Guidelines for the Management of Center-Involving Diabetic Macular Edema: Treatment Options and Patient Monitorization

Abstract

Diabetic macular edema (DME) is the main cause of visual impairment associated with diabetic retinopathy (DR) and macular laser, during approximately three decades, and was the single treatment option. More recently, intravitreous injections of anti-angiogenics and corticosteroids modified the treatment paradigm associated with significant vision improvements. Nevertheless, not all patients respond satisfactorily to anti-VEGF or corticosteroid injections, so an adequate treatment choice and a prompt switch in therapeutic class is recommended. Several algorithms and guidelines have been proposed for treating center involving DME to improve patients’ vision and quality of life. However, in Portugal, such guidelines are lacking. The present review aimed to provide guidelines for the treatment options and patient monitorization in the management of center-involving DME. We recommend anti-vascular endothelial growth factor (VEGF) as first-line therapy after a clinical evaluation accompanied by a rigorous metabolic control. Depending on the response obtained after 3–6 monthly intravitreal injections we suggest switching outside the class in case of a non-responder, maintaining the anti-VEGF-therapy in responders to anti-angiogenics. The treatment regimen for Dexamethasone intravitreal implant (DEXii) should be pro-re-nata with bi-monthly or quarterly monitoring visits (with a scheduled visit at 6–8 weeks after DEXii for intraocular pressure control). If a patient does not respond to DEXii, switch again to anti-VEGF therapy, combine therapies, or re-evaluate patients diagnose. There is a resilient need to understand the disease, its treatments, regimens available, and convenience for all involved to propose an adequate algorithm for the treatment of diabetic retinopathy (DR) and DME in an individualized regimen. Further understanding of the contributing factors to the development and progression of DR should bring new drug discoveries for more effective and better-tolerated treatments.

Prediction of Visual Acuity after anti-VEGF Therapy in Diabetic Macular Edema by Machine Learning

“…Several anti-VEGF treatment regimens have been developed, such as monthly or bimonthly injections, pro re nata (PRN), and treat and extend (TAE) regimen [ 16 ]. PRN is the most common regimen in the treatment for DME to optimize the treatment effects and cost-effectiveness [ 17 ]. Many random clinical trials recommend three loading doses of anti-VEGF injections followed by a PRN regimen, namely, 3 + PRN [ 17 ].…”

“…PRN is the most common regimen in the treatment for DME to optimize the treatment effects and cost-effectiveness [ 17 ]. Many random clinical trials recommend three loading doses of anti-VEGF injections followed by a PRN regimen, namely, 3 + PRN [ 17 ]. But in the real world, three loading injections would be a great economic and psychological burden for patients with DME, especially in developing countries [ 18 ].…”

Microvascular Changes After Conbercept Intravitreal Injection of PDR With or Without Center-Involved Diabetic Macular Edema Analyzed by OCTA

“…Our results suggested that vision has significantly improved before and after intravitreal injection of conbercept in the CI-DME group. Some clinical trials have demonstrated that anti-VEGF therapy has been adopted as the first-line therapy in CI-DME ( 5 – 7 , 27 ) and it is more effective in improving the vision and visual acuity in CI-DME compared with focal laser treatment. Anti-VEGF treatment blocked the formation of neovascularization and reduced retinal thickening ( 5 , 26 , 27 ).…”

“…All of them are naive patients who have never been diagnosed and treated. Informed consent was obtained from all patients who received intravitreal conbercept injection ( 5 – 7 , 25 , 26 ).…”

“…Patients with CI-DME, retinal thickening in the macula that involves a central subfield zone is 1 mm in diameter ( 11 , 22 , 23 ). Patients with NCI-DME, retinal thickening in the macula that does not involve a central subfield zone is 1 mm in diameter ( 5 – 7 ). (4) The patients who met the criteria of anti-VEGF treatment guidelines would receive at least 3 months consecutive intravitreal conbercept.…”