Dear colleagues,

Peter K. Kaiser, MD
Editor-in-Chief,
Retinal Physician

We can’t use a cookbook in retina, and nowhere is that more apparent than when we’re caring for patients who have diabetic macular edema (DME). Despite high-definition imaging modalities, we can’t base our treatment decisions on anatomy alone, nor can we use functional vision as the sole criterion for our treatment approach. How often have we seen patients who have significant edema and good vision? Do we treat? Observe? Conversely, how do we manage patients with minimal edema but poor vision?

Our treatment decisions are informed by clinical trials as well as studies by the Diabetic Retinopathy Clinical Research Network. Meanwhile, scientists continue to study and provide insights on the various complex mechanisms that drive diabetic macular edema. We know that early DME follows more of an ischemic pathway, and anti-VEGF agents are usually effective at that stage. Anti-VEGF therapy alone, however, may not achieve optimal results because of the inflammatory nature of the disease. When faced with a poor response, we have options.

In general, I use anti-VEGF agents as first-line therapy. If the response is suboptimal, I may switch anti-VEGF agents, in particular switching from bevacizumab (Avastin, Genentech) to aflibercept (Eylea, Regeneron), which was shown to have greater potency in the DRCR Protocol T study. When Eylea stops working, or if the response isn’t as good as I’d like, I’m apt to add a corticosteroid, which often resets the intraocular milieu, allowing the patient to once again become responsive to anti-VEGF agents.

When choosing a steroid, again, we have options. We can use off-label intravitreal triamcinolone or one of the new sustained-release implants — dexamethasone (Ozurdex, Allergan) or fluocinolone (Iluvien, Alimera Sciences) — however, we must be mindful of the significant differences among them. Ozurdex is a much more potent steroid, and it may have a lower side effect profile than triamcinolone injection.

Even with a clear-cut diagnosis and a definitive treatment plan, we must consider other factors to fully assess how a patient may respond to treatment. How long has he had diabetes? Does he maintain his target A1c? How good is his blood pressure control? A patient’s lifestyle also plays a significant role in successful DME therapy. Is the patient working full time? Does he have comorbidities from his diabetes that require numerous appointments with other medical professionals? Will he be able to adhere to a monthly treatment schedule? We have to take the whole patient — and each patient’s unique situation — into account as we strive to manage his or her disease. Simply put, we must individualize our treatments.

In this special supplement to Retinal Physician, we present five case histories that illustrate not only the broad spectrum of diabetic macular edema but also the various treatment approaches clinicians are using. I believe seeing how patients respond to various treatment modalities over time is informative and instructive. These are patients we see on a daily basis, and these cases offer insights that we can bring to our clinics right away.