Anti-VEGF Indications in Diabetic Retinopathy
Intravitreal anti-VEGF injections are indicated as first-line treatment for center-involved diabetic macular edema that impairs visual acuity, and serve as a reasonable alternative to panretinal laser photocoagulation for proliferative diabetic retinopathy. 1
Primary Indications
Diabetic Macular Edema (First-Line Treatment)
Anti-VEGF therapy is the standard of care for most eyes with diabetic macular edema involving the foveal center that impairs vision. 1
- Center-involved DME with vision impairment represents the strongest indication, where anti-VEGF provides superior visual and anatomic outcomes compared to laser monotherapy 1
- Treatment typically requires injections every 4-8 weeks during the first 12 months, with fewer injections needed in subsequent years to maintain remission 1
- Five anti-VEGF agents are currently used: bevacizumab, ranibizumab, aflibercept (2 mg and 8 mg), brolucizumab, and faricimab 1
For eyes with moderate visual impairment (20/50 or worse), aflibercept provides superior vision outcomes compared to bevacizumab. 1 This represents the highest quality comparative data available for agent selection.
For eyes with good vision (20/25 or better) despite DME, close monitoring with initiation of anti-VEGF only if vision worsens provides similar 2-year outcomes to immediate treatment. 1 This allows for a more conservative approach in select cases.
Proliferative Diabetic Retinopathy (Alternative to Laser)
Anti-VEGF injections are a reasonable alternative to traditional panretinal laser photocoagulation for proliferative diabetic retinopathy. 1
- Anti-VEGF therapy is effective at regressing proliferative disease and leads to noninferior or superior visual acuity outcomes compared to panretinal laser over 2 years 1
- Patients treated with ranibizumab demonstrate less peripheral visual field loss, fewer vitrectomy surgeries for complications, and lower risk of developing diabetic macular edema compared to laser 1
- The FDA has approved aflibercept and ranibizumab specifically for diabetic retinopathy treatment 1
Secondary and Emerging Indications
Nonproliferative Diabetic Retinopathy (Not Routinely Recommended)
Anti-VEGF treatment of nonproliferative diabetic retinopathy reduces subsequent development of retinal neovascularization and diabetic macular edema, but has not been shown to improve visual outcomes over 2 years and is therefore not routinely recommended for this indication. 1
Persistent DME Despite Anti-VEGF (Second-Line)
When DME persists despite anti-VEGF therapy, macular focal/grid photocoagulation or intravitreal corticosteroids are reasonable second-line treatments. 1
Critical Clinical Considerations
Treatment Burden and Compliance
A major drawback of anti-VEGF therapy is the requirement for more frequent visits and treatments compared to panretinal laser. 1 This may not be optimal for all patients, particularly those with:
- Limited access to ophthalmologic care
- Poor compliance with scheduled follow-up
- Inability to maintain frequent injection schedules 1
Patients with nonintentional lapses in anti-VEGF treatment are at risk for worse visual acuity and anatomic outcomes. 1 This represents a critical pitfall when selecting anti-VEGF over laser therapy.
Special Populations: Pregnancy
Anti-VEGF use in pregnant individuals may be justified only if potential benefit outweighs potential risk to the fetus. 1
- Current anti-VEGF medications are FDA pregnancy category C (animal studies show embryo-fetal toxicity, no controlled human data) 1
- Caution is warranted due to theoretical risks to the developing fetal vasculature 1
- Laser photocoagulation and corticosteroids represent reasonable first-line alternatives in pregnancy 1
Referral Triggers
Promptly refer individuals with any level of diabetic macular edema, moderate or worse nonproliferative diabetic retinopathy, or any proliferative diabetic retinopathy to an experienced ophthalmologist. 1 Early referral is essential to prevent vision loss and optimize treatment outcomes.