Let's Talk About Diabetic Macular Edema Treatment
You've got options for treating your DME. This info will help you make those decisions with confidence. by Patty Onderko Health Writer
Every case of diabetic macular edema is different and so is every treatment plan. Your eye doctor will go over all your options and offer recommendations based on several factors: the severity of your edema, your degree of vision impairment, other eye conditions you may have, the latest research, and their own experience. But ultimately your treatment path is up to you.
Our Pro Panel
We went to some of the nation’s top vision experts in diabetic macular edema treatment to bring you the most up-to-date information possible.
Michelle Liang, M.D.
Tufts Medical Center
Abdhish R. Bhavsar, M.D.
Spokesperson for the American Academy of Ophthalmology and President and Director of Clinical Research
Retina Center of Minnesota
Jennifer Sun, M.D.
Associate Professor of Ophthalmology
Harvard Medical School
Unless your eye doctor decides to take a wait-and-see approach to your DME, injections of anti-VEGF medications are typically the first line of defense. So chances are, you will need to receive an ocular injection to best preserve your vision at some point in your treatment. But rest assured that eye-numbing drops are always used and you should not feel pain.
VEGF stands for vascular endothelial growth factor and it is a naturally occurring "signal" protein that alerts the body to create new blood vessels when under duress. In most cases, that's a good thing: VEGF helps tissue heal after injury and helps repair muscles after exercise. But when it comes to diabetic retinopathy, it's a case of too much of a good thing. Anti-VEGF drugs aim to stop the activity of VEGF and prevent the formation of problematic new vessels.
Yes! Studies show that anywhere from 20% to 60% of patients with DME do not respond to anti-VEGF drugs, so you’re not alone. Thankfully, there are other effective treatments, including corticosteroid medications and laser therapy.
Not necessarily. If your vision is 20/25 or better and your DME is center-focused, your eye doctor may want to hold off on treatment and schedule very frequent eye exams instead.
What Is Diabetic Macular Edema, Again?
If you've been living with diabetic retinopathy (DR), this is probably a moment you hoped would never happen: You've been diagnosed with diabetic macular edema, a severe form of DR that causes swelling in the macula, the centermost part of the retina. It occurs when high blood sugar levels weaken the eyes' blood vessels, causing them to leak blood, fluid, and lipids. That buildup contributes to the swelling, distorts vision, and can lead to blindness if not treated.
And that treatment usually means eye injections. The thought of needles anywhere near your eyes, combined with the threat of vision loss, can be paralyzing.
So, allow us to reassure you of two things:
Treatment for diabetic macular edema should be relatively painless, and
Today's therapies are incredibly effective at halting—and often even reversing—vision loss.
Choices may include anti–vascular endothelial growth factor (anti-VEGF) injections, steroid implants, and/or laser treatments. Sometimes, a wait-and-see approach may be recommended as the best course of treatment, too, if you have center-focused DME and your vision is still good. Let's take a clear look at each option, starting with the current gold standard of care, anti-VEGF medications.
While laser therapy was the go-to treatment for diabetic macular edema less than a decade ago, the new first line of defense is anti-VEGF medications.
How they work: VEGF stands for vascular endothelial growth factor and it is a naturally occurring "signal" protein that alerts the body to create new blood vessels when under duress. In most cases, that's a good thing: VEGF helps tissue heal after injury and helps repair muscles after exercise. But when it comes to retinopathy, it's a case of too much of a good thing.
See, once your body catches wind of the damaged retinal vessels in your eye—weakened from high glucose levels—it releases extra (or "overexpresses," as your doctor might say) VEGF, triggering the growth of new blood vessels. Unfortunately, these newly formed vessels are very fragile themselves and can leak even more blood into the retina and macula, causing edema.
Anti-VEGF drugs aim to stop the activity of VEGF and prevent the formation of these problematic new vessels. There are three main anti-VEGF drugs currently used:
And all work similarly to block VEGF. One study from the National Eye Institute found that the three medications are equally effective in patients with mild vision problems, but that Eylea had an advantage in treating more serious vision loss (20/50 or worse). Talk to your eye doctor about the medication that is right for you.
What will happen: Your eye doctor will use a topical anesthetic (usually in the form of drops) to numb your eye. Then, he or she will use a small needle to inject the medicine through the white part of your eye and into the vitreous, which is the clear, jelly-like substance in the middle of the eye. Multiple injections may be required.
You should know: Unfortunately, anti-VEGF injections do not work for everyone. In fact, studies show that anywhere from 20% to 60% of patients with DME do not respond to them. If your vision does not improve after anti-VEGF treatment, your doctor may call you a "suboptimal responder." But don't worry, there are other effective treatments (Also: We think you're optimal in every way!).
Corticosteroid (Steroid) Medications
Your doctor may suggest corticosteroids if anti-VEGF medications were not helpful.
How they work: Remember those new retinal blood vessels that your body creates in response to the damaged ones? They create inflammation as they grow into places where they shouldn't. They create further inflammation when they leak blood into the retina and macula.
This inflammation contributes to the swelling that distorts your vision. Since steroids are anti-inflammatory drugs, they can be used in conjunction with anti-VEGFs or on their own to help resolve your diabetic macular edema.
Steroids may be administered via pills, eye drops, intraocular injections, or small, sustained-release eye implants. All can be effective, but the implants may provide longer-lasting relief for more serious and chronic cases of DME. Currently, there are three FDA-approved corticosteroid implants:
Iluvien (fluocinolone acetonide)
Retisert (fluocinolone acetonide)
Your doctor may choose injections first to see how you respond to the medication before proceeding with an implant.
What will happen: It depends on the delivery system. If you and your doctor decide on corticosteroid injections, she or he will follow the same protocol as for anti-VEGF injections (see above). If an implant is chosen, your doctor will make a tiny and usually self-healing incision—under local or general anesthesia in a hospital or surgery center—in the white part of your eye. A small implant (Retisert is about the size of a grain of rice, for example) will then be inserted into your vitreous.
You should know: Steroid treatment comes with a risk of developing glaucoma, which is why your doctor will almost always recommend anti-VEGF medications first.
Focal Laser Treatment (Also Called Focal Photocoagulation)
Once the standard treatment for DME, lasers are still used to seal off damaged retinal blood vessels. Think of this procedure as "spot welding" specific, extra-leaky vessels or the vessels within a very small area.
What will happen: Your eye doctor will use a topical anesthetic (usually in the form of drops) to numb your eye. They will then aim the laser into one eye at a time. Feel free to make "Beam me up, Scotty!" jokes. A repeat laser session may be necessary after four months or so.
You should know: If your edema is located in the very center of your macula, focal laser treatment may not be the right treatment for you.
If your vision is good (20/25 or better) and your DME is center-focused, don't be alarmed if your doctor tells you they want to hold off any treatment at all for the time being. One 2019 study compared the outcomes of three different treatments in patients with DME: One group received anti-VEGF injections (aflibercept), one group underwent focal laser treatment, and the third group received no treatment at all. After two years, the study found that all three groups had comparable rates of visual acuity. Of course, observation means frequent and regular eye exams. And if you notice any changes in your eyesight, get to your eye doc stat.
Being diagnosed with diabetic macular edema is a scary thing...and the treatment options that follow can be even scarier (needles!), but over time it becomes something worth embracing that helps keep eyes healthy and happy for years to come.
Personalizing Your DME Treatment: American Academy of Ophthalmology. (n.d.) aao.org/eyenet/article/diabetic-macular-edema-personalizing-treatment
Macular Edema Treatment Overview: The National Eye Institute. (2019.) nei.nih.gov/learn-about-eye-health/eye-conditions-and-diseases/macular-edema
Anti-VEGFs and DME: Clinical Ophthalmology. (2017.) "Anti-VEGF treatment of diabetic macular edema in clinical practice: effectiveness and patterns of use (ECHO Study Report 1)." ncbi.nlm.nih.gov/pmc/articles/PMC5328320/
Steroids and DME: Turkish Journal of Ophthalmology. (2017.) "Corticosteroid Treatment in Diabetic Macular Edema." ncbi.nlm.nih.gov/pmc/articles/PMC5468529/
Laser Therapy Stats: Middle East African Journal of Ophthalmology. (2012.) "Diabetic Macular Edema: Current and Emerging Therapies." ncbi.nlm.nih.gov/pmc/articles/PMC3277023/
Observation and DME: Journal of the American Medical Association. (2019.) "Effect of Initial Management With Aflibercept vs Laser Photocoagulation vs Observation on Vision Loss Among Patients With Diabetic Macular Edema Involving the Center of the Macula and Good Visual Acuity." jamanetwork.com/journals/jama/fullarticle/2732608