PRP vs Anti-VEGF for PDR

For intravitreal Anti-VEGF round:

A major breakthrough in the treatment of PDR has been the development of anti-VEGF medications. Studies have shown that anti-VEGF can be used in conjunction with PRP, if not instead of it. In most studies, anti-VEGF results in improved VA gains and a significant reduction in CST. Anti-VEGF treatment has the additional advantage of regressing PDR back to NPDR more quickly in treated eyes. Due to the fact that anti-VEGFs can reduce the severity of DR, especially when DME coexists. Still, it remains to be seen whether anti-VEGF is better than PRP. Ophthalmologists in developing countries have been faced with this dilemma constantly. A patient's best treatment must take into account cost, compliance, and practicality.

For PRP round:

Every patient is a distinct case, think of the patient’s lifestyle and examination status before making a decision. PRP is still a mainstay treatment for vitreous hemorrhage, patients who can’t follow up, pregnancy, and patients at high risk of cardio-cerebral vascular events. Always consider the chance of endophthalmitis and retinal detachment in every injection along with the increased cost burden on the patient.

For expert opinion round:

Always think about the patient as a whole person. Keep in mind different aspects of DM and use a checklist to tailor the best treatment for your patient. Consider:

• Patient Condition
• Fundus exam
• Lens condition
• Iris rubeosis
• Insurance coverage
• Access to medications and access to laser
• The condition of the other eye

For verdict round (Rational Use):

• Mainstay: PRP is a mainstay treatment for cases of very severe NPDR and early PDR without DME and in cases that are contraindicated to Anti-VEGF injections.
• Durability: PRP is more durable and cost-effective.
• Mandatory: PRP must be applied in cases of vitreous hemorrhage and rubeosis iridis.
• Combination: In cases of high-risk PDR adding an intravitreal injection of Anti-VEGF will reduce the need for aggressive PRP with rapid regression of PDR. In cases of PDR combined with DME, adding the intravitreal injection of VEGF will help to manage both proliferative changes and DME.
• Compliance: Always consider adding PRP when treating PDR with Anti-VEGF, especially in patients with compliance issues.
• Burden: Intravitreal injection of Anti-VEGF will have rapid regression of PDR but it has a cost burden, needs close follow up, and requires multiple injections annually.