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Management Paradigms for Diabetic Macular Edema

  • Paul Mitchell
    Affiliations
    Centre for Vision Research, Westmead Millennium Institute, University of Sydney, Sydney, Australia
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  • Tien Yin Wong
    Correspondence
    Inquiries to Professor Tien Yin Wong, Singapore Eye Research Institute, Singapore National Eye Centre, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore 119228
    Affiliations
    Singapore Eye Research Institute, Singapore National Eye Centre, National University of Singapore, Singapore
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  • for theDiabetic Macular Edema Treatment Guideline Working Group
Published:November 21, 2013DOI:https://doi.org/10.1016/j.ajo.2013.11.012

      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.
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