Guidelines for the Management of Center-Involving Diabetic Macular Edema: Treatment Options and Patient Monitorization

Abstract

João Figueira,1,2 José Henriques,3 Ângela Carneiro,4,5 Carlos Marques-Neves,6– 8 Rita Flores,9,10 João Paulo Castro-Sousa,11– 13 Angelina Meireles,14,15 Nuno Gomes,16 João Nascimento,17 Miguel Amaro,18 Rufino Silva1,2,19 1Ophthalmology Department, Centro Hospitalar e Universitário de Coimbra (CHUC), Coimbra, Portugal; Faculty of Medicine, University of Coimbra (FMUC), Coimbra, Portugal; 2AIBILI - Association for Innovation and Biomedical Research on Light and Image, Coimbra, Portugal; 3Retina Department, Retinal Surgical Unit, Dr. Gama Pinto Ophthalmology Institute, Lisbon, Portugal; 4Department of Ophthalmology, Centro Hospitalar Universitário de São João, Porto, Portugal; 5Department of Surgery and Physiology, Faculty of Medicine of University of Porto, Porto, Portugal; 6Department of Ophthalmology, Centro Hospitalar Universitário de Lisboa Norte, EPE - Hospital de Santa Maria, Lisbon, Portugal; 7Department of Ophthalmology, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal; 8ALM Oftalmolaser, Lisbon, Portugal; 9Department of Ophthalmology, Centro Hospitalar de Lisboa Central EPE, Lisbon, Portugal; 10CEDOC, Chronic Diseases Research Center, NOVA Medical School, Lisbon, Portugal; 11Department of Ophthalmology, Centro Hospitalar de Leiria, Leiria, Portugal; 12CICS-UBI, Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal; 13Faculty of Medical Sciences, Universidade da Beira Interior, Covilhã, Portugal; 14Ophthalmology Department, Centro Hospitalar Universitário do Porto, Porto, Portugal; 15Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal; 16Ophthalmology Department, Hospital de Braga, Braga, Portugal; 17Instituto de Retina e Diabetes Oculares de Lisboa, Lisbon, Portugal; 18Ophthalmology Department, Hospital Vila Franca de Xira, Vila Franca de Xira, Portugal; 19Coimbra Medical Space, Coimbra, PortugalCorrespondence: João Figueira Praceta Mota Pinto, Coimbra, 3000-075, PortugalTel [phone]Email [email protected]: Diabetic macular edema (DME) is the main cause of visual impairment associated with diabetic retinopathy (DR) and macular laser, during approximately three decades, and was the single treatment option. More recently, intravitreous injections of anti-angiogenics and corticosteroids modified the treatment paradigm associated with significant vision improvements. Nevertheless, not all patients respond satisfactorily to anti-VEGF or corticosteroid injections, so an adequate treatment choice and a prompt switch in therapeutic class is recommended. Several algorithms and guidelines have been proposed for treating center involving DME to improve patients’ vision and quality of life. However, in Portugal, such guidelines are lacking. The present review aimed to provide guidelines for the treatment options and patient monitorization in the management of center-involving DME. We recommend anti-vascular endothelial growth factor (VEGF) as first-line therapy after a clinical evaluation accompanied by a rigorous metabolic control. Depending on the response obtained after 3– 6 monthly intravitreal injections we suggest switching outside the class in case of a non-responder, maintaining the anti-VEGF-therapy in responders to anti-angiogenics. The treatment regimen for Dexamethasone intravitreal implant (DEXii) should be pro-re-nata with bi-monthly or quarterly monitoring visits (with a scheduled visit at 6– 8 weeks after DEXii for intraocular pressure control). If a patient does not respond to DEXii, switch again to anti-VEGF therapy, combine therapies, or re-evaluate patients diagnose. There is a resilient need to understand the disease, its treatments, regimens available, and convenience for all involved to propose an adequate algorithm for the treatment of diabetic retinopathy (DR) and DME in an individualized regimen. Further understanding of the contributing factors to the development and progression of DR should bring new drug discoveries for more effective and better-tolerated treatments.Keywords: anti-vascular endothelial growth factor, center-involving diabetic macular edema, dexamethasone intravitreal implant, diabetic retinopathy

Keywords

• anti-vascular endothelial growth factor
• center-involving diabetic macular edema
• dexamethasone intravitreal implant
• diabetic retinopathy