Diabetic Retinopathy Treatment in India and UAE | Complete Patient Guide

• ELIGIBLE PATIENTS:

• Adults with Type 1 or Type 2 diabetes mellitus diagnosed with any stage of diabetic retinopathy (Mild NPDR through PDR) confirmed by a retinal specialist

• Patients with centre-involving diabetic macular oedema (CI-DMO) with best-corrected visual acuity (BCVA) of 20/32 or worse, or significant structural OCT changes threatening central vision

• Patients with severe NPDR (4-2-1 rule: haemorrhages in 4 quadrants, venous beading in 2 quadrants, IRMA in 1 quadrant) at high risk of progression to PDR

• Patients with PDR complicated by active neovascularisation, recurrent vitreous haemorrhage, or early tractional membranes without significant TRD

• Patients with TRD threatening or involving the macula, requiring pars plana vitrectomy (PPV)

• Patients who have failed or shown suboptimal response to prior anti-VEGF therapy (defined as <5 letters gain and persistent fluid after 3–6 monthly injections) who may be candidates for switch therapy or intravitreal corticosteroid implants (dexamethasone implant / fluocinolone acetonide insert)

• REQUIRED DIAGNOSTIC WORKUP PRIOR TO TREATMENT:

• Dilated fundus examination with slit-lamp biomicroscopy and indirect ophthalmoscopy

• Spectral-domain OCT (SD-OCT) with en-face imaging for macular mapping and CST quantification

• OCT-Angiography (OCTA) for FAZ assessment and retinal capillary perfusion mapping

• Ultra-widefield fundus photography (Optos/Clarus) for peripheral retinal ischaemia grading

• Fundus fluorescein angiography (FFA) for leakage points, NVD/NVE grading, and capillary non-perfusion mapping

• HbA1c measurement (optimal target <7.0% pre-treatment; poor control >10% noted as elevated risk factor)

• Blood pressure, renal function panel (eGFR, serum creatinine), coagulation profile

• Systemic cardiovascular evaluation if intravitreal anti-VEGF is planned in patients with recent (within 3 months) MI or stroke (relative contraindication)

• B-scan ultrasonography for dense vitreous haemorrhage precluding fundus visualisation

• CONTRAINDICATIONS:

• Active ocular or periocular infection (absolute contraindication to intravitreal injection)

• Known hypersensitivity to anti-VEGF agents (ranibizumab, aflibercept, faricimab)

• Uncontrolled glaucoma with IOP >30 mmHg (relative contraindication to intravitreal injection without prior IOP management)

• Severe ischaemic maculopathy (enlarged FAZ >1000 µm on OCTA) — precludes expectation of significant visual improvement

• Recent thromboembolic event (stroke, MI within 90 days) — caution with systemic anti-VEGF exposure, though intravitreal doses carry lower systemic bioavailability

• Inability to maintain post-operative positioning requirements (face-down) for 7–14 days in cases requiring silicone oil or gas tamponade post-vitrectomy

• Pregnancy (intravitreal anti-VEGF is relatively contraindicated; laser photocoagulation is preferred in pregnant patients with PDR)

INTRAVITREAL ANTI-VEGF PHARMACOTHERAPY (First-Line for CI-DMO and High-Risk PDR)

Anti-VEGF agents are administered as outpatient intravitreal injections under topical anaesthesia and aseptic technique. Current agents and their evidence base include:

• Ranibizumab (Lucentis, 0.3 mg / 0.5 mg): RISE/RIDE trials demonstrated 36.8% of patients gained ≥15 ETDRS letters at 24 months.

• Aflibercept (Eylea, 2 mg): VIVID/VISTA and Protocol T trials showed superiority over bevacizumab and ranibizumab in eyes with BCVA ≤20/50 at baseline.

• Faricimab (Vabysmo, 6 mg): The YOSEMITE/RHINE trials demonstrated non-inferiority to aflibercept with potential for extended dosing intervals (up to 16 weeks) via dual angiopoietin-2/VEGF-A blockade — now available at premium centres in India and UAE.

• Bevacizumab (Avastin, 1.25 mg): Off-label use with equivalent efficacy to ranibizumab for mild-moderate DMO (Protocol T); widely used in India for cost-effectiveness.

• Loading phase: 3–6 monthly injections, followed by treat-and-extend (T&E) or pro re nata (PRN) protocols guided by OCT response.

INTRAVITREAL CORTICOSTEROID IMPLANTS (Second-Line / Anti-VEGF Non-Responders)

• Dexamethasone intravitreal implant (Ozurdex, 0.7 mg biodegradable): Indicated for pseudophakic eyes with persistent DMO; effect lasts 3–6 months. MEAD trial: 22.2% of patients gained ≥15 letters at 3 years.

• Fluocinolone acetonide intravitreal implant (Iluvien, 0.19 mg sustained-release): 36-month sustained delivery; FAME trial showed superior outcomes in patients with chronic DMO >3 years duration.

• Primary risks: cataract progression and IOP elevation requiring monitoring.

LASER PHOTOCOAGULATION

• Pan-Retinal Photocoagulation (PRP): Conventional and navigated PRP (NAVILAS laser system) for severe NPDR and PDR. The DRCR.net Protocol S demonstrated non-inferiority of ranibizumab vs. PRP for PDR; however, PRP remains essential when injection compliance is uncertain or for rapid neovascular regression. Pattern scanning laser (PASCAL) allows high-speed multi-spot delivery with reduced collateral thermal damage.

• Focal/Grid Laser: Largely superseded by anti-VEGF for CI-DMO but retains a role for non-centre-involving DMO with focal leakage points on FFA and for combination therapy in anti-VEGF partial responders.

• Subthreshold Micropulse Laser (SML): 577 nm or 810 nm micropulse delivery selectively targets the retinal pigment epithelium (RPE) without producing visible burns, preserving parafoveal photoreceptors. Increasingly adopted at advanced centres for DMO without significant structural risk.

PARS PLANA VITRECTOMY (PPV) — Surgical Management

• Indicated for: non-clearing vitreous haemorrhage (>3 months or with TRD), TRD threatening or involving the macula, combined tractional-rhegmatogenous retinal detachment, dense premacular haemorrhage, and epiretinal membrane with significant DMO.

• Technique: 23-gauge, 25-gauge, or 27-gauge microincision vitrectomy surgery (MIVS) using wide-angle viewing systems (BIOM, Resight). Intraoperative adjuncts include:

- Pre-operative intravitreal anti-VEGF (bevacizumab 1.25 mg, 3–7 days pre-op) to reduce intraoperative bleeding during fibrovascular membrane segmentation/delamination.

- Triamcinolone acetonide-assisted posterior vitreous detachment (PVD) induction.

- Intraoperative endolaser PRP.

- Tamponade agents: C3F8 gas (14–16% concentration), SF6 gas (20%), or silicone oil (1000/5000 cSt) for complex detachments — determining the fit-to-fly timeline.

• 27-gauge MIVS allows sutureless, self-sealing sclerotomies with reduced post-operative inflammation and faster visual rehabilitation compared to 20-gauge systems.

COMBINATION AND EMERGING THERAPIES

• Anti-VEGF + PRP combination: Offers additive benefit in high-risk PDR with active neovascularisation.

• Port Delivery System with Ranibizumab (Susvimo): Surgically implanted refillable ocular implant for continuous ranibizumab delivery — available at select tier-1 centres.

• Gene therapy (investigational): AAV-based subretinal delivery of anti-VEGF constructs (e.g., ADVM-022, 4D-150) in Phase II trials; not yet standard of care.

• Photobiomodulation (PBM): Emerging non-invasive modality for early NPDR and DMO; available at select centres as adjunct therapy.

PHASE 1 — PRE-ARRIVAL & REMOTE CONSULTATION (Weeks 1–2 before travel)

• Patient submits medical records (fundus photographs, OCT reports, FFA, HbA1c, systemic workup) to GAF Healthcare's ophthalmology coordination team.

• Remote review by a senior vitreoretinal surgeon; preliminary treatment plan (anti-VEGF injection vs. laser vs. surgical PPV) communicated within 48–72 hours.

• GAF Healthcare initiates e-Medical Visa application (India) or confirms UAE entry visa status.

• Pre-travel optimisation: endocrinology review recommended to achieve HbA1c as close to target as possible; antihypertensive therapy adjusted; anticoagulant bridging plan discussed with referring physician.

• Travel dates confirmed; appointment scheduling, hospital admission pre-registration, and accommodation bookings completed by GAF Healthcare case manager.

PHASE 2 — ARRIVAL & IN-HOSPITAL ASSESSMENT (Day 1–2)

• Airport pickup by GAF Healthcare driver with multilingual coordinator.

• Day 1: Comprehensive ophthalmic evaluation at hospital — dilated examination, SD-OCT, OCTA, ultra-widefield fundus photography, FFA (if not recently performed), IOP measurement, biometry if cataract co-extraction is planned.

• Systemic review: anaesthesia fitness assessment (for PPV patients), blood pressure optimisation, HbA1c and renal function confirmation.

• Surgical/injection consent obtained; treatment plan finalised with the treating vitreoretinal surgeon.

• Day 2 (if anti-VEGF injection or laser): Procedure performed as day care — topical anaesthesia, betadine antisepsis, intravitreal injection/laser under slit-lamp or operating microscope. Duration: 10–20 minutes. Discharged same day with topical antibiotics and anti-inflammatory drops.

• Day 2 (if PPV scheduled): Admission, pre-operative fasting, pre-operative anti-VEGF injection (if indicated, 3–5 days prior; in combined cases, on the day of PPV), anaesthesia review.

PHASE 3 — PROCEDURE DAY (Day 2–3 for PPV / Day 2 for outpatient procedures)

• Anti-VEGF Injection / Laser: Outpatient. Patient rests for 30–60 minutes post-injection; IOP checked at 30 minutes. Discharged with written instructions. Return visit at Day 7 for wound check and IOP measurement.

• PPV (Vitreoretinal Surgery): Performed under local (peribulbar) or general anaesthesia; duration 1–3 hours depending on complexity. Intraoperative steps: core vitrectomy, PVD induction, fibrovascular membrane dissection (segmentation/delamination), endolaser PRP, fluid-air exchange, tamponade insertion (gas or silicone oil). Post-operative hospitalisation: 1–2 days for monitoring of IOP, choroidal detachment, and early hypotony.

PHASE 4 — EARLY RECOVERY (Days 3–14, in-country)

• Anti-VEGF/Laser patients: Day 3–7 post-procedure review; discharge from active in-country care if no adverse events (endophthalmitis, IOP spike, subconjunctival haemorrhage with pain). Topical antibiotics continued for 7 days. Patients can typically fly after 7–10 days.

• PPV patients (gas tamponade — C3F8 or SF6): ABSOLUTE CONTRAINDICATION TO AIR TRAVEL until gas bubble fully resorbed. C3F8 (perfluoropropane): resorption 6–8 weeks; fit to fly at 8–10 weeks. SF6 (sulphur hexafluoride): resorption 10–14 days; fit to fly at 3–4 weeks. Patients are counselled on face-down positioning (if inferior retinal pathology) for 7–14 days.

• PPV patients (silicone oil tamponade): No absolute flight restriction for gas; however, silicone oil removal surgery required in 3–6 months — patients must plan a return visit.

PHASE 5 — IN-COUNTRY RECOVERY & DISCHARGE MILESTONES (Weeks 2–4)

• Week 2: Follow-up OCT, fundus examination, IOP check, suture review (if applicable).

• Week 3–4 (gas PPV patients): OCT confirmation of retinal reattachment, gas bubble volume assessment, visual acuity measurement.

• Fit-to-fly clearance letter issued by treating surgeon, mandatory for airline medical check-in.

• GAF Healthcare case manager arranges return airport transfer and ensures all medical records, discharge summaries, and post-operative prescription medications are packaged for the patient.

PHASE 6 — LONG-TERM FOLLOW-UP (Home country, Months 1–12)

• Anti-VEGF patients: Monthly or treat-and-extend follow-up OCT monitoring with local ophthalmologist; GAF Healthcare provides telemedicine review slots with treating surgeon at 1 month, 3 months, and 6 months.

• PPV patients: Silicone oil removal planned at 3–6 months post-operatively (second visit to India/UAE coordinated by GAF Healthcare if required).

• HbA1c and blood pressure optimisation remain critical ongoing systemic goals to prevent disease progression.