First-line treatment algorithm and guidelines in center-involving diabetic macular edema

Abstract

Management of center-involving diabetic macular edema represents a real therapeutic challenge. Diabetic macular edema is the leading cause of visual acuity impairment in diabetic patients. Since the advent of intravitreal drugs, management of diabetic macular edema has significantly evolved. The historical grid laser photocoagulation is no longer recommended as first-line treatment of diabetic macular edema owing to the findings of the pivotal randomized controlled trials, and anti-vascular endothelial growth factor therapy has emerged as first-line therapy. Steroids also represent a valid treatment option in the management of naïve diabetic macular edema and their efficacy has also been confirmed in several studies. The optimal treatment for diabetic macular edema should consider both general and ophthalmological comorbidities. Patient compliance and motivation should also be carefully evaluated as some treatments require monthly follow-up. Based on recent literature evidence, the present review provides clinicians with a first-line treatment algorithm for center-involving diabetic macular edema tailored to the patient’s individual characteristics.

Diabetic retinopathy and diabetic macular oedema pathways and management: UK Consensus Working Group

“…As such, the management of diabetic eyes with cataracts, particularly those with pre-existing DMO is important, as the CRT can change from <400 μm to >400 μm. Evidence from elsewhere supports treatment of such eyes with dexamethasone implant (Ozurdex) in the perioperative period, and best if given pre-cataract surgery [20,21]. Currently, some clinicians resort to IFRs in order to treat patients with DMO and CRT <400 μm who are not pseudophakic.…”

Reduction in Retinal Thickness Fluctuations After Treatment With Fluocinolone Acetonide Implant for DME: A Post-Hoc Analysis of the USER Study

“…2,3 A variety of DME treatment options are available, including laser photocoagulation, antivascular endothelial growth factor (VEGF), steroids, and surgical therapy, 4 with anti-VEGF being the first-line treatment option. 5,6 However, many patients have a suboptimal response or are nonresponders to anti-VEGF therapy, 7,8 with deteriorating clinical outcomes over time, often because of nonadherence to the therapeutic regimen. 9 Consequently, patients with persistent DME despite anti-VEGF therapy receive second-line corticosteroid injections into the vitreous humor to reduce the levels of inflammatory cytokines responsible for macular edema.…”

Visual Acuity Gain Profiles and Anatomical Prognosis Factors in Patients with Drug-Naive Diabetic Macular Edema Treated with Dexamethasone Implant: The NAVEDEX Study

“…Patients included in this real-life study were drug-naive, knowing that the use of previous treatment for DME is a negative factor of recovery [ 24 ]. Herein, DEX-implant was chosen in first-line therapy as it can decrease the burden of the treatment injection for diabetic patients that often have many other multidisciplinary appointments, keeping a high efficiency and low rates of non-responders [ 9 ]. Moreover, the absence of systemic side effects such as cardiovascular events was another priority to choose this molecule because the presence of DME is a predictor of cardiovascular morbidity and mortality [ 25 ].…”

“…Predictive factors of response to treatment are thus required to help the clinician to best adapt the therapy, regardless of the regimen or the therapeutic class used. Dexamethasone implant (DEX-implant) is approved in first-line treatment for DME and anti-VEGF [9]. It has been demonstrated that DEX-implant can achieve similar rates of VA improvement compared to an anti-VEGF for DME, with even better anatomic outcomes and requiring fewer injections [10,11].…”