Management Paradigms for Diabetic Macular Edema

Am J Ophthalmol. 2014 Mar;157(3):505-13.e1-8. doi: 10.1016/j.ajo.2013.11.012. Epub 2013 Nov 19.

Abstract

Purpose: To provide evidence-based recommendations for diabetic macular edema (DME) management based on updated information from publications on DME treatment modalities.

Design: Perspective.

Methods: A literature search for "diabetic macular edema" or "diabetic maculopathy" was performed using the PubMed, Cochrane Library, and ClinicalTrials.gov databases to identify studies from January 1, 1985 to July 31, 2013. Meta-analyses, systematic reviews, and randomized controlled trials with at least 1 year of follow-up published in the past 5 years were preferred sources.

Results: Although laser photocoagulation has been the standard treatment for DME for nearly 3 decades, there is increasing evidence that superior outcomes can be achieved with anti-vascular endothelial growth factor (anti-VEGF) therapy. Data providing the most robust evidence from large phase II and phase III clinical trials for ranibizumab demonstrated visual improvement and favorable safety profile for up to 3 years. Average best-corrected visual acuity change from baseline ranged from 6.1-10.6 Early Treatment Diabetic Retinopathy Study (ETDRS) letters for ranibizumab, compared to 1.4-5.9 ETDRS letters with laser. The proportion of patients gaining ≥ 10 or ≥ 15 letters with ranibizumab was at least 2 times higher than that of patients treated with laser. Patients were also more likely to experience visual loss with laser than with ranibizumab treatment. Ranibizumab was generally well tolerated in all studies. Studies for bevacizumab, aflibercept, and pegaptanib in DME were limited but also in favor of anti-VEGF therapy over laser.

Conclusions: Anti-VEGF therapy is superior to laser photocoagulation for treatment of moderate to severe visual impairment caused by DME.

Publication types

  • Comparative Study
  • Practice Guideline
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Angiogenesis Inhibitors / therapeutic use*
  • Clinical Trials as Topic
  • Databases, Factual
  • Diabetic Retinopathy / drug therapy
  • Diabetic Retinopathy / surgery
  • Diabetic Retinopathy / therapy*
  • Evidence-Based Medicine
  • Humans
  • Laser Coagulation*
  • Macular Edema / drug therapy
  • Macular Edema / surgery
  • Macular Edema / therapy*
  • Treatment Outcome
  • Vascular Endothelial Growth Factor A / antagonists & inhibitors
  • Visual Acuity

Substances

  • Angiogenesis Inhibitors
  • VEGFA protein, human
  • Vascular Endothelial Growth Factor A