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    Selecting the right DME patients for long-term steroidal implants

    Editor’s Note: Welcome to “Eye Catching: Let's Chat,” a blog series featuring contributions from members of the ophthalmic community. These blogs are an opportunity for ophthalmic bloggers to engage with readers with about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Joshua Mali, MD, a vitreoretinal surgeon at The Eye Associates, a private multispecialty ophthalmology practice in Sarasota, FL. The views expressed in these blogs are those of their respective contributors and do not represent the views of Ophthalmology Times or UBM Medica.

     

    An increasing number of treatment options have given patients facing diabetic macular edema (DME) new hope in the face of this chronic, progressive, and blinding disease. Experience and time have shown us there is not a one-size-fits-all solution for patients with DME. To get the results we want, we need to screen our patients and match them with the treatment protocol best suited to their needs.

    Selecting the right candidate makes all the difference

    Anti-VEGF therapy is typically the first line of defense against DME. Accepted as a well-tolerated and effective regimen, there remain two major reasons why we still need alternative treatments. First, the frequency and expense of this treatment can potentially become burdensome on patients, the healthcare system, and providers. The injection schedule maintained in clinical trials is rarely adhered to in the actual clinic precisely because it is a huge burden. In addition, not all patients respond ideally to anti-VEGF therapy. New data indicates that we can determine within the first three injections whether patients will have a successful or a limited response to anti-VEGF therapy. Rather than continue a sub-optimal treatment plan, we must consider different treatment options such as steroids, focal laser photocoagulation, micropulse laser, or a combination of these therapies. Without an alternative treatment, we risk leaving vision on the table for this subset of patients.

    There are two major criteria to contemplate prior to beginning a steroid regimen: potential cataract development and increased IOP. When considering steroids, pseudophakic patients are the best candidates. However, I will consider the risks and benefits with phakic patients. For example, if the phakic patient is older and is not responding to any other treatment modality, the potential of advancing a cataract may not be more important than the damage being caused by the macular edema that possibly only responds to corticosteroids. In addition, I consider using a fluocinolone acetonide intravitreal implant (Iluvien, Alimera Sciences) preoperatively in stable phakic DME patients that are undergoing cataract surgery to help blunt any postoperative rise in DME.  

    Joshua Mali, MD
    Joshua Mali, MD, is a vitreoretinal surgeon at The Eye Associates, a private multispecialty ophthalmology practice in Sarasota, Florida.

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