“I’m really sorry that there’s nothing more I can do for you.” These were some of the most painful words I’ve ever had to say when my patient presented with bilateral advanced neovascular glaucoma due to proliferative diabetic retinopathy.

He was light perception in one eye and hand motions in the other. What’s even more heartbreaking is that there was more that could have been done early on. I’d been seeing this patient for several years and treating his PDR with anti-VEGF injections on a quarterly basis.

 We had multiple discussions over the years about doing panretinal photocoagulation since I had explained the injections really weren’t curative. Despite my strong recommendation for PRP, he kept deferring, stating that he had no issues coming back regularly and would much rather continue injections than undergo PRP.

I look back and wonder whether I could have been more forceful. Did he truly understand what I had explained to him about the pros and cons of PRP over injections? After unexpectedly losing his job, he lost his insurance and thought he couldn’t afford to return for treatments for well over a year. Despite glaucoma surgery, cataract surgery, anti-VEGF injections and panretinal photocoagulation, his vision was essentially unchanged.

It’s stories like this that have inspired me to study the problems and potential ways to mitigate the challenges surrounding treatment adherence. As detailed in this issue’s article, “Overcoming Anti-VEGF Treatment Burden and Adherence Challenges” by Sidra Zafar, MD, and Omesh Gupta, MD, MBA (pg. 32), my group was one of the first to demonstrate the alarmingly high rates of loss to follow-up along with risk factors in patients receiving anti-VEGF injections for various retinal diseases. 

While adding protocols to track patients who are receiving injections is critical to optimize treatment adherence, there are so many dimensions to this problem that it’s not the only solution. More durable treatment options will likely help, but they may not be a panacea since even therapeutics such as the port delivery system and gene therapy aren’t a cure and require monitoring for disease activity. 

Circling back to my patient, I still believe that PRP should remain in the forefront of our minds when managing patients with PDR until we truly have a therapy that is a superior “one and done.” RS