This article is more than 5 years old. Information may no longer be current.
Vitreoretinal surgeon relates stepwise approach to managing DME
Click Here to Manage Email Alerts
When managing patients with diabetic macular edema, it is important that clinicians have defined first-line and second-line therapies, according to one vitreoretinal surgeon.
“We now have a much better handle on how to control diabetic macular edema based on recent research studies for guidance,” Ankoor R. Shah, MD, said, citing the Diabetic Retinopathy Clinical Research Network (DRCR.net) Protocol T study findings.
Shah said he now favors monthly intravitreal injections of Eylea (aflibercept, Regeneron) as first-line therapy, especially in patients with worse than 20/50 vision but also often in patients who see better than 20/50.
“Typically, I’m watching the OCT to show signs of resolution of the macular edema,” Shah said. “As long as I am making progress, I will continue to use aflibercept. After three monthly injections of aflibercept alone, I expect about 75% to 80% of patients to respond quite nicely.”
However, when patients do not achieve a robust reduction of central retinal thickness as seen on OCT, Shah discusses with his patients one of two further treatment options: switching to another anti-VEGF or switching to a steroid medication.
“It comes down to the patient. Each option has its pros and cons,” Shah said, with his patients choosing each of the two second-line therapies equally.
If the patient is pseudophakic, for instance, and has no issues with glaucoma, then steroids may be a good option, he said. In these cases, Shah usually chooses the sustained drug delivery device Ozurdex (intravitreal dexamethasone 0.7 mg, Allergan) and sees improvement in roughly two-thirds of his patients.
“Patients may need to return to the office far less frequently than for monthly anti-VEGF injections,” he said, because the steroid’s effects last about 3 to 4 months, depending on the patient.
“The two most common complications I am worried about with steroids are cataract formation and development of high intraocular pressure,” Shah said.
But if the patient has glaucoma, Shah often opts for Lucentis (ranibizumab, Genentech). Published 36-month results of the RISE/RIDE study showed that the gains achieved at 2 years were maintained at 3 years, he said.
“About one-third of my patients will get better when I switch to ranibizumab,” he said. “However, a number of them still have recalcitrant DME.”
A third-line therapy is vitrectomy with membrane peeling, which Shah is performing less often due to success with his first- and second-line therapies.
“I think the challenge of DME treatment now is what to do with these recalcitrant patients,” Shah said. “Some clinicians will alternate between anti-VEGF therapies, which I certainly do to a certain degree. But I find that if the patient has failed aflibercept, you are unlikely to do that much better with bevacizumab (Avastin, Genentech).”
In the steroid space, the sustained drug delivery implant Iluvien (fluocinolone acetonide 0.19 mg, Alimera Sciences) was approved by the FDA in September 2014 and is designed to last up to 3 years.
Shah said it is important to evaluate eyes for DME to prevent chronic macular edema, which in some cases can lead to irreversible vision loss. – by Bob Kronemyer
- For more information:
- Ankoor R. Shah, MD, can be reached at Retina Consultants of Houston, 6560 Fannin St., Suite 750, Houston, TX 77030; email: ankoors@gmail.com.
Disclosure: Shah reports having served on Allergan’s advisory board for Ozurdex.