What if a patient shows up with old burnedout disease that was never treated

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Although most of your life you will be faced with patients who are in the progressive stages of PDR, remember that if left untreated the neovascular stimulus eventually fades as the retina just plain dies off. Most of the time, if the disease is allowed to run its course the retina ends up like a shriveled orchid in the center of a blind eye (hence the existence of books such as this one). You may, however, occasionally see patients in whom this process has occurred with little disruption of the central retina—these patients essentially avoided the typical disastrous outcome and "survived" the proliferative phase of their retinopathy. Such patients often have very broad areas of fibrosis in the periphery, where the old neovascularization involuted and became quiescent. Deciding whether to treat such patients can be difficult—the standard rules do not apply. These patients have somehow achieved a metastable state, and there is always a concern that by going in and aggressively treating with laser you will push them into hemorrhagic or tractional problems that they might not otherwise have developed. In general, however, it is safer to gently work in a PRP, rather than to do nothing. This is because the wide swathes of untreated peripheral retina may become more ischemic with time, and lead to late problems such as recurrent retinal proliferation or anterior segment neovascularization.

Figure 13. A patient with fibrotic, end-stage PDR. Note how everything seems to be quiescent prior to treatment, but after laser, there is an area where subtle neovascularization regressed and became fibrotic (arrow). The omnipresent neovascular stimulus of the ischemic retina makes treatment a safer bet than observation in eyes like this; you are buying the patient insurance that nothing worse happens in the future. Do go slow if you treat such an eye, however. Rapid carpet-bomb laser will likely stir things up in such a fragile eye, perhaps even causing a fractional retinal detachment.

Figure 13. A patient with fibrotic, end-stage PDR. Note how everything seems to be quiescent prior to treatment, but after laser, there is an area where subtle neovascularization regressed and became fibrotic (arrow). The omnipresent neovascular stimulus of the ischemic retina makes treatment a safer bet than observation in eyes like this; you are buying the patient insurance that nothing worse happens in the future. Do go slow if you treat such an eye, however. Rapid carpet-bomb laser will likely stir things up in such a fragile eye, perhaps even causing a fractional retinal detachment.

If you decide to treat an eye like this, and usually you will, the patient (and you) must understand that there is always a small risk of stirring up trouble. The one thing you don't want to do is to decide that you have to make up for lost time by hammering the entire retina aggressively. This carries a high risk of screwing things up in such a delicate eye. It is much better to treat these patients gradually over a number of sessions, and to avoid heavy burns around the atrophic or tractionally detached retina which could lead to hole formation.

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