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  5. FP408 : Visual Quality of Life of Patients with Diabetic Retinopathy After Pan Retinal Photocoagulation

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Dr. Shivaprasad C, S11804, Dr. Renuka Srinivasan, Dr. Ramesh Babu K 

Introduction :

There are 150 million diabetics worldwide with one third in developing countries. India having approximately one fifth diabetic patients, is ahead of China and USA. The prevalence of diabetic retinopathy among diabetics in India is noted to be high. (1) Proliferative diabetic retinopathy is one of the leading causes of vision loss worldwide, and the prevalence is projected to increase. The current standard treatment for PDR, pan-retinal photocoagulation (PRP), acts by converting the hypoxic peripheral retina into anoxic retina. The possibility that it induces a sudden, temporary increase in free radical activity either by direct thermal damage or by oxygen reperfusion. (2)The established therapy for retinal neovascularization in diabetic retinopathy, laser photocoagulation, may be effective in delaying the progression of the disease but lacks specificity and is associated with retinal destruction, causing impaired visual function.Assessment of visual functioning by Visual Functioning Questionnaire-25 (VFQ-25) is valid and reliable.(3,4) Using this VFQ-25, it has been found that there is no significant change after panretinal photocoagulation even though it is destructive. However the study had a small sample size.(5)

Materials and methods :

The Institute Ethics Committee approval was obtained prior to initiation of study. The purpose and details of the study protocol were explained to each subject and written informed consent will be obtained. The study was conducted at the Out-Patient Department, Ophthalmology, JIPMER, Pondicherry where subjects were enrolled based on inclusion and exclusion criteria. All the patients with proliferative diabetic retinopathy were included. Exclusion criteria are patients with dense vitreous hemorrhage, corneal opacities, glaucoma and other coexisting ocular co morbidities, dense cataract. All patients underwent the blood tests which included fasting blood glucose, post prandial blood glucose, fasting lipid profile, hemoglobin levels, glycosylated hemoglobin (HbA1c) and creatinine.

.All patients undertook the interviewer administered visual function questionnaire. Visual acuity, intraocular pressure, slitlamp examination, indirect ophthalmoscopy, slitlampbiomicroscopy using +90 D lens was performed. A color fundus photograph was taken using fundus camera. All the patients underwent panretinal photocoagulation in three sittings using Zeiss visalis  double frequency NdYag laser. The patients were followed up at one week, one month, three months and six months after the laser treatment.Complete ophthalmic evaluation was done at each visit.

Outcome measures

  • Primary outcome measures
    • Best-corrected visual acuity
    • Macular thickness – documented using Stratus OCT
    • Change in the Visual functioning questionnaire – 25 (VFQ-25)
  • Secondary outcome measure

Intraocular pressure 

Results :

120 patients were enrolled in the study. Patients were aged 42- 68 years with an average age of 58.5 years.All patients undertook VFQ25 before undergoing PRP. 66 were males and 54 females.108 patients completed VFQ at 6th month post PRP laser.

The average scores for the part 1 of VFQ-25 which assesses general health and vision was 12 before PRP while the scores worsened to 16.5 six months after undergoing PRP laser. The average scores for the part 2 of VFQ-25 which assesses difficulty with activities was 34 before PRP while the scores worsened to 42, six months after undergoing PRP laser. The average scores for the part 3 of VFQ-25 which assesses general health and vision was 36 before PRP while the scores reduced to 28 six months after undergoing PRP laser. There was a statistically significant worsening in the VFQ-25 scores after PRP (p 0.05). The average scores for the 4th question in the questionnaire was 1.5 before PRP laser while it worsened to 3.8 after the PRP laser.

Conclusion :

Panretinal photocoagulation worsens visual quality of life in patients with proliferative diabetic retinopathy. 

Discussion :

Panretinal photocoagulation is the standard treatment for high risk proliferative diabetic retinopathy. However it acts by destroying the peripheral retina. Hence, it may affect the visual quality to a considerable level. This may impair the function in these patients.Tsilimbaris MK et al in their study have found no significant change in the visual function in patients undergoing panretinal photocoagulation.  In our study, it was found that there was a significant worsening in the visual function scores as assessed by interviewer administered VFQ 25 visualfunction questionnaire. The negative result in the study by Tsilimbaris may be due to a smaller population size used in their study. Hence, alternative treatments like anti vascular endothelial growth factors may be considered in the treatment of proliferative diabetic retinopathy.

References :

  1. Rema M, Pradeepa R. diabetic retinopathy : An Indian perspective. Indian J Med Res 2007:125; 297-310.
  2. Jennings PE, MacEwen CJ, Fallon TJ, Scott N, Haining WM, Belch JJ.Oxidative effects of laser photocoagulation.FreeRadicBiol Med.1991;11(3):327-30.
  3. Mangione CM, Lee PP, Gutierrez PR, Spritzer K, Berry S, Hays RD; National Eye Institute Visual Function Questionnaire Field Test Investigators. Developmentof the 25-item National Eye Institute Visual Function Questionnaire. 2001 Jul;119(7):1050-8.
  4. Mangione CM, Lee PP, Pitts J, Gutierrez P, Berry S, HaysRD.Psychometricproperties of the National Eye Institute Visual Function Questionnaire (NEI-VFQ). NEI-VFQ Field Test Investigators. 1998 Nov;116(11):1496-504.
  5. Tsilimbaris MK, Kontadakis GA, Tsika C, Papageorgiou D, Charoniti M. Effect of panretinal photocoagulation treatment on vision related quality of life of patients with proliferative diabetic retinopathy.2012 Nov 27.
  6. Warrian KJ, Lorenzana LL, Lankaranian D, Dugar J, Wizov SS, SpaethGL.The assessment of disability related to vision performance-based measure in diabetic retinopathy.Am J Ophthalmol.2010 May;149(5):852-60.
  7. Mangione CM, Lee PP, Gutierrez PR, et al.Development of the 25-Item National Eye Institute Visual Function Questionnaire. Arch Ophthalmol 2001;119:1050–8.
  8. Ivers RQ, Mitchell P, Cumming RG.Visual functiontests, eye disease and symptoms of visual disability: a population-based assessment.ClinExpOphthalmol. 2000 Feb;28(1):41-7.

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