Choosing the Best Treatment for Diabetic Macular Edema

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Swelling around the macula (macular edema) caused by the leakage and accumulation of fluid can occur in people with diabetes. The swelling alters the position of the retina and causes blurred vision. Loss of vision is more pronounced when the center of the macula is affected. Alterations in vision may be minimal or severe enough to result in classification as legally blind if both eyes are affected.

Three anti-VEGF agents have been shown to work for people with diabetic macular edema: aflibercept, bevacizumab, and ranibizumab. Recent findings from the Diabetic Retinopathy Clinical Research Network, published last year in Current Opinions in Ophthalmology, offer important insights into choosing the best treatment. The network, funded by the National Eye Institute, conducts large multicenter trials to test therapies for eye diseases.

Previous research findings had shown that for eyes with a visual acuity of 20/32 to 20/40, the three treatments were equally effective in preserving vision. A follow-up analysis showed that among eyes with this level of visual acuity that had a central subfield thickness of 400 microns or more (a measure of the macula’s thickness), aflibercept had a better vision outcome than bevacizumab.

The latest research shows that for eyes with 20/50 visual acuity or worse, aflibercept offers better outcomes over two years than either ranibizumab or bevacizumab. Aflibercept was also associated with higher rates of improvements in the severity of diabetic retinopathy over two years. The conclusion: if your visual acuity is 20/50 or worse or you have diabetic retinopathy, aflibercept may be your best choice.

One interesting side note from the study relates to patients with phakic intraocular lenses, which are placed over the existing natural lens. When diabetic macular edema persists even after antiVEGF injections, some ophthalmologists have recommended the use of intravitreous steroids. The new findings suggest that they offer no benefit.