How to treat macular edema?

From the Guidelines

The most effective treatment for macular edema is the use of anti-VEGF agents, such as ranibizumab, aflibercept, or bevacizumab, due to their favorable risk-to-benefit profile and strong evidence supporting their efficacy in improving visual acuity and reducing macular edema. The treatment of macular edema typically involves a comprehensive approach, including:

• A thorough eye examination by an ophthalmologist or retina specialist to determine the underlying cause of the macular edema
• The use of specialized equipment such as optical coherence tomography (OCT) to measure retinal thickness and detect fluid accumulation
• Fluorescein angiography to identify leaking vessels that cause edema
• Fundus photography to document the appearance of the macula
• Amsler grid testing to detect central vision distortions The use of anti-VEGF agents has been shown to be effective in treating macular edema associated with retinal vein occlusions, with studies such as the BRAVO trial demonstrating significant improvements in visual acuity and reductions in macular edema with ranibizumab treatment 1. Additionally, the COPERNICUS study showed similar findings with aflibercept treatment, with a 15-letter gain in 56% of treated eyes compared to 12% of sham injections 1. The use of intravitreal corticosteroids, such as triamcinolone or dexamethasone, may also be considered in cases where there is a failure to respond or an inadequate response to anti-VEGF agents, but their use is associated with known risks of cataracts and glaucoma 1. Overall, the treatment of macular edema should be individualized and based on the underlying cause and severity of the condition, as well as the patient's overall health status and medical history. Some key points to consider when treating macular edema include:
• The importance of prompt treatment to prevent vision loss and improve outcomes
• The need for regular follow-up and monitoring to adjust treatment as needed
• The potential benefits and risks of different treatment options, including anti-VEGF agents and intravitreal corticosteroids
• The importance of addressing any underlying medical conditions that may be contributing to the development of macular edema.

From the FDA Drug Label

The safety and efficacy of ranibizumab were assessed in two randomized, double-masked, 1-year studies in patients with macular edema following RVO. In Study RVO-1, patients with macular edema following branch or hemi-RVO, received monthly ranibizumab 0.3 mg or 0. 5 mg intravitreal injections or monthly sham injections for 6 months. CIMERLI 0.5 mg (0.05 mL of 10 mg/mL solution) is recommended to be administered by intravitreal injection once a month (approximately 28 days) for Macular Edema Following Retinal Vein Occlusion (RVO).

Treatment for Macular Edema:

• Ranibizumab 0.5 mg intravitreal injections once a month for Macular Edema Following Retinal Vein Occlusion (RVO) 2
• CIMERLI 0.5 mg (0.05 mL of 10 mg/mL solution) administered by intravitreal injection once a month for Macular Edema Following Retinal Vein Occlusion (RVO) 2

From the Research

Diagnosis of Macular Edema

• Macular edema can be diagnosed using various imaging modalities, including optical coherence tomography (OCT) and fluorescein angiography (FA) 3, 4, 5, 6, 7
• OCT is a non-contact, diagnostic method that uses infrared light to analyze the retinal structure and is widely recognized as the new reference standard for assessment of diabetic macular edema (DMO) 3
• FA is an invasive procedure that involves injecting a dye into the bloodstream to visualize the blood vessels in the retina and can be used to detect macular edema, but it has a higher risk of adverse reactions compared to OCT 4, 7

Optical Coherence Tomography (OCT)

• OCT is able to image retinal thickness and structure, producing cross-sectional and three-dimensional images of the central retina 3
• OCT has a high sensitivity and specificity for detecting macular edema, with a pooled sensitivity of 0.78 and specificity of 0.86 in patients with diabetic retinopathy 3
• OCT can be used to quantify the effects of treatment of macular edema and to monitor disease progression 3, 6

Fluorescein Angiography (FA)

• FA is a diagnostic procedure that involves injecting a dye into the bloodstream to visualize the blood vessels in the retina 4, 7
• FA can be used to detect macular edema, but it has a lower sensitivity and specificity compared to OCT, with an overall sensitivity of 0.97 and kappa agreement of 90.3% with SD-OCT 7
• FA is more sensitive than SD-OCT in detection of macular edema in cases of retinovascular diseases, but can fail to detect macular edema in cases of macular holes 7

Comparison of OCT and FA

• OCT and FA offer only moderate agreement regarding macular edema status in uveitis cases, probably because what they measure (retinal thickness and fluorescein leakage) are related but non-identical macular pathologic characteristics 4
• OCT is a safer and more convenient procedure compared to FA, with no risk of adverse reactions and higher likelihood of obtaining usable information 4, 7