Abstract
Diabetic macular edema (DME) represents a prevalent and disabling eye condition. Despite that DME represents a sight-threatening condition, it is also among the most accessible to treatment. Many different treatment options including photocoagulation, intravitreal medical treatment (either vascular endothelial growth factor inhibitors or corticosteroids therapies), and surgical removal are currently available. Although laser has been considered as the gold standard for many years, over the past several years vascular endothelial growth factor inhibitors (anti-VEGFs) have become first-line therapy. However, many patients do not adequately respond to them. With the development of sustained-release corticosteroid devices, steroids have gained a presence in the management of the DME. We review and update the role of anti-VEGF and intravitreal sustained-release corticosteroid management of DME. According to the currently available scientific evidence, the choice of one anti-VEGF over another critically depends on the baseline best-corrected visual acuity (BCVA). While aflibercept may be the drug of choice in low baseline BCVA, the three anti-VEGFs (bevacizumab, ranibizumab, and aflibercept) provided similar functional outcomes when the baseline BCVA was higher. DEX implants are a valuable option for treating DME, although they are usually seen as a second choice, particularly in those eyes that have an insufficient response to anti-VEGF. The new evidence suggested that, in eyes that did not adequately respond to anti-VEGF, switching to a DEX implant at the time to 3 monthly anti-VEGF injections provided better functional outcomes.
Highlights
Because the prevalence of diabetes is rising, the relevance of diabetic eye disease increases [1, 2]
E efficacy and safety of Dexamethasone intravitreal (DEX) implant in Diabetic macular edema (DME) eyes that did not adequately respond to three monthly intravitreal injections of anti-vascular endothelial growth factor (VEGF) were evaluated in a prospective clinical trial [106]. e results of this study suggested that DEX significantly improved best-corrected visual acuity (BCVA) at month 2 (p 0.0381) and significantly reduced central macular thickness (CMT) at months 1, 2, and 3 (p 0.0343, p 0.0288, and p 0.0370, respectively)
A retrospective and multicenter study assessed the efficacy and safety of repeated DEX, over a 24-month followup period, in DME eyes, either naıve or refractory to antiVEGF, in a real setting [118]. e results of this study showed that both, naıve and refractory eyes, improved significantly in vision after 24 months (p < 0.001), BCVA improvement was significantly greater in the naıve eyes that in the refractory ones (p < 0.01.) A statically significant CMT reduction was observed in both groups [118]
Summary
Because the prevalence of diabetes is rising, the relevance of diabetic eye disease increases [1, 2]. In Europe, it was estimated that approximately 6.4 million people are currently affected by any diabetic eye disease and 8.6 million people will be affected in 2050 [3]. E prevalence of any DME in Europe was 3.7% and its pooled mean annual incidence in type 2 diabetes patients was 0.4% [3]. Many different treatment options including laser photocoagulation, intravitreal medical treatment (either vascular endothelial growth factor inhibitors or corticosteroids therapies), and pars plana vitrectomy [6] are currently available. A retrospective analysis, conducted on a population of 13,410 treatment-naıve DME patients, has found that the treatment patterns within 28 days of initial DME diagnosis were as follows: observation in 9,990 (74.5%) patients, vascular endothelial growth factor inhibitors (anti-VEGFs) in 2,086 (15.6%) patients, laser in 1,133 (8.4%) patients, corticosteroids in 133 (1.0%) patients, and combined treatment in 68 (0.5%) patients [7]. This paper is going to evaluate the current evidence about the convenience of switching to intravitreal dexamethasone implant in those patients with suboptimal response to antiVEGF therapies
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