What is the recommended management for diabetic macular edema?

Management of Diabetic Macular Edema

Intravitreal anti-VEGF therapy is the first-line treatment for center-involving diabetic macular edema, with agents like ranibizumab, bevacizumab, and aflibercept being the primary therapeutic options. 1, 2, 3

First-Line Treatment: Anti-VEGF Therapy

Anti-VEGF medications have revolutionized DME management by directly targeting vascular endothelial growth factor, the key mediator driving blood-retinal barrier breakdown and fluid accumulation. 1 These agents effectively reduce macular edema and improve visual acuity in the majority of patients. 1, 3

The three main anti-VEGF options include:

• Ranibizumab 1, 3
• Bevacizumab 1, 3
• Aflibercept 1, 3

These are administered via intravitreal injection and represent the standard of care for center-involving DME. 2, 3

Second-Line Treatment: Intravitreal Corticosteroids

When patients show suboptimal response to anti-VEGF therapy, intravitreal steroids become the appropriate next step. 4, 3 Steroids work through multiple mechanisms including reducing inflammation, inhibiting VEGF expression, and stabilizing the blood-retinal barrier. 4

Available steroid options include:

• Triamcinolone acetonide injections 4, 5
• Dexamethasone implants 4
• Fluocinolone acetonide implants 4

Critical caveat: Steroids carry significant risks of intraocular pressure elevation and cataract development, requiring careful patient selection and monitoring. 4, 3

Laser Photocoagulation

Focal or grid laser photocoagulation, once the gold standard, is now reserved for specific scenarios. 5, 2, 3

Current indications:

• Non-center-involving DME 3
• Small focal microaneurysms with localized edema 5
• Adjunctive therapy in combination with pharmacological treatments 5

Surgical Intervention: Pars Plana Vitrectomy

Vitrectomy without inner limiting membrane (ILM) peeling is effective for reducing retinal thickness and improving visual acuity in selected cases. 5

Specific indication:

• DME with documented vitreous traction or posterior vitreous attachment 5, 2

Essential Systemic Management

Control of systemic risk factors remains the foundational strategy underlying all DME treatment. 4

Key targets to optimize:

• Glycemic control (chronic hyperglycemia triggers the pathogenic cascade) 4
• Blood pressure management 4
• Lipid control 4

Treatment Algorithm

1. Start with anti-VEGF therapy for all center-involving DME 2, 3
2. Switch to intravitreal steroids if inadequate response to anti-VEGF after appropriate trial 4, 3
3. Add focal/grid laser for non-center-involving areas or persistent focal leakage 5, 3
4. Consider vitrectomy only when vitreous traction is documented 5, 2
5. Combination therapy may be necessary to maintain central vision in refractory cases 5

Common pitfall: The burden of frequent anti-VEGF injections can lead to treatment non-compliance, which significantly impacts outcomes. 3 Address patient expectations and logistics early in the treatment course.