Choosing the Right Treatment Path for Diabetic Macular Edema

Treatment options for diabetic macular edema (DME) include anti–vascular endothelial growth factor (anti-VEGF) injections and panretinal laser therapy, with patient-specific factors like severity of vision loss, compliance, and comfort guiding the choice and regimen, explains Jose A. Martinez, MD, president and retina specialist at Austin Retina Associates. Longer-duration treatments like high-dose aflibercept (Eylea HD) are also helping reduce injection frequency, improving patient convenience while maintaining effective management of DME.

Transcript

What are the different treatment options for DME, and what do you and the patient consider when choosing a treatment path?

Yeah, some patients are very direct. Most patients tolerate intravitreal injections quite well. Of course, as I say to them, "it sounds terrifying, but trust me, it doesn't hurt. We numb you up. You may feel a little pressure. We give the injection." Most patients tolerate it well. Some are anesthetized with simple eyedrops. Others require what I call a Q-tip where I hold some lidocaine on the surface of their eye and numb it a little more. Others' next step ladder is some patients require subconjunctival anesthesia. So, it really depends on the patient, determines how I treat them, but 90% of the time, a simple 2 rounds of proparacaine eyedrops is sufficient to make it a comfortable experience for the patient.

Most patients tolerate intravitreal injections. I think it's very good to get anti-VEGF in the eye, particularly those patients that have center-involved diabetic macular edema and those that have neovascularization. Most of the time, injecting anti-VEGF in my office, usually it's generally a series of 3 anti-VEGF injections followed by panretinal photocoagulation, if they don't have significant diabetic macular edema as well. And that panretinal photocoagulation reduces their treatment burden to where I don't need to give so many anti-VEGF treatments down the road.

I'll have a conversation with the patients about the potential of peripheral visual field loss, but that's why I treat them lightly. I have found visual field loss is not a big concern down the road. It's always interesting being in practice now for over 30 years, I see patients that I treated 30 years ago [or] 25 years ago with panretinal photocoagulation. And it's amazing to see how much those laser scars expand in size over time, which I think is the secondary side effect of these laser treatments.

I think the tendency now is to give lighter treatments when you're doing panretinal laser to try to reduce that severe scarring and enlargement of those scars. [For] patients with diabetic macular edema, center-involved diabetic macular edema especially, I think [it is] pretty well established that anti-VEGF therapy is the way to go to manage these folks.

It's really interesting, patients that have really bad vision, when they show up 20/200, they're really symptomatic, and you start anti-VEGF, and they see an improvement over the course of several months, those tend to be patients that are very motivated and understand the benefits of this treatment option, because they really can see the difference in their vision. And I have found through the years that they tend to be very compliant with follow-ups because they've had bad vision, they know what it's like, and they benefited from the anti-VEGF therapy.

The trick is, those patients that have mild vision loss 20/25, 20/30 and they have center-involved DME, oftentimes it's hard to get them to remain as compliant. But be it as it may, those that do tend to do very well, and having the availability of a high-dose Eylea usually reduces their need for Q4 to 8-week dosing, often we can extend it out to 8 to 12-week dosing, even longer in some patients. So it's just nicer for the patient.

We're very busy in the retina clinic, so being able to decompress the number of patients we're seeing is very helpful for us in terms of patient flow and just the quantity of patients we have to see. So, it's been a win-win for both the patients to reduce our intervals, it's reduced our clinic size which is nice, and I think the insurance companies in the long run wins out on using HD because studies showed that they'll require less injections, which will save the insurance company and the whole health care system money as well in the long run. So, I think these longer duration drugs like Eylea HD have been very helpful in managing these patients, and hopefully, ultimately, they'll reduce the incidence of vision loss from diabetic eye disease.