Panretinal Photocoagulation for Diabetic Retinopathy

To the Editor: Patients with proliferative diabetic retinopathy are not only at increased risk for severe visual loss but also have a significantly increased risk of death, and indications are that both risks are heightened when there is tight control of diabetes.1-4 Of the 759 patients in the Diabetic Retinopathy Study (ClinicalTrials.gov number, NCT00000160), 139 (18%) died over a follow-up period of 4.5 years. At the end of the Early Treatment Diabetic Retinopathy Study (NCT00000151) conducted by Bressler et al. (Oct. 20 issue),5 61% of the patients were deceased, and mortality was significantly increased across all age groups. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) study on type 2 diabetes had to be terminated after 3.5 years because of increased mortality in the group receiving intensive glycemic therapy.1,2 In the Diabetes Control and Complications Trial (DCCT), the group of patients with mild-to-moderate nonproliferative diabetic retinopathy and well-controlled glucose levels had significant worsening of the retinopathy at the 6and 12-month follow-up visits.4 The DCCT also indicated that for patients with retinopathy that is already approaching the high-risk stage, it may be prudent to delay the initiation of intensive treatment until photocoagulation can be completed, particularly if levels of glycated hemoglobin are high.4 What to do?