Dr. Regillo: The latest clinical trials for diabetic macular edema suggest that we should be initiating treatment with pharmacotherapy, namely
Narrator: In 2012, the US FDA approved a 0.3-mg intravitreal dose of ranibizumab for the treatment of diabetic macular edema. Consequently, intravitreal pharmacotherapy with ranibizumab is currently often the initial treatment of choice, but the precise interrelation between this treatment and other modalities is not yet conclusively defined. Recently presented data from VIVID and VISTA, two parallel studies testing separate regimens of aflibercept injections against laser photocoagulation, showed that patients randomized to either dosing regimen of aflibercept had superior visual acuity outcomes compared with
A meta-analysis of trials evaluating the VEGF inhibitors showed that, compared with grid laser photocoagulation, the anti-angiogenic agents bevacizumab, ranibizumab, or aflibercept increased the chance of gaining three or more lines of vision and decreased the risk of losing three or more lines (RR 0.13, 95% CI, 0.05 to 0.34).20 Compared with laser alone, the combination of ranibizumab plus photocoagulation approximately doubled the chances of gaining three or more lines of vision and decreased the chance of losing three or more lines.
Adverse events associated with intravitreal injections of anti-VEGF drugs that threaten patients’ sight are very rare and include endophthalmitis and retinal detachment.21 For example, larger studies have shown an approximate rate of 0.1% for endophthalmitis in patients receiving intravitreal injections of VEGF inhibitors.22,23
Dr. Regillo: So a patient who presents with some visual symptoms and decreased acuity and has
Narrator: In addition to treatment with anti-VEGF agents, laser photocoagulation continues to be a reasonable choice in many clinical scenarios.
Dr. Regillo: When the DME is not involving the foveal center—and the visual acuity is likely to be very good—standard laser photocoagulation is still a good choice. It's a proven therapy, based on ETDRS [Early Treatment Diabetic Retinopathy Study] results, and it can, indeed, control the edema and prevent vision loss and may be the better way to go in patients who have non–foveal-involving DME and relatively good visual acuity.24,25 So laser is still utilized both as primary therapy and [it] can be utilized later, of course, for any clinically significant diabetic macular edema in conjunction with
Lastly, corticosteroids injected intravitreally as an off-label form of therapy have shown some benefits.26-31 It's just that there are side effects with steroids in the eye, such as cataract progression and elevated intraocular pressure.31 And these side effects often put steroids in the second position for treating DME.