Diabetic retinopathy (DR) is the leading cause of visual impairment worldwide. Severe non-proliferative diabetic retinopathy, diabetic macular edema, and proliferative DR (PDR) are defined as vision-threatening DR (VTDR). In the context of managing systemic disease, the primary treatments for VTDR include panretinal photocoagulation (PRP), intravitreal injection of anti-vascular endothelial growth factor (VEGF) drugs or dexamethasone sustained release agents, and microincision vitreous surgery. Although these therapies are already widely used in clinical practice, there is still much debate about the optimal timing and method of their application, especially in the pursuit of optimal efficacy, cost-effectiveness, patient compliance, and the reduction of frequent ongoing treatments. There is no consensus on the best treatment for PDR. Determining the specific criteria for each therapy indication is one of the key considerations. In addition, consideration should be given to the priority between PRP and intravitreal injection, as well as to compare the relative effectiveness of anti-VEGF agents with PRP. Early surgical intervention is not always a necessary option for PDR patients with vitreous hemorrhage and fibrovascular membranes. Combining different therapies to optimize treatment strategies is also an important topic. These issues address several points of contention in best practice guidelines that need to be addressed through more in-depth research to provide better guidance for clinical practice and ultimately improve patient outcomes.

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