, if anti-VEGF injections or laser are delayed, either macular oedema or proliferation develops, and treatment is less likely to prevent visual loss. Sometimes no matter what approach is taken macular oedema develops, but this is much reduced with the anti-VEGF injections or laser.

Laser has a small chance in increasing in macular oedema, although this risk is much lower if subthreshold laser is used.

Anti-VEGF injections have not been generally used for pre-proliferative retinopathy, but in future it may be used more often, and will certainly help if there is also macular oedema.

 

Remember the 'targets' for good control

By keeping to these levels as much as possible (or lower still) you will be doing your best to stop your eyes getting worse. Occasionally by sticking to these targets your retinopathy will improve, even without laser. Review BMJ17   

 

lifestyle

blood pressure

HbA1c

sudden decrease in HbA1c

cholesterol and statins

smoking

insulin

education

Diabetes education courses

sleep apnoea etc

glucose level

Glitazones

hypoglycaemia

neuropathy

issues

compliance

type 2 at diagnosis

Photos (details see case 15)

Colour

 

Red free

 

Abbreviations