What is the management plan for a patient with blurred vision in the right eye, diabetes mellitus, history of intravitreal (intraocular injection) injection for diabetic maculopathy, pseudophakia (artificial lens) in the right eye, cataract in the left eye, proliferative diabetic retinopathy in both eyes, and massive macular edema in the right eye?

Management of Massive Diabetic Macular Edema with Proliferative Diabetic Retinopathy

The optimal management for this patient with massive macular edema in the right eye and proliferative diabetic retinopathy in both eyes should begin with diagnostic fluorescein angiography followed by anti-VEGF therapy (intravitreal aflibercept injections) as first-line treatment. 1

Diagnostic Assessment

1. Fluorescein Angiography

   • Indicated for this patient with massive macular edema and proliferative diabetic retinopathy
   • Will help assess:
     • Extent of macular ischemia
     • Areas of capillary non-perfusion
     • Presence of microaneurysms and leakage
     • Neovascularization patterns 2, 3

2. OCT (Optical Coherence Tomography)

   • Essential to:
     • Quantify macular edema (central subfield thickness)
     • Identify intraretinal fluid patterns
     • Monitor treatment response
     • Establish baseline for comparison 1

Treatment Plan

First-Line Treatment

1. Anti-VEGF Therapy

   • Aflibercept (Eylea) 2 mg intravitreal injection:

     • Initial dosing: Every 4 weeks (monthly) for first 5 injections
     • Maintenance: Every 8 weeks thereafter
     • Some patients may require continued monthly dosing based on response 4, 1

   • Benefits for this patient:

     • Addresses both proliferative diabetic retinopathy and macular edema
     • More effective than laser alone for center-involving macular edema
     • May reduce need for panretinal photocoagulation 1

2. Treatment Monitoring

   • Monthly follow-up initially with:
     • Visual acuity assessment
     • OCT measurements of central subfield thickness
     • Evaluation for resolution of intraretinal fluid 1
   • Adjust treatment intervals based on response:
     • Continue monthly if improvement seen but edema persists
     • Extend to 8 weeks if stable improvement achieved 2, 1

Additional Interventions

1. Consider Panretinal Photocoagulation (PRP)

   • May be needed for proliferative diabetic retinopathy in both eyes
   • Can be performed after initial anti-VEGF treatment has reduced macular edema
   • Helps prevent vitreous hemorrhage and tractional retinal detachment 2

2. Focal/Grid Laser

   • Consider as adjunctive therapy if macular edema persists despite anti-VEGF treatment
   • Can be added approximately 24 weeks after initiating anti-VEGF therapy
   • Target microaneurysms and areas of thickening not responding to anti-VEGF 2

Special Considerations

1. Right Eye Pseudophakia

   • Beneficial as cataract has already been addressed
   • No concern for cataract progression affecting visual outcomes 5

2. Left Eye Cataract

   • Monitor for progression
   • Consider cataract surgery after stabilization of diabetic retinopathy
   • Pre-operative optimization of retinopathy reduces risk of post-cataract surgery macular edema worsening 5

3. Systemic Management

   • Optimize glycemic control
   • Blood pressure management
   • Lipid control
   • These measures support ocular treatment efficacy 1

Treatment Pitfalls to Avoid

1. Undertreatment

   • Inadequate frequency or premature discontinuation of anti-VEGF therapy
   • Insufficient follow-up leading to missed disease progression 1

2. Delayed Intervention

   • Postponing treatment can lead to irreversible vision loss
   • Massive macular edema requires prompt and aggressive management 1

3. Medication Interactions

   • Monitor for medications that may worsen macular edema (e.g., thiazolidinediones like pioglitazone) 6

4. Relying on OCT Alone

   • Fluorescein angiography provides critical information about ischemia and leakage patterns that OCT cannot detect 3

The management of this complex case requires aggressive treatment of both the macular edema and proliferative diabetic retinopathy, with regular monitoring and adjustment of therapy based on treatment response.