Update on Diabetic Macular EdemaDr Khaled El Khaled, MD, MRCOphth

Introduction

•Diabetic retinopathy is one of the largest causes of visual loss worldwide and is the principal cause of impaired vision in patients between 25 and 74 years of age.• The prevalence of diabetic retinopathy increases with duration of diabetes

Prevalence

•DR virtually all patients with type 1 diabetes by 20 years.• The increased incidence in type 2 diabetes at three years is a probable reflection of the difficulty in determining the time of onset of that disease

Prevalence

•Good glycemic control does not guarantee that retinopathy will not develop or preclude regular screening for diabetic retinopathy

Screening Schedule1

1Standards of medical care in diabetes--2014. Diabetes Care 2014; 37 Suppl 1:S14.

Diabetic Macular Edema

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Detection

Diabetic Macular Edema• Prophylactic treatment of ME that is not clinically significant is not recommended.

• The initial therapy of choice:–Intravitreal anti-VEGF pharmacotherapy–Laser treatment (focal photocoagulation)

•A complementary role for vitreous surgery.

VEGF inhibitors • Intravitreal ranibizumab and aflibercept are approved by the FDA and European Medicines Agency for treatment of diabetic ME.

•Bevacizumab is used off-label for the treatment of ME. (the quality of the studies available for drug use by FDA)

Anti-VEGF versus laser, Gain 3+ lines of visual acuity at 1 year.

Anti-VEGF plus laser versus laser alone, Visual acuity at 1 year.

Anti-VEGF plus laser versus laser alone, Visual acuity at 2 years.

Experience: Addition of focal laser photocoagulation to anti-VEGF therapy may be beneficial in eyes that do not respond to or have an incomplete response to anti-VEGF

therapy.

Schedule and guidelines (discussion)

Intravitreal glucocorticoids for ME

• Intravitreal triamcinolone injection is an option for ME of any cause.

• Injection of 4 mg of triamcinolone acetonide produces a rapid reduction in macular thickness, often within days.

Intravitreal triamcinolone acetonide injection versus other treatment, Change in visual acuity (LogMAR).

VEGF inhibitors versus intravitreal triamcinolone injection •A single intravitreal injection of triamcinolone (4 mg) versus bevacizumab (1.25 or 1.5 mg) in patients with refractory diabetic ME.•A greater reduction in macular thickness and better visual acuity (20/100 versus 20/160) at 12 weeks with intravitreal triamcinolone injection.• The improvements were transient in both treatment groups.•Macular thickness and visual acuity returned to baseline within 12 weeks after injection of bevacizumab, 24 weeks with triamcinolone.• Intravitreal triamcinolone injection increased intraocular pressure more than bevacizumab

VEGF inhibitors versus intravitreal triamcinolone injection •One large trial (691 participants, 854 eyes) evaluated intravitreal ranibizumab (0.5 mg) or triamcinolone acetate (4 mg) combined with focal/grid laser versus laser alone for the treatment of diabetic ME involving the fovea.

•One year results:–Improvement in visual acuity was significantly

greater in the ranibizumab plus laser group compared with laser alone.– The difference between triamcinolone plus laser

versus laser alone was not significant

Oral protein kinase C inhibitor (ruboxistaurin)

Vitrectomy for clinically significant ME

•A systematic review of trials assessing a combination of these techniques versus observation or focal photocoagulation reported that vitrectomy may be beneficial in some patients with clinically significant ME, particularly in those with evidence of vitreomacular traction, although the evidence was weak

Thank you